Claims can be fraudulent when they are?

Claims can be considered fraudulent when they are unsupported by documentation because documentation substantiates the services provided and the need for those services. In the context of healthcare, every claim submitted for reimbursement must have adequate documentation that verifies the type and level of care provided, justifying the charges made.

Without proper documentation, it becomes impossible to determine the legitimacy of the claim. This can lead to misunderstandings regarding the services rendered or, in some cases, attempts to mislead payers by submitting claims that do not accurately reflect the clinical situation or services actually provided. This lack of support can be a clear indicator of potential fraud, as it indicates that the claim might not truthfully reflect provided services.

The other options, while they may raise flags for compliance or billing issues, do not inherently indicate fraud. For instance, using too many modifiers does not constitute fraud if justified by documentation; submitting claims for inpatient services isn't fraudulent as long as the services are legitimate; and sending claims via paper rather than electronically is a method of submission and does not affect the validity of the claims themselves. Thus, the absence of documentation is the critical factor that clearly distinguishes fraudulent claims.