If I Suspect That a Provider is Committing Medicare Fraud or Abuse; What Should I Do?Medicare fraud occurs when someone knowingly deceives Medicare to receive payment when they should not, or to receive higher payment than they should. Medicare abuse involves billing Medicare for services that are not covered or are not correctly coded, when the provider has unknowingly and unintentionally misrepresented the facts to obtain payment. Some common examples of Medicare fraud or abuse are:

  • Billing for services or supplies that were not provided
  • Providing unsolicited supplies to beneficiaries
  • Misrepresenting a diagnosis, a beneficiary’s identity, the service provided, or other facts to justify payment
  • Prescribing or providing excessive or unnecessary tests and services
  • Violating the participating provider agreement with Medicare by refusing to bill Medicare for covered services or items and billing the beneficiary instead
  • Offering or receiving a kickback (bribe) in exchange for a beneficiary’s Medicare number
  • Requesting Medicare numbers at an educational presentation or in an unsolicited phone call

You can watch out for fraud by keeping a calendar of all of your medical appointments and comparing it with your Medicare statements (Medicare Summary Notices (MSNs) if you have Original Medicare and Explanations of Benefits (EOBs) if you have Medicare Advantage) and bills from your providers. If something does not seem right—for example, if you see in your MSN that your provider billed Medicare for an office visit on a day when you did not see them, you should first contact your provider. Call your doctor or their billing office and let them know about the problem in case it was a billing error. If your doctor does not fix the error or if you continue to suspect fraud or abuse, you can call:

  • Your Senior Medicare Patrol (SMP): Your SMP can help you identify Medicare fraud, abuse, and errors, and can help you report fraud or attempted fraud to the correct authorities. To find your SMP, call 877-808-2468 or visit smpresource.org.
  • The Office of the Inspector General fraud hotline: If the Inspector General’s staff determines that your complaint is worth further study, the complaint will be sent to the appropriate agency for review. The complaint resolution process usually takes at least six months. The hotline number is 1-800-HHS-TIPS.

Read More: If a Plan is Engaging in Inappropriate or Misleading Marketing; What Should I Do?
Learn About: As a Medicare Beneficiary What Other Resources are Available to Me?
Return to: Medicare In-Depth

If I Suspect That a Provider is Committing Medicare Fraud or Abuse; What Should I Do?Medicare fraud occurs when someone knowingly deceives Medicare to receive payment when they should not, or to receive higher payment than they should. Medicare abuse involves billing Medicare for services that are not covered or are not correctly coded, when the provider has unknowingly and unintentionally misrepresented the facts to obtain payment. Some common examples of Medicare fraud or abuse are:

  • Billing for services or supplies that were not provided
  • Providing unsolicited supplies to beneficiaries
  • Misrepresenting a diagnosis, a beneficiary’s identity, the service provided, or other facts to justify payment
  • Prescribing or providing excessive or unnecessary tests and services
  • Violating the participating provider agreement with Medicare by refusing to bill Medicare for covered services or items and billing the beneficiary instead
  • Offering or receiving a kickback (bribe) in exchange for a beneficiary’s Medicare number
  • Requesting Medicare numbers at an educational presentation or in an unsolicited phone call

You can watch out for fraud by keeping a calendar of all of your medical appointments and comparing it with your Medicare statements (Medicare Summary Notices (MSNs) if you have Original Medicare and Explanations of Benefits (EOBs) if you have Medicare Advantage) and bills from your providers. If something does not seem right—for example, if you see in your MSN that your provider billed Medicare for an office visit on a day when you did not see them, you should first contact your provider. Call your doctor or their billing office and let them know about the problem in case it was a billing error. If your doctor does not fix the error or if you continue to suspect fraud or abuse, you can call:

  • Your Senior Medicare Patrol (SMP): Your SMP can help you identify Medicare fraud, abuse, and errors, and can help you report fraud or attempted fraud to the correct authorities. To find your SMP, call 877-808-2468 or visit smpresource.org.
  • The Office of the Inspector General fraud hotline: If the Inspector General’s staff determines that your complaint is worth further study, the complaint will be sent to the appropriate agency for review. The complaint resolution process usually takes at least six months. The hotline number is 1-800-HHS-TIPS.

Read More: If a Plan is Engaging in Inappropriate or Misleading Marketing; What Should I Do?
Learn About: As a Medicare Beneficiary What Other Resources are Available to Me?
Return to: Medicare In-Depth

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