What is the main distinction between fraud and abuse?

The main distinction between fraud and abuse lies in the intent of the overbilling. Fraud involves intentional deception or misrepresentation made by a healthcare provider or entity for the purpose of obtaining unauthorized benefits or payment from a healthcare program. This means that fraud is characterized by the deliberate intent to deceive, with an understanding that the action is wrong and unlawful.

On the other hand, abuse may occur without any intent to deceive and often involves practices that are inconsistent with sound fiscal, business, or medical practices, which can lead to unnecessary costs or services. Abuse might result from misunderstandings, lack of knowledge, or misinterpretation of rules and guidelines, rather than an intention to commit fraud.

In essence, it is the intent behind the action that separates these two concepts, making the focus on intent crucial for understanding the legal implications surrounding billing in healthcare.