October 6, 2016

Billing Medicare for services that were never received constitutes Medicare fraud and is punishable by law. Of course, Medicare billing errors can also happen, and although these may not constitute Medicare fraud, they can still cost you money, so it’s important for you to learn how to detect Medicare fraud and Medicare billing errors and what to do in such situations.

Avoid Medicare billing errors

Medicare billing errors can sometimes happen. For example, the doctor’s office staff may use the wrong code on a Medicare claim or even place the wrong patient name on a claim. These Medicare billing errors are usually innocent and generally do not constitute Medicare fraud, but they can still cost you money, so it’s always a good idea to check your payment notice carefully.

Whenever Medicare or your private insurance company pays a claim for health services, it will send you a notice explaining your benefits called an Explanation of Benefits or EOB. This notice describes the service you received along with a special code used for that particular service. The notice also shows the total amount charged, how much the insurance paid, and your share of the total cost. If you think the description or the amount charged is a mistake, inform your doctor or provider of service immediately. A trained professional in the office will review the notice and your medical record and either explain the issue or submit a correction if there was a Medicare billing error.  If a correction is issued, you will receive a second explanation of benefits from Medicare or your private insurance company that shows the correction.

What is Medicare fraud and abuse?

There are some individuals, however, who intentionally abuse or defraud the Medicare system. An example of Medicare fraud is when someone uses another person’s Medicare card for health-care services or supplies. Medicare fraud could also involve a health-care provider billing an insurer for services you never received or for equipment that has been returned. This type of Medicare fraud and abuse costs the Medicare system millions of dollars each year, often resulting in higher premiums for Medicare beneficiaries like you.

How to prevent Medicare fraud

Medicare takes action to ensure it does business with only doctors and suppliers who provide quality health care. The Centers for Medicare and Medicaid Services (CMS), which administers Medicare, also works with federal agencies like the Department of Health and Human Services Office of the Inspector General, the FBI, and the Department of Justice to prevent and detect Medicare fraud and Medicare abuse. As a Medicare beneficiary, you can also help prevent Medicare fraud and abuse by doing the following:

  • Give your Medicare card or claim number only to your doctor or health-care providers. Never give it to anyone else.
  • Never let anyone but medical professionals who are caring for your health see your medical records.
  • Never ask your doctor for a medical service or supply that you do not need personally.
  • Be wary of medical services offered for free or no copay, especially when asked to provide your Medicare card. If you are unsure whether or not your Medicare coverage provides for this service, contact your Medicare plan before you receive the service. Be wary of providers who say that the more tests they perform, the cheaper they are. Also be cautious of offers for gifts (monetary or otherwise) to go to a specific clinic or office.
  • Avoid providers who use telemarketing and door-to-door sales or who pressure you to buy high-priced medical services.
  • Be suspicious of providers who routinely waive copayments, unless your plan specifically waives copayments. Conversely, be suspicious of providers who charge a copayment for a service for which the copayment should be waived.
  • Know that the federal government and Medicare do not endorse any health-care provider. Be cautious of anyone who claims otherwise.
  • Understand exactly what Medicare or your insurance plan covers, and be cautious of anyone who claims they know how to get Medicare to pay for a certain service that is not covered by your plan.

How to report Medicare fraud and abuse

If you suspect Medicare fraud or abuse, report it to the Office of the Inspector General. Provide as much information as possible, including the suspected Medicare fraud and/or the abuser’s name, address, and telephone number to help the investigation. You can do any of the following:

  • Call 1-800-HHS-TIPS (1-800-447-8477) (TTY users 1-800-377-4950) between 7AM and 8PM EST, Monday through Friday.
  • Send an email to HHSTips@oig.hhs.gov.
  • Mail a letter to Office of the Inspector General, HHS Tips Hotline, P.O. Box 23489, Washington, DC 20026-3489.
  • You can also report Medicare fraud and abuse to Medicare:
    • Call 1-800-633-4227 (TTY users 1-877-486-2048) 24 hours a day, seven days a week.
    • Mail at a letter to Medicare Beneficiary Contact Center, P.O. Box 39, Lawrence, KS 66044.