With more than 4 million Medicare claims processed each and every day, instances of Medicare fraud can easily get buried in the shuffle. And if your provider is forced to pay out on a fraudulent claim, that could result in your premiums going up through no fault of your own. That’s why it is important that you know how to spot potential Medicare fraud and what to do about it if and when you find something suspicious. 

Sometimes Medicare fraud is relatively easy to spot. For instance, if someone else uses your name and insurance information to get prescription drugs, you will most likely notice right away. But in some cases, Medicare fraud isn’t so obvious, like when a care provider bills Medicare for procedures or equipment that were not used (also known as Phantom Billing). So, to help you know what to look for, here is a quick guide to Medicare fraud:

Types of Fraud

There are many different types of Medicare fraud. Some instances of fraud come from simple mistakes and clerical errors, where others might be intentional. Here are a few of the most common types of Medicare fraud:

Phantom Billing - As mentioned above, phantom billing is any instance in which your provider bills Medicare for a procedure that was never performed, or equipment that was not used or needed.

Upcoding – This is a scam in which your care provider intentionally uses a false code on your bill indicating that you needed more expensive treatments or procedures than what was actually necessary.

Repeat Billing – Repeat billing involves billing patients more than once for the same procedure, supplies, or medicine.

Length of Stay Overcharge – This is when patients are charged for extra days in a hospital or other medical facility.

How to Spot Medicare Fraud

Spotting Medicare fraud might require some extra alertness and diligence on your part, but if it ends up saving you money and protecting you from fraud, it will be well worth it. Here are a few steps you can take to make sure you don’t fall victim to fraudsters:

  • Any time you receive care or services of any kind, record the dates and save your receipts. 
  • Once you get your statement from Medicare, compare the dates and services on your statement to the dates and receipts you saved to make sure all the details are correct.
  • If you notice any items or services listed in your claims that don’t look familiar, it’s possible that you, or Medicare, may have been billed for items you did not need or receive.
  • Check your claims as soon as possible. The sooner you notice and report errors, the better. You can view your claims as soon as they're processed by simply logging into MyMedicare.gov, or calling 1-800-MEDICARE (1-800-633-4227).

How to Report Medicare Fraud

If you've contacted your provider and still suspect fraud, you can report it by either calling 1-800-MEDICARE (1-800-633-4227), or contacting the Office of the Inspector General at 1‑800‑HHS‑TIPS (1‑800‑447‑8477). TTY: 1‑800‑377‑4950.

Before you call to report fraud, make sure you have the following information handy: 

  • Your name and Medicare Number
  • The provider's name 
  • The service or item you find suspicious
  • The date that the service or item was supposedly given or performed
  • The payment amount approved and paid for by Medicare
  • The date on your Medicare statement

Reporting fraud not only helps protect yourself and others from unnecessary bills and expenses, but if your report is successful, you might be eligible for a reward of up to $1,000. So, make sure you stay alert, keep track of your dates and statements and always be on the lookout for potential Medicare fraud.

What’s the Big Deal?

You may be thinking right about now, “this isn’t my problem though, right? These people committing Medicare fraud are stealing from Uncle Sam’s deep pockets, and the government has it coming to them.   I would argue that Medicare fraud creates a ripple effect and impacts everyone. Medicare Fraud Strike Force estimated Medicare fraud cost American taxpayers approximately $10.8 billion in 2017.  It’s not just the government’s pockets getting pick-pocketed — it’s yours too.  Whether you have government-sponsored insurance or not Medicare fraud will ultimately drive up the cost of health care for everyone. 

Luckily, the hospitals you are trusting with your health are also taking action and cracking down on scammers. Not only are they putting confidential, anonymous hotline reporting solutions into place, like ETHIX360 offers, they also require down-stream vendors like ETHIX360 to pass stringent audits.  As the Chief Compliance Officer of ETHIX360, one of my most important responsibilities is to ensure all employees from the CEO to entry level have taken all the required compliance training, such as Fraud, Waste, and Abuse, and reviewed all applicable policies.    The healthcare community understands that Medicare fraud is everyone’s responsibility and they are doing their part as should you.  

Stephanie is a seasoned ethics and compliance (E&C) professional. She has earned an MA in both Business and Professional and Applied Ethics and is a graduate of The Ethics & Compliance Initiative Managing Ethics in an Organization Program. Prior to and during her E&C career, Stephanie served in the United States Marine Corps Reserves and the North Carolina Air National Guard.