Submitting bills to Medicare that are the responsibility of other insurers is an example of

• A. An example of abuse
• B. An example of fraud
• C. A clerical error
• D. A permissible billing practice

Answer: (A)

The situation tests how billing practices are categorized in how Medicare is billed relative to other insurers. Submitting bills to Medicare when another insurer should be primary is considered abuse because it reflects an improper billing practice that can lead to improper payments. It often stems from unintended consequences of sloppy processes or gaps in payer determination, rather than a deliberate attempt to defraud. Fraud would require knowing misrepresentation or deception to obtain payment, which isn’t necessarily shown in this scenario. A clerical error would be a simple mistake, but abuse covers patterns of improper practices that aren’t strictly fraud. And this isn’t a permissible billing practice because payer responsibility rules are being ignored.