Federal legislation that regulates civil action for filing of a false or inaccurate claim for payment, knowingly using a false record or statement to obtain payment on a false or fraudulent claim paid by the government, and conspiring to defraud the government by getting a false or fraudulent claim allowed or paid. Under this act, any person who knowingly presents or causes to be presented a false or fraudulent claim to the government for payment or approval is liable. This law covers all types of government payments, not just medical insurance claims.

Occur when the patient’s medical record contains evidence of a service that does not exist in the encounter data. This is the most common problem in partially or fully managed care capitated plans because the provider does not need to submit an encounter in order to receive payment for the service and therefore may have a weaker incentive to conform to data collection standards.

Occur when the encounter data contain evidence of a medical service that is not documented in the patient’s medical record. If we assume that the medical record contains complete information on the patient’s medical history, a false positive may be considered a fraudulent service. In a fully managed care capitated environment, however, the provider would receive no additional reimbursement for the submission of a false-positive encounter.