Question

When a health insurance professional intentionally and knowingly misrepresents facts to increase the payment of a claim, it is commonly known as ____.

Answer 1

Fraud is a term used to describe the purposeful and knowing misrepresentation of facts by a health insurance professional in order to raise the payout of a claim.

What is a fraud?

Fraud is the deliberate misrepresentation of facts that one knows to be untrue (or does not believe to be true) in order to obtain benefits that are not legally permitted for oneself or another.

Examples of fraud can be:

• Modifying claim forms to achieve a bigger reimbursement amount or charging the patient for a higher level of service than was actually supplied

• Using a Medicare card belonging to someone else to get health care

• Billing for services that have previously been paid for by another insurance company or for services that the provider cannot prove was performed.

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