How to Spot Medicare Fraud – And What To Do If You Become a Victim

How to Spot Medicare Fraud

How to Spot Medicare Fraud

Each year, the Medicare program loses billions of dollars to claims that are fraudulent. These claims can include providers billing Medicare for services or equipment that were never received by patients, as well as individuals using another person’s Medicare ID number in order to illegally obtain care.

Because of this fraud, health care costs become higher for everyone – including individuals, businesses, and even the federal government. But there are ways to detect and to stop fraud, which can in turn help to lower these overall costs – and in some cases, helping to fight Medicare fraud could even pay off for those who report it.

How Medicare is Defrauded

There are many ways in which the Medicare program is defrauded out of benefit dollars each year. Some of the more popular scams include:

  • Individual benefit recipients who use the Medicare ID card of another individual for the purpose of receiving medical care, equipment, and / or medical supplies fraudulently.
  • Health care providers who bill Medicare for services that were never actually performed.
  • Companies that use falsified information in order to mislead consumers in joining a Medicare plan.
  • Health care providers who pay kickbacks in exchange for patient referrals.
  • Companies offering Medicare drug plans that are not actually approved by Medicare.
  • Medical suppliers who bill Medicare for equipment that is not actually received.

Suppliers who bill Medicare for home medical equipment – even after those items have already been returned.
Because the program is so large and funded by the U.S. government, the pockets of Medicare run deep. Therefore, it can attract some very organized crime groups who can essentially receive large payoffs and profits.

Yet another incentive for these criminals is that – even if caught – the scammers will oftentimes receive a much lighter sentence than those who are caught doing other crimes such as drug trafficking – yet Medicare fraud can have a much bigger payoff for those who don’t get caught.

Spotting Possible Fraud with Medicare

Although it may appear difficult to detect, there are ways that consumers can help in detecting Medicare fraud. For example, certain “red flags” may be present if a medical provider states any of the following to you regarding your health care equipment or services:

  • The services and / or the medical equipment are free
  • The testing is free, however, the provider of the service will require your Medicare ID number for their records
    Medicare is requiring you to obtain the service or item
  • You will receive a “quantity discount” (i.e., the more tests that you have done, the less costly each individual test will be)

In addition, you may also be dealing with a provider that is committing Medicare fraud if they are engaging in any of the following:

  • Advertisements for “free consultations” for Medicare enrollees
  • Routinely waiving of copayments without checking your ability to pay for services
  • Claiming that they represent Medicare directly
  • Using high pressure or “scare” tactics in order to sell you costly medical services or testing procedures
  • Billing Medicare for services that you did not actually receive

How You Can Report Medicare Fraud

If you have been a victim of Medicare fraud, or even if you suspect that a fraudulent Medicare-related incident has taken place, there are several ways in which you can report it. One way is to call Medicare directly, toll-free, at 1-800-633-4227.

Alternatively, you can contact the Office of the Inspector General, at 1-800-447-8477, or you can go online to the Office of Inspector the General website, where you will find a Report Fraud Form by clicking here.

Prior to contacting either of these entities to report Medicare fraud, it is recommended that you have the following information on hand:

  1. Name and / or identifying number of the provider
  2. Details regarding the item or the service being questioned
  3. The date that the item or service was supposedly delivered or performed
  4. The amount of the payment approved or paid for by Medicare
  5. The date listed on your Medicare MSN

You will also be asked to provide your name and Medicare number, as well as the reason(s) why you feel that the incident is fraudulent.

Because Medicare fraud costs the U.S. government millions of dollars every year, those who report fraudulent incidents may be eligible for a reward of up to $1,000, provided that all of the following criteria are met:

  1. The incident being reported is specific (as versus just a general allegation)
  2. The incident is confirmed by the Program Safeguard Contractor, the Medicare Drug Integrity Contractor, or the Zone Program Integrity Contractor as being a potential fraud, and is then formally referred to the Inspector General for further investigation
  3. The individual who is reporting the fraud is not also involved in the incident
  4. The entity that is being reported is not already under investigation
  5. The report leads directly to the recovery of at least $100 of Medicare funds

Other Ways to Help Stop Medicare Fraud

Putting a stop to Medicare fraud can require joint cooperation from many different entities, including individuals, health care providers, insurance companies, law enforcement, and even the U.S. government.
There are several programs that have been put into place that contain measures on stopping Medicare fraud. These include:

  • The Affordable Care Act – This Act, also referred to as health care reform, includes provisions on fighting health care fraud and abusive tactics. So far, the government has recovered in excess of $10 billion due to the measures taken from this legislation alone.
  • The Health Care Fraud Prevention and Enforcement Action Team (HEAT) – This joint effort between the Department of Justice and the Department of Health and Human Services combines officials that will lead Medicare Strike Force teams who are focused on fighting Medicare fraud.
  • Senior Medicare Patrols – These groups of senior citizens are volunteers that work to educate their peers in better identifying, preventing, and reporting Medicare and other types of health care fraud.
  • Public-Private Partnership to Prevent Health Care Fraud – This partnership brings together both public and private organizations to detect and fight against health care fraud.