Medicare fraud, waste, and abuse aren’t new issues in the healthcare industry. In fact, Medicare loses billions of dollars annually because of these issues.

When you report, there is an option to remain anonymous so that all information is confidential. But fraud, waste, and abuse can take many forms, and sometimes it’s harder to spot than you’d think.

What Is An Example of Medicare Fraud, Waste, and Abuse?

Fraud is intentionally lying to get money. Waste is overusing services carelessly. Abuse is when best practices aren’t followed.

Seems easy enough, let’s take a closer look to compare these issues in the Medicare system.

What Is Considered Medicare Fraud?

Fraud is when false claims are submitted, or misrepresentations of facts are made to obtain a federal healthcare payment. Also, knowingly offering kickbacks or bribes to induce referrals for services reimbursed by Medicare.

Knowingly billing for services or supplies not provided or falsifying records is a form of fraud. Ordering items that are not medically necessary or billing Medicare for appointments patients don’t keep are also examples of Medicare fraud.

So, fraud is billing for services or supplies that were not provided.

What Is Considered Medicare Waste?

When a doctor orders excessive diagnostic tests, mostly unnecessarily, this is an example of Medicare Waste. Overusing services costs Medicare 80% of the approved amount, and those things add up.

What Is Considered Medicare Abuse?

Medicare Abuse is when practice results in unnecessary costs to the federal health program. Charging excessively for services or supplies is an example of Medicare abuse.

Also, misusing codes on a claim to increase reimbursement from Medicare. Abuse is improper billing, like upcoding.

What Is the Difference Between Fraud, Waste, and Abuse?

The big difference between fraud, waste, and abuse is intent and knowledge. A person committing Medicare fraud knows their actions are wrong and they do it anyway to obtain payment from Medicare.

Waste and Abuse can include things like improper payment, but that doesn’t always have the same knowledge of error or malicious intent.

How Can Medicare Fraud And Abuse Be Prevented?

It’s very important to keep your Medicare number private and secure. You need to keep all your medical records protected. If you notice a doctor trying to provide services you don’t need, say something and report the issue to Medicare.

When you get the “NOT A BILL” letter that goes over all the services you’ve received from your healthcare visit, it’s important to review that. Make sure everything on the paper lines up with the services that were provided.

Many people just throw this paper away, leaving scammers to keep scamming the system.

How Does Fraud Impact Medicare?

When fraud, waste, and abuse happen the result can be higher out-of-pocket costs for Medicare beneficiaries. Reporting issues and stopping them at the source helps keep Medicare costs lower for everyone.

Fraudulent health history can increase your risk for medical issues.

FAQs

What happens when you report Medicare fraud?

If you report Medicare fraud that leads directly to the recovery of Medicare money, you could get a reward of up to $1,000.

Why is Medicare fraud, waste, and abuse necessary?

This is to ensure both patients and the Medicare system don’t suffer or cause abuse, or utilize Medicare unlawfully in any way.

Why is Medicare fraud, waste, and abuse a significant problem?

This is a significant problem because valuable resources are being diverted away from beneficiaries when others misuse them.

How do I report fraud, waste, or abuse of Medicare?

Medicare beneficiaries can report fraud, waste, or abuse by contacting the CMS hotline at 1-800-MEDICARE. (1-800-633-4227). While you may want to remain anonymous, a lack of information may prevent a comprehensive review.

Making Sure You Have The Medicare Coverage You Need

If you want to be more secure in the total health care coverage you receive, then a Medicare Supplemental plan could be the key to that. Medigap can close up any holes in your Medicare.

Speaking with one of our licensed insurance agents can make that process much easier and arm you with the knowledge needed to make the best decision for your health care.

Our licensed agents are free to contact, so you can ask whatever Medicare-related questions you have. Give us a call today, or fill out our quick and easy online rate form to be connected with the best plans in your area.

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by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.