Medicare abuse involves improper billing or unnecessary services. Medicare fraud involves falsifying claims. The main difference is intent, abuse is often done without intent.

Medicare abuse and fraud affect Medicare beneficiaries. The most common type of Medicare fraud is filing inaccurate or falsified Medicare claims to increase profits. The most common type of Medicare abuse is billing improperly or billing for unnecessary services.

Carefully reading your billing statements is the best way to recognize if you’ve become affected by Medicare abuse.

Report suspected Medicare abuse or fraud

Call 800-MEDICARE (800-633-4227) to report suspected Medicare abuse or fraud.

Medicare abuse generally involves the practice of improperly billing for services or billing for services that are not necessary.

Medicare fraud can take many forms, such as knowingly billing for excess services, including canceled appointments. It can also happen in any part of Medicare’s program, from Original Medicare (parts A and B) to Medicare add-ons and Medicare Advantage (Part C) plans.

Common instances of Medicare fraud may include:

  • billing for services above and beyond those performed, if done intentionally, otherwise this may be considered abuse
  • billing for services that were not performed at all
  • billing for cancelled or no-show appointments
  • billing for supplies that were not delivered or provided
  • ordering unnecessary medical services or tests for patients, if done intentionally, otherwise this may be considered abuse
  • ordering unnecessary medical supplies for patients
  • receiving kickbacks and incentives for patient referrals

Medicare fraud may also involve identity theft. This is when a person’s Medicare information is stolen and used to submit fraudulent claims.

The best way to determine if you’ve been a target of Medicare abuse is to review your Medicare summary notices. If you’re enrolled in a Medicare Advantage plan, you can review the billing statements from your plan.

Medicare summary notices and billing statements

Medicare summary notices show you all the Medicare Part A and Medicare Part B services or supplies you were billed for over a 4-month period. They also outline what Medicare paid for these services and the maximum out-of-pocket amount you may owe to your provider.

Medicare Advantage plan billing statements should show similar information regarding the services or supplies you received.

If you notice a service or supply on your bill that isn’t accurate, it could simply be an error. In some cases, making a call to the office can help sort out the mistake.

However, if you notice frequent billing errors on your statements, it’s possible that you have experienced Medicare abuse or identity theft. You should report this to Medicare right away.

Other signs of Medicare abuse

Not all Medicare fraud is billing-related. Other signs of Medicare abuse may include any situation in which you are:

  • charged for free preventive services
  • pressured to have unnecessary services performed
  • pressured to have unnecessary supplies or testing administered
  • given promises of cheaper services or testing than is typical
  • routinely charged a copay when you don’t owe one
  • routinely given a copay waiver when you don’t qualify for one
  • called or visited by an uninvited party selling Medicare plans
  • lied to about the services or benefits you will receive under your plan

Many of these examples blur the line between fraud and abuse. If they are done intentionally, they could be considered fraud.

What to do

  • Keep a list of all your medical appointments and services with dates.
  • Ask questions about any treatment or procedures your doctor recommends. You have a right to understand why they are necessary.
  • If you suspect Medicare fraud, immediately report it to Medicare at 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048.
  • Always review the forms you get from Medicare: Medicare Summary Notices (MSNs) and Explanations of Benefits (EOBs) to be sure you recognize the date of service, received the procedure or service listed, were not billed for appointments you did not have, and do have the condition that was treated.

What not to do

  • Don’t give out your Medicare number except to your healthcare professionals.
  • Don’t “join” a Medicare plan over the phone unless you have called Medicare at 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048.
  • Don’t give your Medicare number to people on the phone or who come to your home offering services.
  • Don’t accept “free” medical items or services in exchange for your Medicare number.

If you believe that you have experienced Medicare abuse or fraud, here’s what you’ll need to have on hand to file a report:

  • your name
  • your Medicare number
  • your provider’s name
  • any services or items that are questionable or seem fraudulent
  • any information on the bill related to the payment
  • the date for the claim in question

Once you have this information ready, you can call Medicare directly at 800-MEDICARE (800-633-4227). You’ll be able to speak directly with a Medicare agent who can help you file a Medicare fraud report.

If you’re enrolled in a Medicare Part D plan, you can call 877-7SAFERX (877-772-3379).

If you have a Medicare Advantage (Part C) plan, check with your plan for how to report fraud and abuse.

You can also report suspected Medicare fraud to the Office of the Inspector General by calling 800-HHS-TIPS (800-447-8477) or filing an unclassified report online. To file a physical report, you can also write to the Office of Inspector General at P.O. Box 23489, Washington, DC 20026 (ATTN: OIG HOTLINE OPERATIONS).

After a report is filed, a variety of agencies will investigate the claim to determine whether Medicare fraud has been committed.

Ultimately, individuals who are convicted of healthcare fraud can receive up to 10 years in prison. This sentence is far more severe if the fraud has resulted in patient injury or death.

Federal and state legislation is in place to prevent healthcare fraud and abuse.

For example, the False Claims Act (FCA) makes it illegal to submit fraudulent or misleading claims to the federal government, such as overcharging for medical services or supplies.

Additional laws, such as the Anti-Kickback Statute, Physician Self-Referral Law (Stark Law), and Criminal Health Care Fraud Statute, are intended to discourage acts that may be considered healthcare fraud.

Under these laws, multiple agencies handle cases of Medicare abuse. These agencies include:

  • The U.S. Department of Justice (DOJ): The DOJ is responsible for enforcing the laws that prohibit healthcare fraud and abuse.
  • The Centers for Medicare & Medicaid Services (CMS): The CMS oversees the Medicare program and handles claims related to Medicare abuse and fraud.
  • The U.S. Department of Health & Human Services (HHS): The HHS oversees the Office of Inspector General and the CMS.
  • The HHS Office of Inspector General (OIG): The OIG helps to detect healthcare fraud by conducting investigations, imposing penalties, and developing compliance programs.

Once Medicare fraud has been identified, each agency plays a role in investigating and charging to the fullest extent of the law.

Medicare abuse costs taxpayers and the government billions of dollars each year.

Common practices of Medicare abuse include billing for unnecessary or different procedures, and ordering unnecessary supplies or tests. If any of these are done with intent, they can be considered fraud. Another type of fraud involves stealing another individual’s Medicare information to submit false claims.

If you suspect that you have experienced or believe you have experienced Medicare abuse, call 800-MEDICARE (800-633-4227) to speak to an agent for more information on what to do next.