New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 521 - Fraud, Waste and Abuse Prevention
Subpart 521-2 - MEDICAID MANAGED CARE FRAUD, WASTE AND ABUSE PREVENTION
Section 521-2.2 - Definitions

(1) "Abuse" means practices that are inconsistent with sound fiscal, business, medical or professional practices, and which result in unnecessary costs to the Medicaid program, payments for services that were not medically necessary, or payments for services which fail to meet recognized standards for health care. It also includes enrollee practices that result in unnecessary costs to the Medicaid program.

(2) "Fraud" means an intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to the provider, Contractor, Subcontractor, or another person and includes the acts prohibited by section 366-b of the Social Services Law. It also includes any other act that constitutes fraud under applicable Federal or State law.