What is the false misrepresentation of fact that is relied on by another to that person’s detriment and a departure from reasonable use?

Fraud and Abuse

Explanation:

Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment and Abuse means actions that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary.

Examples of Fraud

submitting claims for services not provided or used

falsifying claims or medical records

misrepresenting dates, frequency, duration or description of services rendered

billing for services at a higher level than provided or necessary

falsifying eligibility

failing to disclose coverage under other health insurance

Examples of Abuse

a pattern of waiving cost-shares or deductibles

failure to maintain adequate medical or financial records

a pattern of claims for services not medically necessary

refusal to furnish or allow access to medical records

improper billing practices

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