Which of the following is an example of fraud by health care providers?

• A. Patients forging prescriptions to obtain medications.
• B. Employees fabricate claims, submit false application data, or change a provider's address to intercept provider payments.
• C. Organizations deliberately submit or receive undue monetary profit from health care benefit programs by submitting incorrect claims.
• D. Providers bill incorrectly; make false claims about qualifications; alter information on health care plans, prescriptions, and other medical documentation; prescribe unnecessary treatments; use unlicensed personnel; or falsify the diagnosis or procedure to maximize payments.

Answer: (D)

Provider fraud involves deliberate, illicit actions by clinicians, hospitals, or other health care professionals to obtain improper payment. The described behavior covers a wide range of deceitful acts that a provider might commit to maximize reimbursement: billing for services not performed, altering records or diagnoses, prescribing unnecessary treatments, using unlicensed personnel, and falsifying documentation to justify higher payments. These are classic examples of fraud at the provider level because they stem from the actions and intent of the provider to illicitly increase payments from health care programs.

The other scenarios fall outside provider fraud: patients forging prescriptions represent patient-level fraud; employees fabricating claims or intercepting payments describe fraud by staff or intermediaries; and organizations submitting false claims for profit describe organizational or entity-level fraud. Thus the provider-focused deception in the described actions makes it the best fit for provider fraud.