What is Medicare fraud? Medicare fraud is generally defined as a doctor, supplier, or other medical service provider billing the federal government’s Medicare system for services or supplies that Medicare beneficiaries did not receive.

As a Medicare beneficiary, while you are not responsible for detecting and reporting Medicare fraud, it benefits you to do so. Medicare fraud is a multi-million dollar criminal industry. That is one reason why Medicare out-of-pocket expenses have gotten more expensive over time and will continue to do so well into the future. Some fraudsters bill Medicare for services and supplies that don’t meet the federal government’s “medically necessary” criteria. Others knowingly use the wrong medical codes on claims submitted to Medicare. As a patient, you can help detect and destroy Medicare fraud by keeping a close watch on your payment notices.

These notices are sent to you after a health care provider or supplier bills either Medicare or your insurance company for a product or service. The notice should spell out the services and products received by you as well as the total billable amount, the amounts that your insurance company and/or Medicare cover, and the amount that you owe. If you note any discrepancies between the services or products you received and the services or products that Medicare or your insurance company was billed for, you should first consult with your health care provider to see if the billing error was an innocent mistake.

Occasionally health care providers will unknowingly use the wrong medical code on a claim. Even though the description of the service that you received may be correct, an incorrect billing code may mean that you end up paying more out of pocket. Your health care provider should immediately correct the billing error once you bring it to their attention.

Warning signs

In addition to keeping a careful watch on your payment notices, you should be aware of possible warning signs that you are dealing with an individual or a company that is willfully engaging in Medicare fraud. Some dishonest health care providers may tell you that the more tests they perform, the less you will pay out-of-pocket. This is usually incorrect and can be a sign of intent to commit fraud. You should also be wary of providers who contact you at home either using telemarketing or door-to-door sales in order to solicit your business. Similarly, providers who offer gifts as incentives to use their services are generally untrustworthy. Providers who waive co-pays, or who charge co-pays even though your Medicare plan provides the service with no co-pay are likely engaging in fraud. Finally, you should beware of providers who say that Medicare endorses their services or who say they know how to convince Medicare to cover something that your plan does not cover.

You should also be aware of personal behaviors that are considered fraudulent by Medicare. If you lend your Medicare to anyone and allow them to use it to receive products or services, you are committing Medicare fraud. Similarly, if you ask your doctor for services, products, or medication for someone other than you, you are committing Medicare fraud.

Medicare abuse

Medicare abuse is more loosely defined than Medicare fraud, and it generally involves a provider performing services that are not medically necessary. Medicare abuse, like Medicare fraud, is illegal and punishable under the law.

If you suspect Medicare fraud or abuse and you wish to report it, you may do so by calling the Medicare fraud tip line at 1-800-447-8477. You may also email a fraud report to HHSTips@oig.hhs.gov. You may fax a fraud report to 1-800-223-8164. Finally, you may send a report via traditional mail to the following address:

Office of the Inspector General HHS Tips Hotline
PO Box 23489
Washington, DC 20026-3489

If you are a Florida resident, you may ignore the preceding contact information and instead call 1-800-417-2078 or email floridamedicarefraud@hp.com to report fraud or abuse of the Medicare system.

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.