Abuse describes incidents or practices of providers that are inconsistent with accepted sound medical, business or fiscal practices. These practices may, directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and intentionally misrepresented facts to obtain payment.

Standards used when judging whether abusive acts in billing were committed against the Medicare program are:

• Was the service medically necessary?;
• Do the services conform to professionally recognized standards?, and
• Was an excessive price charged for the service?