What defines a fraudulent healthcare claim?

A fraudulent healthcare claim is defined primarily by claiming for services that were not actually rendered. This means submitting a claim for treatment, tests, or procedures that were never performed or provided to the patient. This kind of fraudulent activity can result in financial losses to healthcare payers, including insurance companies and government programs, and can lead to significant legal penalties for the provider involved. Such claims violate principles of honesty and integrity within the healthcare system and undermine trust between patients and providers.

In contrast, accurately representing services, underreporting service costs, or filing claims for services that are covered by insurance does not constitute fraud. Accurately representing services is a fundamental expectation; underreporting could be deceptive but is distinct from outright fraud if the services were indeed rendered; and filing claims for covered services is a standard practice in healthcare billing.