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What is Medicare Fraud and How Can You Avoid It?

There are many different types of Medicare fraud, they all have the same goal – collecting money from the Medicare program under false pretenses.
Friday, 02 December 2016

As the number of senior citizens increases in the United States, Medicare fraud has become far more prevalent in recent years. By definition, Medicare fraud is the collection of Medicare health care reimbursements under false pretenses. While there are many different types of Medicare fraud, they all have the same goal – collecting money from the Medicare program under false pretenses.

How much money is lost to Medicare fraud?

Not all Medicare fraud is detected and not every suspicious claim is actually fraudulent, but some estimates have been made. The Centers for Medicare and Medicaid Services estimated that as much as $60 billion in "improper payments" were dispersed in 2014. That is more than 10% of Medicare's total budget.

Why is the Medicare program subject to fraud?

One reason for all the problems with improper payments from Medicare is because it's based on an "honor system" of billing. Originally, it was designed to help honest physicians who were willing to help the needy with medical services.

How to report suspected Medicare fraud as a consumer

Whenever you receive health care services, record the dates on a calendar and save the receipts and statements you get from providers to check for mistakes. These include the "Medicare Summary Notice" (MSN) or similar statements that list the services you got or prescriptions you filled.

If you think a charge from your healthcare provider is incorrect and you are familiar with the doctor, you may want to call their office to ask about it first.

The person you speak with should be able to help you better understand the services or supplies you received, or your provider may realize a billing error was made.

If you've contacted the provider and you suspect that Medicare is being charged for a service or supply you didn't get, or you don't know the provider on the claim, call 1-800-HHS-TIPS.

When reporting fraud, have the following information available:

  • The provider's name and any identifying number you may have
  • The service or item you're questioning
  • The date the service or item was supposedly given or delivered
  • The payment amount approved and paid by Medicare
  • The date on your MSN
  • Your name and Medicare number
  • The reason you think Medicare shouldn't have paid
  • Any other information you have showing why Medicare shouldn't have paid for a service or item
  • Earn a reward for fighting Medicare fraud

Did you know that fighting fraud can pay up to $1,000? As written on the Medicare.gov site, the following five conditions must be met for you to be eligible for a reward:

  1. When you report your suspected Medicare fraud, the allegation must be specific, not general.
  2. The suspected Medicare fraud you report must be confirmed as potential fraud by the Program Safeguard Contractor, the Zone Program Integrity Contractor, or the Medicare Drug Integrity Contractor and formally referred as part of a case by one of the contractors to the Office of the Inspector General for further investigation.
  3. You are not considered an "excluded individual." For example, you didn't participate in the fraud offense being reported or you are eligible reward under another government program.
  4. The person or organization you're reporting is not already under investigation by law enforcement.
  5. Your report leads directly to the recovery of at least $100 of Medicare money.

Don't hesitate to report suspected fraud. Medicare is a valuable resource for millions of people. Every dollar counts.

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