Billions lost to Medicare/Medicaid fraud means we all pay higher health care costs. Federal and state agencies have teamed up with health insurers to prevent and prosecute fraud. Medicare beneficiaries can learn to recognize signs of fraud to help Medicare and health plans to uncover fraudulent schemes. There are many resources to learn more about health care fraud and abuse and what we all can do to fight it.
Health care fraud occurs when someone intentionally misrepresents a fact for the purpose of receiving--or increasing--reimbursement from Medicare or a health plan. Fraud also occurs when someone misrepresents the delivery of health care services or supplies.
The following are examples of possible health insurance or Medicare fraud:
- Your provider bills Medicare or your health plan for services you never received.
- A supplier bills Medicare or your health plan for equipment you never received.
- Your Medicare card or health plan card is taken or misused in order to get medical services for someone else.
Your pharmacist bills Medicare or your health plan for prescriptions you haven't received or asks you to pay higher costs for a prescription than you were told you would have to pay.
Doctors, providers or suppliers can use your information to bill unnecessary or fraudulent charges to Medicare or a health plan. They might say things like:
- The equipment or service won't cost you anything; the only thing required is your Medicare number for their records.
- Medicare wants you to have the item or service (even if not covered).
- They know how to bill Medicare in such a way as to receive payment for the item or service.
Tests or screenings are cheaper if you get more of them.
These providers, doctors or suppliers may also do the following:
- Bill Medicare or your health plan for services you have not received.
- Put the wrong diagnosis on your claim so that Medicare will pay.
- Bill Medicare or your health plan for services for which you are not eligible. For example, a claim is submitted for a power wheelchair or scooter when you have not been approved for one.
Bill Medicare or your health plan for services paid for by another entity. For example, you receive tests when an inpatient in a hospital. Your hospital claim includes this charge. Yet you also receive a claim from a separate provider for the same test.
In addition, pharmacists might:
- Bill for a brand name when generic drugs are dispensed or bill for noncovered prescriptions as covered items
- Bill for prescriptions that you never pick up, or split a prescription inappropriately—for example, by splitting a 30-day prescription into four seven-day prescriptions. This adds costs to Medicare by increasing copayments and dispensing fees, which provide revenue to the provider.
- Offer you remuneration for enrolling in a certain plan or ordering a certain drug.
- Provide less than the prescribed quantity and does not tell you, but bills your health plan for the full amount
Alter your provider's prescription
There are some basic steps to protect you and your health coverage from fraud.
- Know your health plan coverage. Recognize what is covered by Medicare and what isn't. You can find this information in your "Medicare & You" handbook.
- Review your plan Explanation of Benefits or your Medicare Summary Notice for errors. Also review your health plan's online claims record frequently, even if you haven't been to the doctor lately, to ensure claims aren't made against your benefits fraudulently.
Check with Regence, your provider or doctor if you spot something that doesn't make sense. Chances are it is a billing error, but every billing error corrected helps you and Medicare.
If your concerns aren't addressed or if someone does not respond to your requests, it is important to take action anyway.
- Call 1-800-MEDICARE (633-4227).
- Fraud related to Medicare Part C or D: 1 (800) 323-1693.
- Write a letter to Medicare. Mail it to: Beneficiary Contact Center, PO Box 39, Lawrence KS, 66044.
- Call the United States Department of Health and Human Services (HHS) Office of Inspector General Hotline at
1-800-HHS-TIPS (447-8477). TTY users should call 1 (800) 377-4950. HHS is the federal department that oversees Medicare.
- Send an email to the HHS Office of Inspector General.
- Write a letter to the Department of Health and Human Services. Mail it to: HHS Tips Hotline, PO Box 23489, Washington, DC 20026-3489.
Last updated 11/01/2021