Health Insurance Billing Practice Exam

Medicare abuse refers to practices that may lead to unnecessary costs to the Medicare program while not necessarily involving fraud or intentional wrongdoing. Billing practices that result in Medicare payment when another payer is responsible is a clear example of abuse because it indicates that the provider is not utilizing proper billing protocols.

In this case, it could involve scenarios where a primary insurance should have paid for the services, but the provider improperly billed Medicare instead. Such actions can burden the Medicare system by inappropriately utilizing its funds, diverting them from beneficiaries who truly need coverage under that program. This constitutes abuse as it reflects a mismanagement of billing practices that can lead to higher overall medical costs.

The other options describe activities that are more aligned with fraudulent behavior or unethical coding practices. Submitting false claims and unbundling codes are considered fraud, involving more deliberate actions for financial gain. Charging more than usual and customary rates can indicate overcharging but does not specifically fall under Medicare abuse in the same context as having a secondary payer responsible for costs. Therefore, the definition of Medicare abuse is directly connected to billing practices like those described in option C.