How to Identify and Report Medicare Fraud

Health Line

5 hours ago

Medicare fraud is when a person knowingly submits false information or misuses the Medicare system to achieve personal financial gain or to receive benefits for which they are ineligible. Medicare has numerous official channels for reporting suspected fraud.
While estimates vary, the Senior Medicare Patrol reports that Medicare losses due to fraud could be as high as $60 billion annually.
What's clear is that Medicare fraud and abuse are pervasive, put significant stress on the system, and have the ability to affect the care that older adults receive.
Medicare fraud can be perpetrated by various people and organizations, including healthcare providers, such as doctors, clinics, or hospitals, as well as criminal groups and individuals.
In this article, we'll discuss what Medicare fraud is, how to identify it, and where to report it.
Common types of Medicare fraud
Medicare fraud can take many forms and can affect both beneficiaries and providers. Common types of Medicare fraud include:
Medical identity theft: This can take many forms. It could involve using another person's Medicare number to obtain healthcare services or benefits or using a physician's identifier to fill prescriptions.
Billing for unnecessary services: Under Medicare regulations, many procedures only receive coverage if they're considered medically necessary. If a provider intentionally bills for unnecessary procedures, it is a form of fraud.
Kickbacks: Kickbacks are when a provider receives some form of compensation in exchange for referrals or utilization of services. An example would be a doctor who receives personal payment from a lab facility for referring patients.
Billing for services never rendered: This is when a provider bills Medicare for services or procedures it never actually administered. It may involve falsifying documentation to create the appearance of authenticity.
Upcoding and unbundling of services: Upcoding involves billing for services at a higher complexity than those actually rendered. Unbundling involves submitting bills in a staggered fashion to maximize payment when Medicare requires that those bills be submitted together to reduce costs.
Vigilance is important in matters related to Medicare and billing. Understanding what to look for can help you identify fraud in practice.
As a consumer and Medicare beneficiary, be sure to regularly check your Medicare claims and keep an eye out for irregularities. Look for:
unfamiliar charges on your Medicare summary notice
line items for services you didn't receive
bills from unfamiliar providers
If you have regular contact with a healthcare professional, facility, or other provider, you may notice trends that could signal potential fraud. These include:
unusual billing patterns
geographic anomalies
suspicious documentation
patient complaints
How to report Medicare fraud
If you suspect fraud may be occurring with a given provider, it's important to notify the Centers for Medicare & Medicaid Services (CMS).
Reporting suspected fraud, waste, or abuse in Medicare programs is key to protecting both the integrity of the Medicare system and the individuals it serves.
You can do this in various ways:
Contact Medicare by phone at 800-MEDICARE (800-633-4227).
Submit a complaint online with the Office of Inspector General of the Department of Health and Human Services (HSS-OIG).
Contact the HSS-OIG by phone at 800-HHS-TIPS (800-447-8477).
Individuals with a private Medicare plan, such as a Medicare Advantage (Part C) or Part D plan, can also reach out to the Investigations Medicare Drug Integrity Contractor (I-MEDIC) with fraud complaints. You can reach I-MEDIC by phone at 877-772-3379.
Before filing a complaint, it's important to collect all relevant documentation to back up your claim. This includes:
your Medicare number
the subject of your complaint, including information that can identify them
the service in question and the date of receipt
the cost of the service
Summary
Fraud and abuse cost Medicare billions of dollars each year. Reporting Medicare fraud is important for protecting individuals and maintaining the integrity of the Medicare system.
Always guard your Medicare card, number, and other personal medical information. Additionally, review your Medicare summary notices routinely for irregularities that suggest inappropriate billing.
If you think you were billed incorrectly, consider contacting Medicare for clarification. While errors happen, and not all errors are due to fraud, it's best to be safe and report your concerns.
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