Discover published sets by community

Intentionally providing inaccurate information about the healthcare provider or facility to obtain higher payments. Examples include using a physician’s NPI (National Provider Identifier) without authorization.

A form of healthcare fraud specifically directed at the Medicaid program, involving billing for services not rendered or unnecessary services, among other things. Examples include overbilling and billing for non-performed services.

Illegally acquiring or distributing prescription drugs, which may include forging prescriptions, impersonating medical personnel, or acquiring medications for non-medical use. Examples include doctor shopping and pill mills.

Billing for medical services that were never provided to the patient. Examples include charging for a surgical procedure that was not actually performed.

Practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for healthcare. Examples include excessive services or overuse of services.

Prohibits knowingly submitting false or fraudulent claims to the federal government for payment. Examples include billing for services not provided, upcoding, and submitting claims for unnecessary services.

Charging for a higher level of service than was actually performed, thereby illegally increasing reimbursement amounts. Examples include billing for a complex level of care when a basic one was provided.

Billing separately for services that are typically charged together at a reduced rate, thus increasing the total reimbursement. Examples include billing each step of a surgical procedure as if it were a separate procedure.

Involves submitting claims for reimbursement for fabricated patients or for real patients who never received services. Examples consist of creating fake patient records and identities.

Prevents offering, paying, soliciting, or receiving anything of value to induce or reward referrals or generate Federal healthcare program business involving any item or service. Examples include referral fees, kickbacks, and bribes.

Involves knowingly billing Medicare for services that were not provided or are not medically necessary, or misrepresenting the service provided. Examples include phantom billing and billing for deceased patients.

Falsifying data on Medicare and Medicaid cost reports to obtain higher reimbursements than are due. Examples include inflating reported costs or misreporting data on cost reports.

Occurs when a physician refers a patient to a medical facility in which they have a financial interest, potentially compromising the physician’s professional judgment. Examples include owning shares in an imaging center to which the physician refers patients.

Stealing personal information, such as a patient's health insurance data, to obtain medical services, prescription drugs, or to file fraudulent insurance claims. Examples include using another person's health insurance card to receive care.

Forbids physician referrals for certain designated health services payable by Medicare to an entity with which the physician or an immediate family member has a financial relationship, unless an exception applies. Examples include improper referral arrangements and compensation structures.

Routinely waiving deductibles or co-payments without a legitimate financial hardship or failure to collect after reasonable effort, to entice patients or induce the use of services. Examples include advertising 'no out-of-pocket costs' without proper context.

Submitting multiple claims for the same service to the same or different insurers, with the intention to be paid multiple times. Examples include filing the same claim with primary and secondary insurers.

Theft or misappropriation of funds placed in one's trust or belonging to one's employer. Examples include an employee siphoning funds from a healthcare clinic or a billing clerk pocketing patient payments.