Medicare fraud can happen when a healthcare provider knowingly bills for services they did not provide or files claims incorrectly to receive a larger reimbursement.
Medicare abuse puts a strain on the Medicare program. Healthcare providers may recommend medically unnecessary services to get additional reimbursement.
You can spot Medicare fraud by carefully reviewing your Medicare Summary Notice and checking for any discrepancies.
Medicare fraud and abuse is a criminal offense. Report fraud by contacting Medicare or the Office of Inspector General.
Medicare fraud happens when someone deceives Medicare to receive undue payment. Healthcare providers who bill for services they did not provide are committing fraud. Providers who bill for more-expensive services than what they actually provided are also committing Medicare fraud.
What are examples of Medicare fraud?
Falsifying Medicare claims in any way is a criminal offense. Medicare fraud examples include:
- Billing Medicare for services that were never provided to the Medicare beneficiary
- Billing Medicare for more-expensive services than the services delivered
- Billing Medicare for rented equipment even after it’s been returned
- Billing Medicare for supplies that weren’t given to the beneficiary
- Telling Medicare beneficiaries that Medicare will cover a service that Medicare does not cover. This can potentially leave the beneficiary with a huge healthcare bill
- Billing Medicare for missed or canceled appointments
- Offering kickbacks or gifts for patient referrals
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Medicare abuse occurs when a healthcare provider orders medically unnecessary tests or services to get larger payments. These extra services increase the number of claims submitted to Medicare and put a strain on the Medicare system.
Medicare abuse examples include:
- Overcharging Medicare beneficiaries for services.
- Scheduling services that are not medically necessary.
- Performing an inexpensive service, but billing Medicare for a more expensive service.
What is Medicare fraud waste and abuse ?
Medicare waste is another type of Medicare fraud. This can include prescribing multiple medications for one condition, ordering unnecessary tests and scheduling unnecessary doctor’s appointments. While the healthcare provider gets additional reimbursement, resources go to waste.
A big step in keeping your information safe is knowing how to answer the question, “What is Medicare fraud and abuse ?” Now that you know, it’s time to learn how to spot them when they happen to you. One of the best ways to recognize Medicare fraud is to carefully review your Medicare Summary Notice (MSN). This document details all the claims and charges on your Original Medicare account. You’ll get your MSN in the mail every three months, and it helps you track what services you’ve received.
To spot fraud, carefully check your Medicare Summary Notice. Look for:
- Any claims for services you did not receive
- Ongoing charges for durable medical equipment you’ve returned
- Any charges that you don’t recognize
- Appointments you didn’t schedule
You can also compare appointment dates and services to make sure the claim matches the service you received. If you have a Medicare Advantage plan, you can check your billing statements every month.
When you notice one service or appointment that’s isn’t accurate, it may be an accident or error. Call your plan provider to report the error. But if you notice several inaccuracies or ongoing errors, you may have just spotted Medicare fraud or abuse.
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Are you wondering how to report Medicare fraud? You can report Medicare fraud or suspected fraud in several ways:
- Contact Medicare at 1-800-MEDICARE (TTY 1-877-486-2048)
- Contact the Department of Health and Human Services (HHS) Office of Inspector General (OIG) at 1-800-HHS-TIPS (TTY: 1-800-377-4950)
- File a complaint online with the OIG to report any potential fraud, waste, and abuse
- Contact the Senior Medicare Patrol (SMP) for more help at 1-877-808-2468
To report fraud, you’ll need:
- Your Medicare number
- Your provider’s name and information
- Details about the fraudulent service
- The payment paid by Medicare
- The date of the service
If you notice something unusual on your MSN, report the Medicare fraud or abuse as soon as possible.
Is your provider pressuring you to get services you don’t think you need, or promising that these services are covered? This could be a sign of Medicare fraud or abuse. Be wary of any provider offering additional services, or pushing you to get services that don’t sound medically necessary.
For example, if your provider tells you that a service is covered by Medicare, always check with Medicare or your provider before agreeing to the service. If the service isn’t covered, your provider may be committing Medicare fraud.
And, as we mentioned, make sure to review your information. Keep a tally of the appointments you’ve had and take notes while you’re there. Use that information to double check what your doctors and providers report to Medicare in your name. This is a good practice even if you’re not looking for fraud; remember, honest mistakes do happen, and keeping an eye on your Medicare Summary Notice (or Explanation of Benefits if you have Medicare Advantage) is a good habit for any beneficiary. For those guarding against Medicare fraud and abuse, it’s the first line of defense.
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The biggest difference between Medicare fraud vs abuse is intent.
When a healthcare provider commits fraud, they purposely bill Medicare or the beneficiary to receive higher compensation. Fraud includes billing Medicare for services that were never offered. This is intentional deception.
Abuse is a form of bending the rules. Providers may bill Medicare for a more-expensive service than what they provided, or they might order a number of unnecessary tests. This can be intentional or due to negligence. Abuse can be time consuming and costly for the Medicare beneficiary.
After you report Medicare fraud, OIG staff review the complaint and send it to the right department for further investigation. The complaint resolution process may take six months or more.
The OIG does not provide information about ongoing investigations, so until the complaint is resolved you won’t be able to find out exactly how the investigation is going.
Medicare scams are different from Medicare fraud and abuse. Scams typically involve someone pretending to be a healthcare provider or insurance agent. The person uses deceit to collect your personal information.
For example, if someone calls you and asks for your Medicare number or your Social Security number to activate your Medicare ID card, this is a Medicare scam. Your Medicare ID card is automatically activated, and the person on the phone is not a Medicare representative.
If you receive a call from someone asking for any personal information, hang up! Medicare representatives will never call you, or ask for personal information over the phone unless you’ve given them permission in advance.