Types of Fraud and Abuse in Medicare

Allison Martin
Doctor with piggy bank

Medicare fraud is a serious issue that affects recipients and taxpayers alike. According to CMS.gov, it continues to put the provision of senior care at risk, due to budgetary constraints, while costing taxpayers billions of dollars.

Common Types of Medicare Fraud

There are several types of Medicare fraud you should be aware of.

Fraudulent Billing

This occurs when fraudulent healthcare providers or suppliers remit bills to Medicare for services and supplies that were never rendered. In some instances, healthcare providers will also bill for medical services that are unnecessary or double-bill for the sake of receiving more money at the time of reimbursement.

Fraudulent Use of Medicare Cards

The use of your Medicare card by another individual to obtain supplies and equipment for their personal use is considered illegal and a form of Medicare fraud.

Enrollment Incentives

Fraudsters sometimes offer gift cards, meals, cash, or other perks to sweeten the deal. If the value of these gifts exceed $15, there is a possibility some form of Medicare fraud is taking place.

Inflated Charges

There are cases where Medicare is billed for a more costly healthcare service or supply than the patient actually received. This is referred to as upcoding. You should also be aware of unbundling or fragmentation, which occurs when Medicare is billed separately for individual services within a procedure in lieu of a cheaper flat rate for the treatment plan.

Payments Related to Referrals

Healthcare providers and suppliers sometimes generate fraudulent referrals solely for the purpose of receiving a kickback.

Risk Factors

There are a few ways you may be putting yourself at risk for Medicare fraud.

Unsecured Personal Information

Disclosing your policy data or other identifying information to those outside of your physician and medical providers puts you at risk for Medicare fraud. You could be opening the door to unauthorized use of your policy, fraudulent referrals, and claims for services you have no knowledge of.

Easily Accessible Medical Records

Restrict access to medical records and personal information. To protect yourself, provide that information only to your physician and medical proviers.

Detecting Fraud

Fraudsters devise clever schemes to carry out Medicare fraud. However, there are red flags.

Unsolicited Phone Enrollment

Random telemarketers should not contact you regarding Medicare plans you did not inquire about beforehand.

Request for Phone Payment

By law, the plan is required to remit statements to you via mail. Once you are in receipt, you should follow the guidance on the bill to remit payment.

Door to Door Selling

Be very cautious if a "salesman" visits your home unannounced, as the initial contact should be initiated by you, via phone.

Deceptive Billing Practices

If you notice strange items on your Medical Summary Notice and corresponding billing statements that are outside of the scope of the services rendered, you may have been victimized. Also, be on the lookout for supplies that were billed to Medicare that you never received.

How to Protect Yourself

To prevent becoming a victim of Medicare fraud, take the following precautions:

  • Restrict access to your Medicare card and other identifying information.
  • Review the plan details and seek clarity before enrolling.
  • Record services, supplies, and prescriptions received for medical treatment.
  • Analyze Medicare statements for accuracy upon receipt and report any inaccuracies. Be on the lookout for duplicate entries, services that were not rendered, and services that were received but not ordered by a doctor.

Medicare.gov also recommends routinely viewing claim activity by logging onto the online portal or calling 1-800-MEDICARE.

What to Do If You Have Been Victimized

If you suspect you are a victim of Medicare fraud:

  • Call 1-800-MEDICARE.
  • Report it online to the Office of the Inspector General.
  • Call the Office of the Inspector General at 1‑800‑HHS‑TIPS (1‑800‑447‑8477). TTY users should call 1‑800‑377‑4950.

By reporting the incident, you may be eligible for a $1,000 reward (conditions apply).

Types of Fraud and Abuse in Medicare