Avoid and Report Medicare Fraud & Abuse
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Medicare tries to ensure business with quality doctors and health-care providers, both to help its beneficiaries and for the program's own well-being. However, in the normal course of medical business, unpleasant things can happen, like billing mistakes and, most alarmingly, Medicare fraud and abuse.
Medicare fraud is the general term for someone, such as a doctor, knowingly billing the Medicare system for a service or supply that a beneficiary didn't get.
Medicare Billing Errors
Billing errors are often innocent mistakes not intended to defraud the Medicare system. For example, a doctor may use the wrong medical code on a claim submitted to Medicare. Even though the service description sounds right, the wrong code could change how much you pay out of pocket. This one-time, innocent mistake is not a case of Medicare fraud.
In order to avoid billing errors, be sure to pay close attention to the payment notice you receive from Medicare or your insurance company. If you suspect a mistake, immediately talk to your doctor or a staff member about it. They'll either explain to you why the payment notice is correct, or they will fix the error.
Medicare Fraud
Medicare fraud is illegal, so it's more serious than a billing error. Medicare fraud involves doctors or beneficiaries abusing the Medicare system for their own personal gain.
Medicare billing fraud means knowingly billing Medicare - possibly over and over again - for products and services that were not medically necessary, accurately coded, or for an actual beneficiary. You can help detect Medicare billing fraud by carefully reviewing your payment notice. This is the notice you get whenever a doctor or health care provider bills Medicare or your insurance company for a health care product or service. The notice identifies the product or service and lists the total amount billed, the amount Medicare or your insurance company paid to the provider, and the amount you owe.
Also, beware of providers who:
- Tell you that the more tests they perform, the less you pay out of pocket
- Use telemarketing (calling you at home) and door-to-door sales
- Offer gifts as incentives to use their services
- Routinely waive copay's or routinely charge copay's, even though your plan makes the service available with no copay
- Tell you they know how to get Medicare to pay for something that's not covered under your plan
- Claim that Medicare endorses their products or services
Here are two more examples of Medicare fraud:
- Someone besides you uses your Medicare card to receive products or services. Never give or lend your Medicare card to anyone except your health-care providers.
- You ask your doctor for medication, products or services that you don't need for yourself.
Medicare Abuse
Medicare abuse happens when a provider doesn't follow good medical practices, including performing services that are not medically necessary. It is as serious an offense as Medicare fraud. Medicare abuse, like Medicare fraud, is illegal and punishable to the full extent of the law.
Report Medicare Fraud & Abuse
If you suspect Medicare fraud or abuse, you should report it right away. The Centers for Medicare & Medicaid Services (CMS), which administers Medicare, is cracking down on this type of activity. The agency is working with beneficiaries, doctors, and federal agencies - such as the Department of Justice - to detect and prosecute those who commit Medicare abuse and Medicare billing fraud.
To report Medicare fraud or abuse, you can do any of the following:
