Which scenario qualifies as a false claim?

The scenario in which billing for a service that was never provided qualifies as a false claim is rooted in the fundamental principles of healthcare compliance and ethics. A false claim involves knowingly presenting or causing to be presented to an insurer or governmental health program a claim for payment that is fraudulent or misleading in nature.

In this context, billing for services that were not rendered misrepresents the services provided to the patient, resulting in financial gain through deception. Legally, this practice is a violation of the False Claims Act and can lead to severe penalties, including fines and even criminal charges against the responsible parties.

The other scenarios may involve ethical or compliance issues, but they do not represent false claims in the same clear-cut way. For example, claiming for a service provided with the correct diagnosis and submitting claims for authorized services are legitimate actions, as they accurately reflect the care provided. Providing treatment unrelated to a patient’s diagnosis could raise questions about medical necessity or appropriateness, yet it does not automatically constitute a false claim unless there is an intention to mislead on the claim submission itself.