The Centers for Medicare & Medicaid Services define Medicare fraud as knowingly submitting false claims to improperly obtain federal health care payments, as well as knowingly soliciting, receiving, offering, or paying remuneration (eg, kickbacks, bribes, or rebates) to induce or reward referrals for items or services that are eligible for reimbursement by federal health care programs.¹ Medicare abuse is defined as practices that may directly or indirectly result in unnecessary costs to the Medicare program, including providing patients with medically unnecessary services, as well as fraudulent billing practices such as upcoding.¹ These activities are both illegal and unethical, costing the Medicare program, and thus the broader public, billions of dollars annually. To date, attention to these activities has been driven predominantly by the financial losses incurred.

医疗保险和医疗补助服务中心将医疗保险欺诈定义为故意提交虚假索赔以不当获得联邦医疗保健付款，以及故意索取、接受、提供或支付报酬（例如回扣、贿赂或回扣）以诱导或奖励有资格获得联邦医疗保健计划报销的物品或服务的转介。¹ Medicare 滥用被定义为可能直接或间接导致 Medicare 计划不必要成本的做法，包括向患者提供医疗上不必要的服务，以及欺诈性计费做法，例如升级编码。¹这些活动既非法又不道德，每年给医疗保险计划和广大公众造成数十亿美元的损失。迄今为止，对这些活动的关注主要是由于所发生的财务损失。