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What Is Medicare Fraud and How Do I Report It?

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Just the Essentials

  • Medicare fraud occurs when individuals – both health care providers and beneficiaries – knowingly attempt to access Medicare funds they are not eligible to receive.

  • Additionally, scammers may impersonate Medicare employees to phish for beneficiaries’ personal information and commit identity theft.

  • You can report Medicare fraud by calling 1-800-MEDICARE.

What is Medicare fraud?

We’re all familiar with fraud. If you have a phone number or spend any time online, you’re likely exposed to scams on a regular basis.

However, there are many different types of fraud, and some of them are more difficult to identify than others. Medicare fraud doesn’t always involve fishing for personal information via a phone call, email, or web page. It exists in many forms.

Most Medicare fraud is an attempt to knowingly access benefits or reimbursements from Medicare that the perpetrator is not entitled to receive. This is a crime that affects everyone who pays taxes. When the perpetrators of fraud are successful, the funds they gain are no longer available to actual beneficiaries of Medicare.

Common Types of Medicare Fraud

Medicare fraud is one of the most common forms of health care fraud. In 2018, Former U.S. Attorney General Jeff Sessions estimated that more than 10% of Medicare funds are lost to fraud each year. 

There are several different forms of Medicare fraud. Some are committed by providers, while others may be committed by beneficiaries. And, while it may not be considered Medicare fraud in the strictest sense, scammers may also attempt to impersonate Medicare employees in order to obtain personal information and commit identity theft.

Fraud Committed by Providers

When providers commit Medicare fraud it typically involves fraudulent billing – Providers may provide false information or bill Medicare for treatment and services that were never delivered in order to collect reimbursements. 

Provider fraud can include:

  • Billing for unnecessary services
  • Billing for services that were never provided
  • Writing unnecessary prescriptions
  • Soliciting or offering kickbacks

Fraud Committed by Beneficiaries

When beneficiaries commit Medicare fraud, it typically involves providing false information to receive coverage they are not entitled to receive, or willingly sharing their Medicare information so that others may use it to receive coverage.

Beneficiary Fraud can include:

  • Providing incorrect information to qualify for benefits or services
  • Sharing Medicare information and allowing someone else to use it to obtain services
  • Accepting payment for referring other beneficiaries to a certain provider

Identity Theft

Some scammers will attempt to impersonate Medicare to obtain your personal information. Medicare will never call beneficiaries to ask for their Medicare information without prior permission.

If you are ever in doubt, do not share your Medicare information with anyone who contacts you unsolicited, or who offers you goods or services in exchange for your Medicare number.

Medicare Fraud vs Medicare Abuse

The Centers for Medicare and Medicare Services (CMS) defines Medicare fraud and Medicare abuse differently. The difference depends on the specific circumstances of each potentially fraudulent situation.

A general rule is that Medicare fraud is knowingly committed. Perpetrators of fraud submit false claims or information with the intent of profiting from Medicare. If a provider bills incorrectly for services but does so due to an error or misunderstanding, it will likely not be classified as fraud.

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How to Spot Medicare Fraud

It won’t always be obvious to a beneficiary when a provider is committing Medicare fraud. However, checking your Medicare statements and verifying that the services you received and dates you received them are accurate is a great way to monitor what claims are being submitted on your behalf.

You should also be wary of providing your Medicare information to others. Guard your card! If you receive any unsolicited phone calls, emails, or traditional mail asking you to provide your Medicare number for a suspicious reason, you may wish to report them.

How to Report Medicare Fraud

The government takes Medicare fraud very seriously.  If you suspect your provider or any other individual is committing Medicare fraud, you can call the Medicare hotline at 1-800-MEDICARE (1-800-633-4227).

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