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What is Medicare Fraud?

Anytime there's an opportunity to take something of value through deception, you'll find examples of (or at least attempts at) fraud. And Medicare, the government-run health care program serving primarily elderly Americans, is no exception. So what is Medicare fraud, exactly? For the most part, it involves an act of identity theft. For example, someone who gains unlawful access to your Medicare Number or other personal identifying information (Social Security Number, birth date, etc.) can access your benefits without your knowledge.

This article provides an overview of Medicare fraud, including ways to spot fraud, how to prevent it, and what to do if you suspect fraud.

What is Medicare Fraud? The Basics

Medicare fraud is the act of claiming reimbursement for health care services through Medicare to which you're not entitled, often through identity theft or using someone else's Medicare Card number. It may help to think of your Medicare Card like a credit card, and to safeguard it in a similar fashion.

One of the ways perpetrators try to gain access to your Medicare account is by calling you and claiming they're with the U.S. Centers for Medicare and Medicaid Services. They may ask for your card number or personal identifying information. But Medicare rarely calls members; and even then, it's typically only in response to your request that they call you back.

Other types of Medicare fraud include the following:

  • Phantom Billing - Medical providers fraudulently bill Medicare for unnecessary (or never performed) procedures.
  • Upcoding and Unbundling - Insurance companies fraudulently inflate billing amounts through the billing code in order to get additional risk adjustment payments from Medicare.
  • Fraudulent Patient Billing - Patients work in tandem with providers, who bill their Medicare account for fraudulent services in exchange for kickbacks.

How to Detect Medicare Fraud

Unfortunately, fraud typically happens without your knowledge. But there are ways to detect fraud after the fact. Generally, you'll want to keep a record of the dates on which you've received health care services and save receipts and statements from providers. Mistakes don't necessarily mean fraud has occurred, but they could be an indicator.

Medicare provides the following tips:

  • Compare Medicare statements to your own records (i.e. dates and specific services). If you have Original Medicare (Parts A and B), then you'll check the Medicare Summary Notice (MSN) that's sent every three months.
  • You can check your claims at the time they're processed by logging into or calling 1-800-MEDICARE (1-800-633-4227). Early detection is key.
  • Check for services listed in your claims report that you haven't received, as well as charges that seem incorrect.

How to Report Medicare Fraud

As long as you're not part of the fraudulent act, Medicare offers rewards of up to $1,000 for substantiated reports of fraud. In order to be eligible for a reward, the allegation must be specific and confirmed as potential fraud by a Medicare official; the suspected perpetrator must not already be under investigation; and your report must lead to at least $100 in recovery of Medicare funds.

For all claims of fraud (regardless of whether the above conditions are met), you may call 1-800-MEDICARE, report the allegation online, or call the Office of the Inspector General at 1-800-HHS-TIPS (TTY: 1-800-377-4950).

Gather the following information before reporting the fraud allegation:

  • Care provider's name and contact information (if applicable);
  • Service or billing item being questioned;
  • Date of service;
  • Payment amount approved and paid by Medicare;
  • Date of service listed on the Medicare Summary Notice;
  • Your name and Medicare Card number; and
  • Your reason why it appears to be fraudulent.

Protect Yourself From Medicare Fraud

The best way to protect yourself from fraud is to safeguard your Medicare Card number, Social Security Number, and other personal identifying information. Also, you should have a general understanding of what your provider can and can't bill to Medicare (i.e., some providers may attempt to bill Medicare for services that aren't generally covered).

Other tips include the following:

  • Make sure you receive the correct number of pills (or other covered and billed items, such as medical equipment and supplies);
  • Regularly check your MSN and compare Medicare records to your own information (i.e. dates and services provided); and
  • Immediately report any suspected instances of fraud.

Are You a Victim of Medicare Fraud? An Attorney Can Help

Prevention of Medicare fraud is always the best policy, but there are steps you can take if you're the victim of fraud. In some instances, you may want expert legal help with your case. If you have questions or need representation, a local health care attorney will be able to help you.

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