Understanding and Recognizing Medicare Fraud

September 20, 2020



September 20, 2020

Do you have an older friend or relative who has a hard time hanging up on telemarketers? 

It’s estimated that up to 10% of healthcare spending was on fraudulent activity in recent years.

Medicare fraud is hard to spot and often goes undetected. Being able to identify and avoid this fraudulent activity will save taxpayers on unnecessary costs and allow the government to continue to have money to fund Medicare. 

What is Medicare Fraud?

Fraud in healthcare can happen in a few different ways: 

  1. Healthcare providers can bill for services that weren’t provided. Oftentimes, this is in the form of billing for a more expensive version of what was actually provided.

  2. Healthcare providers can suggest, and then bill for, unnecessary services. A likely example of this is a diagnostic test, such as an MRI, that wasn’t actually needed.

  3. Services can be billed for individually, rather than in a commonly defined bundle, so that the reimbursement to the healthcare provider is higher.

  4. A healthcare provider can expect the patient to pay the outstanding balance on a bill even when they, and their insurance company, have already paid their share. This is called balance billing.

These are only just some of the ways that Medicare fraud can occur. There are also many ways that a scammer, who is not a healthcare provider, can trick someone into believing they owe money to Medicare. 

For example, a  “Medicare sales person” might have recently called your house, sent you an email, or knocked on your door. This is a big red flag, as Medicare doesn’t sell anything. Ever.

Not only are fraudulent costs inaccurate and cost patients money, but they can also lead to false claims on medical records. Doctors won’t know that these services or diagnostic tests weren’t actually performed, which could lead to mistakes later on. That’s why it’s important for patients to spot Medicare fraud.

How Patients Can Prevent Medicare Fraud

Some of the populations most vulnerable to fraud are those in poverty, with poor English skills, and the elderly.

Review your bills

As patients, we can start to become aware of all costs - and potential scams - by reviewing medical bills for errors. This can be compared to your Explanation of Benefits (EOB), which usually arrives before the bill itself. 

While going through the bill and EOB, match all the services to each other and ensure you actually received them. Remember that healthcare providers can “upcharge” to increase their reimbursement amount. You can use the FAIR Health Consumer tool to review codes and their cost. 

If you notice something on the bill that doesn’t seem right, contact your insurance company to report the finding. They should be happy to walk you through the bill, because at the end of the day, it could save them money, too. 

Don’t fall for false advertisements

We all like to win prizes, but don’t fall for advertisements claiming free equipment through Medicare. Speak with your doctor about anything you think you need, such as new equipment. Together, you can verify if it's covered before ordering it in a secure way.

Medicare communicates by mail only. That means that you should never accept phone calls from someone claiming to be with Medicare. Remember, Medicare does not have “salespeople” and therefore no one should be knocking on your door or calling you.

There are lots of scams that happen over the phone. Don’t give anyone your information, including your Medicare number or banking information, under any circumstances.

Report Medicare fraud

You can report Medicare fraud if you think that you have been targeted with Medicare fraud. In addition to saving the government money, you may also be eligible for a reward for issuing the report.