What You Need to Know About Medicare Fraud

Updated for November, 2021

In July of 2017, the U.S. witnessed the largest healthcare fraud takedown this nation has ever seen. By the time this joint effort conducted by the Department of Health and Human Services Office of the Inspector General (OIG) and state and federal law enforcement agencies was done, more than 400 defendants were charged in a court of law and accused of participating in some type of fraudulent Medicare and/or Medicaid scheme.

Senior Bills Medicare

“Medicare fraud” is actually a blanket term encompassing different fraudulent activities related to the Medicare system.

What is perhaps most staggering is the amount of money alleged to be falsely billed by this collection of once-trusted medical professionals and agencies. The total? Somewhere around $1.3 billion.

The large sums of money being scammed out of elderly people is part of the reason why Medicare Fraud Strike Force Teams across the country spend their days trying to shut down these types of dishonest healthcare professionals. In some cases, they net extremely positive results.

For instance, as of mid-2018, there were already 11 court cases involving the Strike Force Teams where healthcare professionals committing fraudulent activities have either pleaded guilty to, been convicted of, or received a sentence for committing some form of healthcare fraud.

What are these individuals doing that makes them guilty (or allegedly guilty) of Medicare fraud? There is a number of potential answers.

Every dollar they fraudulently take is a dollar that can’t be spent elsewhere to help U.S. citizens live a better life.

Sure, it may not seem like this is a huge problem, especially with only 15 total Strike Force cases in the news through half of 2018, but it’s important to realize that many of these investigations involve millions upon millions of dollars. Furthermore, this is money that has essentially been stolen from the U.S. government, which also means that it has been stolen from every tax-paying citizen.

For instance, the DOJ reports that in June 2018 four physicians and a CEO from Michigan and Ohio were charged in a scheme that included a number of healthcare frauds and kickbacks. The total amount of money taken was approximately $200 million.

To give a better idea of how this amount could impact our society as a whole, funding for all of the Violence Against Women Act (VAWA) and related programs for the entire year of 2018 is $215 million, according to the National Network to End Domestic Violence. Based on the actions of these five individuals alone, they could have essentially wiped out this entire domestic violence division by taking the amount of money they did.

This doesn’t even account for the countless other healthcare providers who have either been charged or convicted of taking their unfair share of payments from the Medicare system. Put simply, every dollar they fraudulently take is a dollar that can’t be spent elsewhere to help U.S. citizens live a better life. There are individual effects of Medicare fraud, too.

sad senior medicare

This type of fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage.

For starters, it’s simply maddening to think that individuals who commit these types of offenses are bringing in much more than the typical, hard-working family earns just to survive. For instance, Money reports that the median real income is $54,635 for households in Michigan and $57,259 for a household in Ohio.

Based on these numbers, the physicians and CEO in the previously discussed case fraudulently received roughly 727 times that amount (which was calculated using $200 million divided by the five defendants, equaling about $40 million each). And they did so solely by billing the government’s healthcare system for services not rendered and taking kickbacks along the way.

The NHCAA adds that these fraudulent activities hit individual Americans financially as well. How? Because, added together, this type of fraud “inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage,” according to the NHCAA. In other words, the losses that occur due to these fraudulent activities have to be made up for somewhere. Sadly, that ‘somewhere’ is often from the individuals receiving coverage.

The NCHAA further says that Medicare fraud can result in negative physical consequences for patients as well. This occurs when healthcare professionals and agencies perform unnecessary or unsafe medical procedures just to increase their billing amounts. Depending on the procedures, the damage to the individuals involved can be devastating.

In an article published by CNN, Dr. Sei Lee, associate professor of geriatrics at the University of California-San Francisco, shares that medical professionals can end up doing more harm than good when running cancer tests on older patients—those unlikely to benefit from being diagnosed with a slow-growing tumor.

Dr. Deborah Korenstein, chief of general internal medicine at New York’s Memorial Sloan Kettering Cancer Center added to the piece, indicating that this harm oftentimes appears as a result of testing that leads to “anxiety, invasive follow-up procedures and harsh treatments.” Admittedly, the doctors in this article aren’t accused of committing Medicare fraud, but the effects of being subjected to unnecessary medical testing and treatments is still the same.

What can you do to protect yourself from the various types of Medicare fraud? One of the first things involves protecting your card.

Medicare is so intent on stopping the frauds committed against the system that they even offer a 10 percent or $1,000 reward for sharing this type of information.

According to Medicare.gov, you should always “treat your Medicare card like it’s a credit card.” In other words, don’t give the number out to just anybody, because there’s a chance it could be used to open up a fraudulent claim.

Granted, it isn’t possible to hide your number from your healthcare provider because he or she will need it for billing purposes. However, you don’t want to give it out to anyone else, even if they offer you something of value (like money or a free gift) in exchange for free medical care.

But what if someone calls you saying they’re from Medicare and then requests your personal information over the phone? Medicare.gov says there are only two instances in which this agency will ever call you and request this type of information:

  1. The first is if they’re from a Medicare plan that you’re already a member of, which automatically rules out anyone who calls you about a plan that you’re not currently on.
  2. The other is if you called them and left them a message and they are calling you back.

Other than these two instances, if you get a phone call from someone claiming to be from Medicare and asking for your number, don’t give it out as this is likely a scam. Some may even threaten to cancel your benefits if you are unwilling to give up the information, but don’t fall for this. Instead, if there is ever a question about the validity of the call or caller, just hang up and call Medicare directly at (800) 633-4227 to let them know what happened. If they were the ones that called, they can connect you with the correct person or department.

It’s also important to realize that between April 2018 and April 2019, all Medicare recipients will receive new identification cards. These red, white, and blue cards will automatically be sent to you at the address listed on your Social Security account, so there is no need to call and request it. Also, the number on the card is different than your Social Security Number, which better protects your identity.

If you’re already on a Medicare plan, this new card will not change your coverage or benefits. However, Medicare.gov does suggest that you keep your old identification cards if you’re in a Medicare Advantage Plan (HMO or PPO) because your healthcare provider may ask to see it too. Other than that, once you get the new card in the mail, which is a paper card so it is easier for your healthcare providers to copy, you can destroy your old one.

Don’t be afraid to inquire about how much Medicaid is going to be billed for any testing the doctor wants to run or for the prescriptions prescribed.

There are other things you can do to avoid being a victim of Medicare fraud.

Medicare.gov suggests that you always take the time to ask questions about your medical care and how it relates to your specific Medicaid plan. Don’t be afraid to inquire about how much Medicaid is going to be billed for any testing the doctor wants to run or for the prescriptions he or she prescribes. You have every right to know this information.

Additionally, if your healthcare provider ever mentions knowing how to bill your Medicaid policy so it pays when it shouldn’t, consider this a red flag. By taking this type of action, he or she is committing fraud against your plan.

Medicare.gov also recommends learning as much about Medicare as possible so you are aware of what types of services and procedures can be billed under your policy and which ones cannot. If you’re not sure and want to find out, perform an online search to find you the information you want.

Another way to keep from being a victim of Medicare fraud is to double-check your Medicare statements when you receive them. This requires taking a moment to compare the dates of your doctor’s appointments and/or medical tests with those listed on the form. Keeping track of them on a calendar makes this process easier because all you have to do is check one against the other. Also, double-check the diagnoses listed on the statement to ensure those are correct as well.

While these are just a few of the things you can do to better protect yourself from becoming a victim of Medicare fraud, Medicare.gov says there are some things you don’t want to do. These include not letting anyone talk you into medical services you don’t need, not accepting medical supplies from anyone who comes to your door to sell them to you, and not letting anyone review your medical records beyond your normal healthcare providers.

Performing these actions can help prevent any type of Medicare fraud that occurs against you as the patient. Yet, despite your best efforts, you may someday have suspicions of fraud or learn that your medical records have been compromised. What should you do then?

Take a few preventative actions and report any suspected fraud immediately.

If you believe that you are a victim of Medicare fraud or if you have unequivocal proof, the first thing you want to do is report it to the authorities. Medicare.gov shares that there are three ways to do this:

  1. Call Medicare.gov at (800) 633-4227
  2. Call the Office of the Inspector General at (800) HHS-TIPS (800-447-8477)
  3. File an online report with the Office of the Inspector General

Regardless of which option you choose, you will need certain information handy before you can file a report. 

  • Your name and Medicare number
  • Allegedly fraudulent provider’s name and identifying information
  • The item or service you’re questioning and the date it was allegedly provided or performed
  • The amount paid by Medicare
  • The reason(s)
  •  why you believe it shouldn’t been covered

Medicare is so intent on stopping the frauds committed against the system that they even offer a 10 percent or $1,000 reward (whichever is less) for sharing this type of information. 

To be eligible to receive the reward, the suspected fraud of course must be confirmed. Additionally, the individual or organization involved cannot already be under investigation for this type of offense, and the fraud has to lead to the recovery of a minimum of $100 in Medicare money. Obviously, you also cannot have been involved in the fraud or the recipient of another fraud-based award under any other qualifying government program.

Medicare fraud is a big business, especially with the many types of fraud that exist. However, as long as you take a few preventative actions and report any suspected fraud immediately, then you’re doing your part to put an end to dishonest healthcare providers intent on earning more than they deserve.