Medicare Fraud and Scams

There are two major types of Medicare fraud: Billing fraud and marketing fraud.

Billing fraud happens when you, a doctor, or health care provider bills Medicare for something you didn’t receive, or for more than it cost. Marketing fraud happens when an insurance agent misleads you about certain coverage.

More than a million health care providers, contractors and suppliers receive payments from Medicare. And nearly 7.5 percent of Medicare spending went to people or companies committing fraud in 2017, according to an investigation by the Government Accountability Office.

The GAO reported Medicare fraud totaled about $52 billion in 2017 and only about $1.4 billion of that was recovered.

If you think you’ve witnessed or been a victim of Medicare fraud, you should report it immediately.

Suspicious payments or unusual amounts on your Medicare Summary Notice can alert you to possible Medicare fraud.

Medicare billing fraud happens when someone bills Medicare too much or charges for services or products that you don’t need.

If you have Original Medicare, you should check your Medicare Summary Notice that arrives in the mail every three months for signs of Medicare fraud. The MSN will list all services and medical products that Medicare paid for during that three month period.

If you have Medicare Advantage, check your Explanation of Benefits (EOB) mailed to you from your plan.

And if you see unusual charges such as items you did not receive or durable medical products you’ve returned, you should report possible fraud to Medicare.

Medicare marketing fraud happens when someone from a private insurance company tries to deceive you about differences between Original Medicare and Medicare Advantage, prescription drug coverage or Medigap plans offered by private insurers.

An agent may try to convince you that if you buy a certain plan, you’ll receive extra benefits that are actually already part of your Medicare coverage. Or they may claim the only way you can get prescription drug coverage is to buy a Medicare Advantage plan.

Make sure you know exactly what a plan includes and ask for all information in writing. If you have proof that an agent has lied to you, keep the marketing materials and the agent’s card so you can report it.

If you buy a plan and it turns out later that you didn’t have the coverage you were promised you should also report it right away. You may be eligible for a Special Enrollment Period from Medicare to switch to another plan.

The GAO’s 2017 report recommended better training in how to spot fraud as one of the ways to reduce Medicare fraud. There are steps you can take to prevent, avoid and report Medicare fraud.

Medicare abuse includes billing Medicare for any unnecessary medical service or product that does not meet professionally recognized standards of care. Abuse can be anything that directly or indirectly contributes to unnecessary costs to Medicare.

Unlike Medicare fraud, which is a crime, Medicare abuse may not always be illegal, but health care providers may have to pay a civil fine or penalty if they commit abuse.

“The difference between ‘fraud’ and ‘abuse’ depends on specific facts, circumstances, intent and knowledge,” according to the U.S. Centers for Medicare & Medicaid Services.

Medicare abuse can include accidents, inefficiencies and illegal actions that cost Medicare more than it should be paying.