Which of the following actions by a billing and coding specialist would be considered fraud?

• A. Billing for services not provided
• B. Upcoding a service
• C. Billing for a service with incorrect CPT code
• D. Waiving patient coinsurance without authorization

Answer: (A)

Fraud means intentionally deceiving a payer to obtain improper payment. Billing for services that were never provided is the clearest example because it claims payment for care that did not occur, which is a deliberate misrepresentation to the payer.

Other actions involve misreporting or improper handling of payments that may stem from error or questionable practices, but they aren’t as definitively fraudulent as claiming a service existed when it did not. Upcoding can be fraudulent if done on purpose, but it can also result from a coding mistake. Billing with an incorrect CPT code is often an error rather than intentional deception, though it can be fraudulent if done knowingly. Waiving coinsurance without authorization is unethical and violates policies, and can be illegal depending on the circumstances, but it isn’t the definitive example of fraud in the same way as billing for services not provided.