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:
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.
You should be suspicious if the provider tells you that:
Be suspicious of providers that:
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:
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.
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:
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:
Office of the Inspector General
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.