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May 19, 2011

Medicare Fraud - Avoiding Abuse

In the complicated world of medicine, billing mistakes can happen. The doctor's office staff may use the wrong code on a Medicare claim. They could even put the wrong patient name on a claim. These mistakes are usually innocent and may not be outright Medicare billing fraud, but they can cost you money.

That is why it is a good idea to check your payment notice carefully. Whenever Medicare or your private insurance company pays a claim for health services, they will send you a notice explaining your benefits. This notice describes the service you received along with a special code that is used for that particular service. It also states the total charged amount, how much the insurance paid, and your share of the cost.

If you think the description or the amount charged is a mistake, tell your doctor. Someone in the office will check it out and either explain it to you, or submit a correction if it was a mistake.

There are some individuals, however, that abuse or defraud the Medicare system. An example of Medicare abuse might be someone who uses another person's Medicare ID card for health care services or supplies. Medicare billing fraud could involve a health care provider billing an insurer for services you never received. Or they might bill Medicare for equipment that has been returned. This Medicare billing fraud and abuse can cost the Medicare system millions of dollars each year. That cost can result in higher premiums.

Medicare takes action to ensure they do business with doctors and suppliers who provide quality health care. The Centers for Medicare & 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.

They also rely on you and your doctors to report suspected Medicare fraud. Here's how you can help:

Prevent Medicare fraud and abuse

  • Give your Medicare ID card or claim number ONLY to your doctor or health care providers. Do not 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 personally need.
  • Be wary of "free" medical services, especially when asked to provide your Medicare ID card. Understand the difference between "free" and "no copay" for some services such as preventive care or flu shots.
  • 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 copays unless your plan specifically waives it. Conversely, be suspicious of providers who charge copay for a service where the copay should be waived.
  • Know that the federal government and Medicare do not "endorse" any health care provider. Be cautious of anyone who claims otherwise.
  • Know what is not covered by Medicare or your insurance plan and be cautious of anyone who claims they know how to get Medicare to pay for it.

Report Medicare fraud and abuse

If you suspect Medicare billing fraud or Medicare abuse, report it to the Office of Inspector General. Provide as much information as possible, including the suspected Medicare fraud and/or abuser's name, address and telephone number, to help the investigation. Your tip will be handled accordingly, but do not expect a reply.

  • Call 1-800-HHS-TIPS (1-800-447-8477), TTY: 1-800-377-4950
  • Fax a letter to 1-800-223-2164 (10 page limit)
  • 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

If you live in Florida, report the suspected Medicare billing fraud to the Florida Fraud Hotline at:

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Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare and provide Medicare Part A and Part B coverage. Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. A Medicare Supplement plan is a health insurance plan provided by a private company that fills in the "gaps" in original Medicare coverage.