Examples of fraud schemes perpetrated by health care institutions and their employees include all of the following EXCEPT:

• A. Unintentional misrepresentation of the diagnosis
• B. Billing for experimental procedures
• C. DRG creep
• D. Improper contractual relationships

Answer: (A)

Fraud in healthcare rests on intent to deceive for financial gain. An unintentional misrepresentation of the diagnosis is simply an error or misdocumentation; without the intent to deceive, it isn’t fraud. In contrast, the other scenarios involve deliberate actions to obtain money through deception: billing for experimental procedures means claiming payment for something not legitimately approved as standard care; DRG creep involves intentionally upcoding to a higher-paying diagnosis-related group; and improper contractual relationships typically entail kickbacks or other illegal arrangements that corrupt referrals and payments. Because those latter actions are purposeful misrepresentations intended to extract funds, they are examples of fraud schemes.