An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (Title 42 CR 455.2; Welfare and Institutions Code 1403.1(i))
Over utilization of services (not caused by criminally negligent actions) and the misuse of resources.
Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (Title 42 CFR 455.2 and as further defined in Welfare and Institutions Code 14043.1(a)).