Definitions of Waste, Abuse and Fraud

Waste is generally defined as activities involving payment or the attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent but the outcome of poor or inefficient billing or treatment methods causes unnecessary costs to the Medicaid/CHIP program.

Abuse is generally defined as activities that unjustly enrich a person through the receipt of benefit payments but where the intent to deceive is not present; or is an attempt by an individual to obtain a benefit payment he or she does not deserve.

Fraud is an intentional representation that an individual knows to be false or does not believe to be true and makes anyway, knowing that the representation could result in some unauthorized benefit to him/herself or some other person.

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