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15 May, 07:32

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

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  1. 15 May, 07:50
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    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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