Healthcare Fraud and Abuse
Expert-defined terms from the Certificate in Healthcare Compliance course at London School of Planning and Management. Free to read, free to share, paired with a professional course.
A #
A
ABN (Advance Beneficiary Notice) – A written notice given to Medicare ben… #
Related terms: Medicare, beneficiary responsibility. The ABN informs the patient that they may be billed directly if the claim is denied, helping to avoid surprise billing and ensuring transparency.
ACA (Affordable Care Act) – Federal legislation enacted in 2010 to expand… #
Related terms: Marketplace, individual mandate. The ACA includes provisions that affect fraud and abuse monitoring, such as enhanced data sharing among agencies.
ACO (Accountable Care Organization) – A group of health care providers wh… #
Related terms: shared savings, risk adjustment. ACOs are subject to compliance oversight to prevent fraudulent billing for services not rendered.
ACS (American Cancer Society) – Not a fraud term but often appears in bil… #
Related terms: diagnostic coding. Misuse of ACS codes can lead to fraudulent claims for unnecessary tests.
Adverse Claim – A claim that is denied, returned, or flagged for potentia… #
Related terms: audit, reversal. Identifying adverse claims is a key step in fraud detection.
Affidavit of Truthfulness – A sworn statement by a provider affirming tha… #
Related terms: attestation. Used in investigations to establish intent.
Agency for Healthcare Research and Quality (AHRQ) – Federal agency that p… #
Related terms: HCUP. AHRQ data can be leveraged to spot outlier billing patterns.
Algorithmic Screening – Use of computer‑based rules to flag suspicious cl… #
Related terms: predictive analytics. Algorithms examine variables such as frequency, dollar amount, and provider specialty.
Anti‑Kickback Statute (AKS) – Criminal law prohibiting the exchange of re… #
Related terms: safe harbor, FCPA. Violations can result in fines, imprisonment, and exclusion from federal programs.
Appeal – The process of requesting reconsideration of a denied claim #
Related terms: CMS 2008, reversal. Improper or repeated appeals may indicate fraudulent activity.
Audit Trail – A chronological record of who accessed or modified claim da… #
Related terms: log file, integrity. Maintaining a robust audit trail helps prove compliance and detect tampering.
Billing Cycle – The regular interval (monthly, quarterly) during which pr… #
Related terms: submission deadline. Shortened cycles can be used to conceal fraudulent activity.
Billing Error – An unintentional mistake in coding, pricing, or documenta… #
Related terms: unbundling, upcoding. Distinguishing errors from intentional fraud is a critical compliance task.
Billing Provider – The entity (individual or organization) that submits c… #
Related terms: NPI, assignor. The billing provider is legally responsible for the accuracy of submitted claims.
Bundling – The practice of grouping multiple services into a single payme… #
Related terms: global fee. Improper bundling may hide separate billable services, constituting fraud.
CAP (Corrective Action Plan) – A documented strategy to remediate identif… #
Related terms: FCPA, OIG. CAPs often include training, monitoring, and reporting enhancements.
CMS (Centers for Medicare & Medicaid Services) – Federal agency that admi… #
Related terms: HCFA, MAC. CMS issues regulations and guidance on fraud prevention.
COBRA (Consolidated Omnibus Budget Reconciliation Act) – Provides continu… #
Related terms: beneficiary notice. Fraud may involve falsifying qualifying events to claim continuation benefits.
COI (Conflict of Interest) – A situation where personal interests could c… #
Related terms: disclosure. Undisclosed COIs can lead to kickbacks or biased referrals.
COQ (Cost of Quality) – The total cost of ensuring and failing to ensure… #
Related terms: risk management.
CPR (Clinical Practice Review) – Evaluation of clinical documentation for… #
Related terms: utilization review. CPR findings can uncover over‑utilization fraud.
CRNA (Certified Registered Nurse Anesthetist) – Advanced practice nurse p… #
Related terms: scope of practice. Incorrect billing for CRNA services can be fraudulent if services are not actually rendered.
CMS #
1500 – Standard claim form for non‑institutional providers. Related terms: UB‑04. Errors or intentional manipulation on the CMS‑1500 can lead to fraud investigations.
Data Mining – Extraction of patterns from large datasets to identify anom… #
Related terms: machine learning. Used by insurers to detect fraudulent claim clusters.
Denial Management – Process of handling denied claims, including appeals… #
Related terms: reversal. Persistent denial patterns may signal fraudulent activity.
Disallowed Charge – A claim line that a payer will not reimburse #
Related terms: non‑covered service. Providers may attempt to re‑bill disallowed charges, constituting fraud.
Duplicate Claim – Submission of the same claim more than once #
Related terms: reimbursement error. Intentional duplicates are fraudulent; accidental duplicates are billing errors.
EBM (Evidence‑Based Medicine) – Clinical decision‑making based on current… #
Related terms: clinical guidelines. Billing for services not supported by EBM may be fraudulent.
Electronic Health Record (EHR) – Digital version of a patient’s chart #
Related terms: HIPAA. EHR data can be audited to verify services billed.
Electronic Data Interchange (EDI) – Standardized electronic transmission… #
Related terms: ANSI X12. Improper EDI formatting can be exploited for fraudulent submissions.
Emergency Medical Treatment and Labor Act (EMTALA) – Requires emergency d… #
Related terms: patient dump. Billing for non‑emergency services after EMTALA stabilization can be fraudulent.
Enforcement Action – Legal steps taken by regulators to address non‑compl… #
Related terms: civil monetary penalty. Actions may include fines, exclusion, or criminal prosecution.
Exclusion – Bar from participating in federal health programs #
Related terms: OIG List. Providers found guilty of fraud may be excluded, ending their ability to bill Medicare/Medicaid.
FCPA (Foreign Corrupt Practices Act) – U #
S. Law prohibiting bribery of foreign officials. Related terms: anti‑bribery. International health organizations must ensure compliance to avoid fraud allegations.
Fee‑for‑Service – Payment model where each service is billed separately #
Related terms: volume incentive. This model can encourage upcoding and unnecessary services.
FQHC (Federally Qualified Health Center) – Community‑based health care pr… #
Related terms: sliding fee scale. Fraud may involve inflating patient counts to receive higher reimbursements.
Fraud Triangle – Framework describing three elements that lead to fraud #
Pressure, opportunity, rationalization. Related terms: risk assessment. Understanding the triangle helps design effective controls.
Fraudulent Claim – A claim that includes false information, misrepresenta… #
Related terms: intent. Examples include billing for services not provided or using false diagnoses.
FWA (Fraud, Waste, and Abuse) – Collective term for improper activities t… #
Related terms: program integrity. Programs target FWA through detection, prevention, and enforcement.
G #
G
GPCI (Geographic Practice Cost Index) – Adjustment factor applied to Medi… #
Related terms: RVU. Manipulating GPCI data can affect reimbursement amounts.
HCFA (Health Care Financing Administration) – Former name of CMS #
Related terms: CMS. Historical documents may still reference HCFA.
HCPCS (Healthcare Common Procedure Coding System) – Set of codes for bill… #
Related terms: CPT, HCPCS Level II. Incorrect HCPCS coding is a frequent fraud mechanism.
HIPAA (Health Insurance Portability and Accountability Act) – Federal law… #
Related terms: PHI, security rule. HIPAA violations can accompany fraudulent billing when data is misused.
HMO (Health Maintenance Organization) – Managed care plan that provides h… #
Related terms: capitation. HMOs may be subject to fraud investigations for inflated enrollment numbers.
ICD (International Classification of Diseases) – Diagnostic coding system… #
Related terms: ICD‑10‑CM. Upcoding involves selecting a higher‑severity ICD code to increase reimbursement.
IDN (Integrated Delivery Network) – A system of health care providers and… #
Related terms: vertical integration. IDNs must monitor internal billing to prevent systemic fraud.
Impairment Billing – Submitting claims for services rendered to a patient… #
Related terms: disability. Fraud occurs when impairment is fabricated or exaggerated.
Indemnity Plan – Insurance plan that reimburses a set portion of charges #
Related terms: fee‑schedule. Providers may inflate charges to increase indemnity reimbursements.
Inflated Charge – Billing for a service at a rate higher than the allowab… #
Related terms: upcoding. Inflated charges are a classic form of fraud.
Inpatient Prospective Payment System (IPPS) – Medicare payment method for… #
Related terms: DRG. Manipulating clinical documentation to achieve a higher‑paid DRG is fraudulent.
Inpatient Rehabilitation Facility (IRF) – Facility that provides intensiv… #
Related terms: IRF‑PPS. Billing for IRF services without meeting intensity criteria is fraudulent.
Internal Controls – Policies and procedures designed to safeguard assets… #
Related terms: segregation of duties. Weak internal controls increase fraud risk.
J #
J
J‑Code – HCPCS Level II code used for drugs administered by a health care… #
Related terms: medication billing. Using a J‑code for a drug not administered is fraudulent.
Kickback – Payment or remuneration given in return for referrals or servi… #
Related terms: AKS, safe harbor. Kickbacks are illegal under federal statutes.
Koch v #
United States – Landmark case clarifying the definition of “kickback.” Related terms: legal precedent. The decision helps interpret anti‑kickback regulations.
L #
L
Lawsuit Settlement – Financial resolution of a legal claim without admiss… #
Settlements may include compliance remediation.
Liability Insurance – Coverage for legal claims arising from professional… #
Related terms: errors and omissions. Insurers may investigate alleged fraud before providing coverage.
Limitation of Liability – Contractual clause capping damages #
Related terms: indemnity. Does not protect against criminal fraud penalties.
Medicaid – Joint federal‑state program providing health coverage to low‑i… #
Related terms: State Medicaid Agency, MMIS. Medicaid fraud often involves false enrollment or billing for non‑covered services.
Medicare – Federal health program for individuals 65+, certain younger pe… #
Related terms: Part A, Part B, Part C, Part D. Medicare fraud is a major focus of OIG investigations.
Medicare Advantage (Part C) – Private‑managed plan offering Medicare bene… #
Related terms: risk adjustment. Fraud may involve inflating risk scores to receive higher payments.
Medical Necessity – Requirement that services be appropriate for diagnosi… #
Billing for services lacking medical necessity is fraudulent.
Medicare Secondary Payer (MSP) – Situation where Medicare pays after anot… #
Related terms: primary payer. Failure to coordinate MSP can lead to overpayment fraud.
MedPAC (Medicare Payment Advisory Commission) – Independent agency advisi… #
Related terms: payment policy. Recommendations influence fraud‑prevention incentives.
Misrepresentation – Providing false information to obtain payment #
Related terms: material fact. Intentional misrepresentation is a core element of fraud.
Mitigation Strategy – Plan to reduce identified fraud risks #
Includes training, monitoring, and corrective actions.
MRA (Medical Review Audit) – Detailed examination of clinical documentati… #
Related terms: clinical validation. MRAs uncover both errors and intentional fraud.
MS #
DRG (Medicare Severity‑DRG) – Refined DRG system incorporating severity of illness. Related terms: case‑mix. Upcoding to a higher MS‑DRG is a fraudulent practice.
N #
N
National Provider Identifier (NPI) – Unique 10‑digit identifier for healt… #
Related terms: enrollment. Using a false NPI on claims is fraudulent.
National Practitioner Data Bank (NPDB) – Repository of information on hea… #
Related terms: disciplinary actions. Fraud convictions are reported to NPDB.
National Health Care Anti‑Fraud Association (NHCAA) – Professional organi… #
Related terms: industry standards. Provides best‑practice guidance.
Non‑covered Service – Service not reimbursable under a specific payer’s p… #
Related terms: benefit limitation. Billing for non‑covered services can be fraudulent if claimed as covered.
Obligation to Report – Legal duty to inform authorities of known fraud #
Related terms: whistleblower. Failure to report can result in liability.
OIG (Office of Inspector General) – Agency within HHS that conducts audit… #
OIG issues advisory opinions on compliance matters.
On‑Site Review – Physical inspection of a provider’s records and operatio… #
Related terms: audit. Used to verify the authenticity of billed services.
Open‑Claims Database – Publicly accessible repository of settled health c… #
Related terms: case law. Useful for compliance training.
Outlier Payment – Additional reimbursement for unusually costly cases #
Related terms: cost‑based. Manipulating data to create artificial outliers is fraudulent.
Overbilling – Charging for more services or higher rates than provided #
Related terms: inflated charge. Overbilling is a primary fraud mechanism.
Overutilization – Providing services in excess of what is medically neces… #
Related terms: unnecessary procedures. Overutilization can be driven by fee‑for‑service incentives.
P #
P
Patient Protection and Affordable Care Act (PPACA) – Formal name for the… #
Related terms: exchange. Includes provisions for fraud prevention financing.
Peer Review – Evaluation of clinical performance by colleagues #
Related terms: utilization management. Peer review can identify patterns of suspicious billing.
Per‑Diem Rate – Fixed daily payment for services such as skilled nursing #
Billing per‑diem for days not actually serviced is fraudulent.
Phantom Provider – Non‑existent entity used to submit claims #
Related terms: shell company. Phantom providers generate false claims for illicit gain.
Phantom Billing – Submitting claims for services never rendered #
Related terms: ghost patient. A classic fraud example.
Physician Self‑Referral (Stark Law) – Prohibits physicians from referring… #
Related terms: safe harbor. Violations can lead to civil penalties.
Plan Sponsor – Entity that establishes and funds a health plan #
Related terms: ERISA. Sponsors must ensure compliance to avoid plan‑level fraud exposure.
Point‑of‑Service (POS) Billing – Billing at the time services are rendere… #
Related terms: real‑time claim. POS systems can incorporate validation checks to reduce fraud.
Pre‑Authorization – Prior approval required for certain services #
Bypassing pre‑authorization and billing anyway may be fraudulent.
Pre‑Existing Condition – Health condition that existed before coverage st… #
Related terms: exclusion. Misrepresenting a condition’s onset can affect eligibility and payment.
Prevention Program – Proactive initiatives to stop fraud before it occurs #
Related terms: education, monitoring. Includes staff training, policy development, and risk assessments.
Primary Care Provider (PCP) – Health professional who delivers first‑line… #
Related terms: medical home. PCPs may be targeted for kickback schemes.
Prior Authorization Denial – Refusal to approve a service before it is pe… #
Related terms: appeal. Billing after denial without justification can be fraudulent.
Prioritization Matrix – Tool for ranking fraud risks based on impact and… #
Helps allocate monitoring resources.
Prohibited Transaction – Any action that violates federal health‑care fra… #
Related terms: AKS, Stark Law. Includes kickbacks, false claims, and illegal referrals.
Provider Enrollment – Process of registering with Medicare/Medicaid to su… #
Related terms: NPI. Fraudulent enrollment (e.G., Using false addresses) leads to false claims.
Provider Number – Identifier assigned by a payer (e #
G., Medicare provider number). Related terms: tax identification number. Misuse of another provider’s number is fraudulent.
Public Law 101‑508 – The Medicare Fraud and Abuse Control Program statute #
Related terms: FFS. Established OIG’s authority to combat fraud.
Q #
Q
Qualifying Event – Circumstance that triggers eligibility for certain ben… #
G., COBRA). Related terms: coverage continuation. Falsifying qualifying events is a fraud method.
Quality Assurance (QA) – Systematic monitoring of performance to ensure s… #
Related terms: continuous improvement. QA data can also reveal anomalies indicative of fraud.
R #
R
RAC (Recovery Audit Contractor) – Contractor hired by CMS to identify and… #
Related terms: overpayment. RAC findings often lead to recoupments.
RBRVS (Resource‑Based Relative Value Scale) – System assigning relative v… #
Manipulating RBRVS codes (upcoding) creates higher payments.
Recoupment – Recovery of overpaid amounts by the payer #
Failure to repay recoupments can result in additional penalties.
Referral – Directing a patient to another provider for services #
Related terms: kickback. Illegal referrals in exchange for remuneration constitute fraud.
Reimbursement – Payment made to providers for services rendered #
Related terms: allowed amount. Claiming reimbursement for unprovided services is fraudulent.
Reportable Event – Incident that must be reported to regulators (e #
G., Fraud, abuse). Related terms: OIG Hotline. Timely reporting is a compliance requirement.
Risk Adjustment – Process of modifying payments based on patient health s… #
Related terms: CMS‑RAC. Inflating risk scores to receive higher payments is fraudulent.
Risk Assessment – Systematic evaluation of potential fraud exposures #
Related terms: risk matrix. Guides the design of monitoring controls.
Rural Health Clinic (RHC) – Facility in underserved areas receiving speci… #
Related terms: RHC PPS. Fraud can involve billing for services not delivered in RHCs.
S #
S
Safe Harbor – Statutory provision that protects certain arrangements from… #
Related terms: AKS. Properly structured contracts can utilize safe harbors.
Scope of Practice – Legal boundaries of services a provider may deliver #
Related terms: licensure. Billing for services outside scope is fraudulent.
Self‑Referral – Provider refers a patient to a service in which they have… #
Related terms: Stark Law. Illegal self‑referral leads to false claims.
Servicing Entity – Organization that processes claims on behalf of a prov… #
Related terms: billing service. Misuse of a servicing entity to hide fraudulent activity is a risk.
Shell Company – Entity created to conceal ownership and facilitate fraud #
Related terms: phantom provider. Used to submit false claims without traceable accountability.
Short‑Term Disability (STD) – Benefit providing income during temporary d… #
Related terms: FMLA. Fraud includes falsifying disability status to obtain payments.
Skilled Nursing Facility (SNF) – Facility providing 24‑hour nursing care #
Related terms: Per‑Diem. Billing for SNF days not actually provided is fraudulent.
SNA (Special Needs Account) – Not a standard term; sometimes used in Medi… #
Related terms: MMIS. Misallocation can be a fraud risk.
Statute of Limitations – Time period within which legal action must be co… #
Related terms: civil action. Fraud may be barred if discovered after the limit expires.
Stark Law – Federal prohibition on physician self‑referral for certain de… #
Violations result in civil penalties and potential exclusion.
State Medicaid Agency (SMA) – State entity administering Medicaid #
SMAs conduct their own fraud investigations.
Statewide Data Warehouse – Central repository of health‑care utilization… #
Related terms: analytics. Enables cross‑payer fraud detection.
Statistical Sampling – Technique for selecting a subset of claims for det… #
Increases efficiency while identifying fraud patterns.
Subrogation – Right of a payer to recover costs from a third party respon… #
Related terms: reimbursement. Failure to subrogate can lead to overpayment.
Supplemental Insurance – Additional coverage that pays after primary insu… #
Related terms: secondary payer. Fraud may involve double‑billing both primary and supplemental insurers.
T #
T
Telehealth – Delivery of health services via electronic communication #
Related terms: remote consult. Fraud includes billing for telehealth when in‑person services were provided.
Therapeutic Misuse – Prescribing or billing for treatments not medically… #
Related terms: off‑label. Can constitute fraud if billed to insurers.
Third‑Party Administrator (TPA) – Entity that processes claims on behalf… #
Related terms: claims processing. TPAs must ensure claims integrity to avoid becoming conduits for fraud.
Tip‑off – Information provided to regulators about suspected fraud #
Tip‑offs can trigger investigations.
Trafficking in Stolen Health Information – Illegal sale or distribution o… #
Related terms: HIPAA breach. Enables identity theft and fraudulent billing.
True‑Up – Adjustment made after the fact to reconcile projected versus ac… #
Related terms: reconciliation. Manipulating true‑up calculations can hide fraud.
U #
U
UCR (Usual, Customary, and Reasonable) – Standard for determining allowab… #
Related terms: charge master. Overcharging beyond UCR may be fraudulent.
UCC (Uniform Commercial Code) – Governs commercial transactions #
Related terms: contract law. May be cited in fraud settlements involving equipment purchases.
Unbundling – Billing separately for services that should be combined unde… #
Unbundling inflates reimbursement and is a fraud violation.
Upcoding – Submitting a claim with a code that reflects a higher level of… #
Upcoding is a common fraudulent practice.
Utilization Review (UR) – Assessment of the appropriateness of health‑car… #
Related terms: medical necessity. UR findings can uncover overutilization fraud.
V #
V
Value‑Based Purchasing (VBP) – Payment model linking reimbursement to qua… #
Related terms: pay‑for‑performance. Manipulating quality data to receive higher VBP payments is fraudulent.
Verification Process – Steps taken to confirm the authenticity of claims… #
Related terms: credentialing. Robust verification reduces fraud risk.
W #
W
Whistleblower – Individual who reports suspected fraud to authorities #
Related terms: qui tam. Whistleblowers may receive a portion of recovered funds under the FCA.
Qui Tam – Legal action allowing private parties to sue on behalf of the g… #
Related terms: False Claims Act. Successful qui tam actions can result in substantial penalties.
False Claims Act (FCA) – Federal law imposing liability for knowingly sub… #
The FCA is a primary tool for prosecuting health‑care fraud.
Fraudulent Inducement – Offering false promises to obtain a contract or e… #
Related terms: misrepresentation. Can be grounds for rescission and damages.
Fraudulent Enrollment – Registering a non‑existent patient or provider to… #
Related terms: phantom billing. Often discovered through data analytics.
Fraud Hotline – Dedicated channel for reporting suspected fraud #
Related terms: OIG. Organizations are encouraged to maintain an accessible hotline.
Front‑Running – Submitting claims for services before verification is com… #
Related terms: premature billing. Increases risk of false claims.
G #
G
Gross Negligence – Severe lack of care that may rise to the level of frau… #
Related terms: recklessness. Courts may treat gross negligence as intentional.
H #
H
HCFA Form 1500 – Earlier version of the CMS‑1500 claim form #
Related terms: paper claim. Still used in some legacy systems.
Hospital Acquired Condition (HAC) – Condition that develops during a hosp… #
Related terms: quality metric. Billing for HAC‑related services when none exist can be fraudulent.
Hospital Compare – CMS website displaying hospital performance data #
Related terms: public reporting. Data can be used to detect outlier billing patterns.
Hospital Outpatient Prospective Payment System (OPPS) – Medicare payment… #
Related terms: HCPCS. Upcoding OPPS services is a fraud risk.
I #
I
Identity Theft – Unauthorized use of another’s personal information #
Related terms: PHI. Enables fraudulent enrollment and billing.
Impersonation Fraud – Pretending to be a provider or patient to submit cl… #
Related terms: credential theft. Often uncovered through verification failures.
Inducement – Something offered to persuade a party to act, potentially il… #
Illicit inducements violate AKS.
Inpatient Hospital Services – Services provided during an admitted stay #
Billing for inpatient services without admission is fraudulent.
Insurance Fraud – Deception to obtain unauthorized benefits #
Related terms: FCA. Health‑care fraud is a subset focusing on medical claims.
Internal Audit – Independent review within an organization to assess comp… #
Findings often trigger corrective actions.
International Classification of Diseases, Tenth Revision, Clinical Modificati… #
S. Adaptation of ICD for diagnosis coding. Related terms: ICD. Accurate coding is essential to avoid false claims.
JCAHO (Joint Commission) – Accrediting body for health‑care organizations #
Related terms: accreditation. Accreditation findings may reveal compliance gaps.
K #
K
Kickback Safe Harbor – Specific statutory criteria that, if met, shield a… #
Must involve fair market value and not be tied to volume.
L #
L
Legal Settlement – Agreement to resolve a dispute without admission of wr… #
May include compliance requirements.
Legitimate Claim – Claim that accurately reflects services rendered and c… #
Serves as a benchmark for identifying false claims.
Liability Exposure – Potential for legal responsibility due to non‑compli… #
Reducing exposure involves strengthening controls.
Loss Prevention – Strategies to prevent financial loss, including fraud #
In health care, loss prevention overlaps with compliance.
M #
M
Medicare Fraud Prevention Law (MFPL) – Legislation enhancing penalties fo… #
Encourages stricter enforcement.
Medical Billing Fraud – Deliberate deception in the billing process to ob… #
Related terms: false claims. Encompasses upcoding, unbundling, phantom billing, and more.
Medical Record Review (MRR) – Examination of documentation to verify serv… #
Related terms: clinical audit. Essential for substantiating claims.
Medicare Advantage Risk Adjustment Data Validation (RADV) – Audit of risk… #
Inaccurate data can trigger fraud penalties.
Misuse of Codes – Applying incorrect CPT/HCPCS/ICD codes #
Can be intentional (fraud) or accidental (error).
Monetary Penalty – Financial sanction imposed for violations #
Penalties may be per claim or per incident.
Motor Vehicle Accident (MVA) Fraud – Submitting false injury claims after… #
Related terms: workers’ comp. Often involves fabricated medical records.
N #
N
National Health Care Anti‑Fraud Association (NHCAA) Guidelines – Best‑pra… #
Used to benchmark compliance programs.
Non‑Compliance – Failure to adhere to laws, regulations, or internal poli… #
Related terms: risk. May lead to investigations and penalties.
Non‑Provider – Entity that does not meet provider definition but may subm… #
Non‑Provider – Entity that does not meet provider definition but may submit claims illicitly.