Medicare fraud and abuse
Medicare fraud costs Medicare billions of dollars every year. It can cost you higher Medicare premiums, deductibles, and co-payments. Losses due to fraud may also prevent Medicare from offering more services and better coverage.
What is Medicare fraud?
Medicare fraud is purposely billing Medicare for services that were never provided or received. For example, your Medicare number can be used to bill Medicare for services and supplies you didn't need or want, services and supplies your doctor did not order, services and supplies you can't even use, and services and supplies you did not receive.
Where do we see Medicare fraud?
- In billing for institutional facilities (Medicare Part A), such as nursing homes, residential facilities, hospitals, and hospices.
- In billing for physician services or visits to physicians (Medicare Part B).
- In billing for Durable Medical Equipment (DME), such as wheelchairs, body jackets, incontinence supplies, etc.
- In improper marketing through telephone, door-to-door sales and flyers (Medicare Part C - Medicare Advantage and Medicare Part D prescription drug benefit).
Medicare fraud is committed when a provider:
- Submits bills for services not provided: Common are “gang visits”, when practitioners visit a nursing home and bill for services for all, or nearly all, residents. The physician may not have provided the service(s) to all residents but bills as if he or she had, Or, the physician may provide service(s) whether every resident needs it or not.
- Upcodes a service: Submitting a bill for surgery when only a bandage was placed over a cut, for example.
- Unbundles services: Submitting separate billing for lab services that include three or four tests combined as one and which are supposed to be billed as one service. This separate billing results in Medicare paying providers more for each service than what would have been paid if they had been billed as a group.
- Solicits, offers, or receives a bribe or a kickback: Often recruiters or what are called “cappers” may stop beneficiaries on the street, or knock on their door and offer money or promotional gifts as incentives to entice them to take a “free” medical exam. Then the patient is presented with a list for durable medical equipment (DME), or prescribed DME that they do not need.
- Bills “non-covered” services as covered services: For example, billing routine toenail clipping (non-covered service) as foot surgery (covered service).
- Does not follow Medicare Marketing rules: Offering a Part D prescription plan at no cost to the beneficiary (when a Part D plan does, in fact, charge a premium).
What you can do to help stop Medicare fraud
- Examine the Explanation of Medicare Benefits or Medicare Summary Notice you get from Medicare when claims are paid for your care. Ask yourself:
- Did I get the latest services listed?
- Did my doctor order these services?
- Are the dates of the services correct?
- Are the dollar amounts shown the same as those on my bill?
- Protect your Medicare card number, as well as your Social Security number. Don't give these numbers to anyone over the phone or in person, unless you initiated the contact and you know to whom you are talking.
- Don't leave your Medicare number on a phone message.
- Don't accept any offer of "free" services or supplies in return for your Medicare number.
- Don’t let anyone convince you to see a doctor for a service that you do not need.
- Don’t accept offers of money, free food or gifts for medical care.
- Ask questions! You have a RIGHT to know about your medical care!
- Never accept medical supplies from door-to-door salespeople.
- Don’t be influenced by media advertisements concerning your health. They raise money for someone and don’t have your best interests at heart.
- Avoid the “it’s free” and “we know how to bill Medicare” scam. As stated earlier, protect your Medicare card number.
- Educate yourself about Medicare. Know your rights and know what a provider can and can’t do for your medical care.
Report suspected fraud or abuse
If you think Medicare should not have paid for something listed on your Medicare Summary Notice (MSN), or you suspect Medicare fraud or abuse, follow these steps.
- Call the health care provider listed on the Medicare Summary Notice (MSN) and inquire about the item you're questioning. In many cases, there's been a billing error, which your health care provider can easily correct.
- Have your MSN in front of you when you call so you can provide as much information as possible about the item you're questioning.
- If your question is not resolved and you still think the charges are fraudulent, then contact a Senior Medicare Patrol (SMP) counselor in your local HICAP office (1-800-434-0222). The counselor will get the pertinent facts from you and begin the process of reviewing your concern. If appropriate, your counselor can help you forward your case to the proper fraud investigation agency.
After meeting with your local SMP counselor, you might need to call the U.S. Department of Health and Human Services, Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477). Your SMP counselor will help you determine whether this step is necessary.
Learn more
If your group or organization would like a free presentation about Medicare fraud and how to prevent it, call a Senior Medicare Patrol (SMP) counselor in your local HICAP office at (1-800-434-0222).
California's SMP project is funded through the Administration on Aging.
Page updated April 9, 2008