What is the difference between fraud and abuse in medical practice?

Answer 1

As defined by HIPAA...

Fraud is the "intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment." The attempt itself is considered fraud, regardless of whether it is successful.

Abuse "involves actions inconsistent with accepted, sound medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments."

The difference between fraud and abuse is the individual's intent; however, both have the same impact in that they steal valuable resources from the health care industry.

Answer 2

Fraud in medical practice involves intentional deception for personal gain, like billing for services not provided. Abuse, on the other hand, refers to practices that are inconsistent with sound business or medical principles, like overcharging for services rendered. Both are illegal and can result in penalties or sanctions.