Fraud and Abuse

Medicare Fraud & Abuse Resource Page

Overview

Most Medicare payment errors are simple mistakes and are not the result of physicians, providers, or suppliers trying to take advantage of the Medicare system. The vast majority of those who serve people with Medicare are committed to providing high quality care and billing the program only for the payments they have earned.

However, there are a few individuals who are intent on abusing or defrauding Medicare, cheating the program (and in some cases the people with Medicare who are liable for co-payments) out of millions of dollars annually. Medicare fraud drains money every year from the Medicare program. People with Medicare pay for it with higher premiums.

Some examples of Medicare fraud include:

• Billing Medicare or another insurer for services or items the patient never received.
• Billing Medicare for services or equipment which are different from what the patient received.
• Use of another person's Medicare card to get medical care, supplies, or equipment.
• Billing Medicare for home medical equipment after it has been returned.
• Offering or receiving anything of value in return for referring or furnishing any item or service payable by Medicare or Medicaid.

Medicare is taking strong action to combat fraud and abuse of the system in key areas. The goal is to make sure Medicare only does business with physicians, providers, and suppliers who will provide those receiving Medicare with high quality services. The effort to prevent and detect fraud is a cooperative one that involves he Centers for Medicare & Medicaid Services (CMS), people with Medicare, providers of Medicare services including physicians, providers, and suppliers, and State and Federal Agencies such as the Department of Health and Human Services, Office of the Inspector General, the Federal Bureau of Investigation (FBI), and the Department of Justice.

This fraud and abuse resource page is designed to acquaint you with general guidelines of compliance as well as how to avoid making inappropriate payments to fraudulent entities. If you have a question or concern regarding a Medicare claim submitted on your behalf, you should discuss it directly with your physician, provider, or supplier that provided the service.

Compliance and the Corporate Responsibility Guide The Office of Inspector General and the American Health Lawyers Association has published valuable guidance regarding the responsibilities of a health care entitiy's board of directors. It is entitled CORPORATE RESPONSIBILITY AND CORPORATE COMPLIANCE: A Resource for Health Care Boards of Directors.

This guide is valuable for both for profit and not for profit home care agencies and hospices. It provides useful recommendations that all organizations should consider during this time of heightened concern about corporate accountability. Click here to view the full PDF.

Detection and Prevention

Detection Tips

You should be suspicious if the provider tells you that:

• The test is free; he only needs your Medicare number for his records. NOTE: For clinical laboratory tests, there is no co-payment and a provider may in good faith state that the test is free, since there is not cost to the person with Medicare.
• Medicare wants you to have the item or service.
• They know how to get Medicare to pay for it.
• The more tests they provide the cheaper they are.
• The equipment or service is free; it won't cost you anything.

Be suspicious of providers that:

• Charge co-payments on clinical laboratory tests, and on Medicare covered preventive services such as PAP smears, prostate specific antigen (PSA) tests, or flu and pneumonia shots.
• Routinely waive co-payments on any services, other than those previously mentioned, without checking your ability to pay.
• Advertise "free" consultations to People with Medicare.
• Claim they represent Medicare.
• Use pressure or scare tactics to sell you high priced medical services or diagnostic tests.
• Bill Medicare for services you did not receive.
• Use telemarketing and door-to-door selling as marketing tools.

Prevention Tips

To help prevent Medicare fraud, you should report suspected instances of fraud. Whenever you receive a payment notice from Medicare, review it for errors. The payment notice shows what Medicare was billed for, what Medicare paid and what you owe. Make sure Medicare was not billed for health care services or medical supplies and equipment you did not receive.

The following is a list of tips to prevent fraud:

• Don't ever give out your Medicare Health Insurance Claim Number (on your Medicare card) except to your physician or other Medicare provider.
• Don't allow anyone, except appropriate medical professionals, to review your medical records or recommend services.
• Don't contact your physician to request a service that you do not need.
• Do be careful in accepting Medicare services that are represented as being free.
• Do be cautious when you are offered free testing or screening in exchange for your Medicare card number.
• Do be cautious of any provider who maintains they have been endorsed by the Federal government or by Medicare.
• Do avoid a provider of health care items or services who tells you that the item or service is not usually covered, but they know how to bill Medicare to get it paid.

It is in your best interest and that of all citizens to report suspected fraud. Health care fraud, whether against Medicare or private insurers, increases everyone's health care costs, much the same as shoplifting increases the costs of the food we eat and the clothes we wear. If we are to maintain and sustain our current health care system, we must work together to reduce costs.

Reporting Medicare Fraud

You, as the Medicare beneficiary, are the most important link in finding Medicare fraud. You know better than anyone what healthcare services you have received. Review your Medicare Summary Notice when you receive it, and make sure you understand all of the items listed.

If you don't remember a procedure that is listed, you should first call your physician, provider, or supplier that is listed on the Medicare Summary Notice. Many times a simple mistake has been made and can be corrected by your physician, provider, or supplier's office when you call.

If your physician, provider, or supplier's office does not help you with the questions or concerns about items listed on your Medicare Summary Notice and you still suspect Medicare fraud or if you cannot call them, you should call or write the Medicare company that paid the claim. The name, address, and telephone number are on the Medicare Summary Notice (MSN) you receive, which shows what Medicare paid.

Before contacting the Medicare claims processing company, carefully review the facts as you know them and as shown on the Medicare Summary Notice. Write down:

• The provider's name and any identifying number you may have
• The item or service you are questioning.
• The date on which the item or service was supposedly furnished.
• The amount approved and paid by Medicare.
• The date of the Medicare Summary Notice.
• The name and Medicare number of the person who supposedly received the item or service.
• The reason you believe Medicare should not have paid.
• Any other information you may have showing that the claim for the item or service should not have been paid by Medicare.

If you plan to write rather than call, clearly state at the beginning of your letter that you are filing a fraud complaint. This will help to ensure that your complaint is forwarded to the fraud unit.

Office of Inspector General Hotline

To further assist you, the Office of the Inspector General maintains a hotline, which offers a confidential means for reporting vital information. The Hotline can be contacted:

If you are attempting to report specific information proving Medicare fraud, please provide as much identifying information as possible regarding your concern. Such information should include subject's name, address and phone number etc. Details regarding the allegation should include the basics of who, what, when, where, why, and how.

Please note that it is current Hotline policy not to respond directly to written communications.