How is fraud best defined in the context of Medicare?

Fraud in the context of Medicare is best defined as intentional misrepresentation to gain something of value. This definition emphasizes the deliberate nature of the act, where an individual or entity knowingly provides false information with the aim of receiving unauthorized benefits or payments. This can include actions such as billing for services that were not provided, falsifying diagnosis codes, or providing false information about a patient’s condition to justify unnecessary procedures.

Understanding fraud as an intentional act is critical for differentiating it from other issues like billing errors or unnecessary services. For instance, situations involving unintentional duplicate payments or accidental errors in billing procedures fall under categories such as errors or mistakes rather than fraud, as they lack the element of intent behind them. Similarly, providing unnecessary but legitimate services may be unethical and could potentially lead to billing issues, but it does not constitute fraud unless there is an intentional misrepresentation involved. Thus, intentional misrepresentation is central to defining fraud in the Medicare context.