Medical Auditing Practice Exam

A deliberate misrepresentation of facts to gain unauthorized benefits is referred to as what?

1. Negligence

2. Fraud

3. Abuse

4. Misrepresentation

The correct answer is: Fraud

The term that describes a deliberate misrepresentation of facts to gain unauthorized benefits is fraud. Fraud involves intentional deceit where an individual or entity knowingly provides false information or conceals the truth to benefit unlawfully. In the context of healthcare, this could manifest as a provider billing for services not rendered or falsifying patient records to receive higher reimbursements. Other terms, while related to unethical behavior or misconduct, do not encapsulate this specific definition. Negligence refers to the failure to take proper care in doing something, which results in damage or injury; it implies unintentional harm rather than deliberate deception. Abuse generally involves practices that are improper or excessive but may not necessarily involve deceit. Misrepresentation refers to providing false information but does not always imply the intent to deceive for personal gain in the same clear-cut way that fraud does. Therefore, fraud is the most accurate term for this scenario.