Which of the following is NOT a typical fraud scheme by health care institutions and their employees?

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

Answer: (B)

Understanding fraud in health care hinges on intentional deception for financial gain. An unintentional misrepresentation of the diagnosis isn’t fraudulent by itself because there’s no deliberate attempt to deceive for money. It would be a mistake or error in coding or documentation, something auditors would correct rather than prosecute as fraud.

The other scenarios describe deliberate schemes. Improper contractual relationships often involve kickbacks or incentives tied to referrals, which corrupt decision-making and are classic fraud tactics. Billing for experimental procedures involves charging for procedures that aren’t medically justified or performed as claimed, aiming to extract payment under false pretenses. DRG creep refers to coding practices that push a case into a higher-paying diagnosis-related group, typically through upcoding or selective documentation, to inflate reimbursement. These require intent to mislead and are recognized as fraudulent activities.

So the unintentional misrepresentation is the one that does not fit as a typical fraud scheme.