Definition and Examples of Fraud

20.3.1 - Definition and Examples of Fraud (Rev. 1, 09-11-02) Fraud is defined as making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person's own benefit or for the benefit of some other party. In order to prove that fraud has been committed against the Government, it is necessary to prove that fraudulent acts were performed knowingly, willfully, and intentionally. Examples of fraud include, but are not limited to, the following: • Billing for services that were not furnished and/or supplies not provided. This includes billing Medicare for appointments that the patient failed to keep; • Altering claims forms and/or receipts in order to receive a higher payment amount; • Duplicating billings that includes billing both the Medicare program and the beneficiary, Medicaid, or some other insurer in an effort to receive payment greater than allowed; • Offering, paying, soliciting, or receiving bribes, kickbacks, or rebates, directly or indirectly, in cash or in kind, in order to induce referrals of patients or the purchase of goods or services that may be paid for by the Medicare program; • Falsely representing the nature of the services furnished. This encompasses describing a noncovered service in a misleading way that makes it appear as if a covered service was actually furnished; • Billing a person who has Medicare coverage for services provided to another person not eligible for Medicare coverage; and • Using another person's Medicare card to obtain medical care.