What Is Medicare Abuse?

What is Medicare abuse?

Medicare abuse generally involves the illegal practice of falsifying Medicare claims to receive higher financial compensation.

Medicare fraud can come in many forms, such as billing for excess services or cancelled appointments. It can happen in any part of Medicare’s program, from original Medicare (parts A and B) to Medicare add-ons and Medicare Advantage (Part C) plans.

Common instances of Medicare fraud may include:

• billing for services above and beyond those performed
• billing for services that were not performed at all
• billing for cancelled or no-show appointments
• billing for supplies that were not delivered or provided
• ordering unnecessary medical services or tests for patients
• ordering unnecessary medical supplies for patients
• receiving kickbacks and incentives for patient referrals

Medicare fraud may also involve identity theft. This is when a person’s Medicare information is stolen and used to submit fraudulent claims.

The National Health Care Anti-Fraud Association estimates that fraud in the healthcare industry costs the government and taxpayers tens of billions of dollars. And while there’s no exact estimate of the magnitude of Medicare fraud, improper Medicare payments were estimated to be $52 billion in 2017 alone. Some of these cases were classified as Medicare fraud.

How to tell if you’re being targeted for Medicare abuse

The best way to determine if you’ve been a target of Medicare abuse is to review your Medicare summary notices. If you’re enrolled in a Medicare Advantage plan, you can review the billing statements from your plan.

Medicare summary notices show you all the Medicare Part A and Part B services or supplies you were billed for over a 3-month period. They also outline what Medicare paid for these services and the maximum out-of-pocket amount you may owe to your provider.

Medicare Advantage plan billing statements should show similar information regarding the services or supplies you received.

If you notice a service or supply on your bill that isn’t accurate, it could simply be an error. In some cases, making a call to the office can help sort out the mistake. But if you notice frequent billing errors on your statements, it’s possible that you are a victim of Medicare abuse or identity theft.

Not all Medicare fraud is billing related. Other signs of Medicare abuse may include any situation in which you are:

• charged for free preventive services
• pressured to have unnecessary services performed
• pressured to have unnecessary supplies or testing administered
• given promises of cheaper services or testing than is typical
• routinely charged a copay when you don’t owe one
• routinely given a copay waiver when you don’t qualify for one
• called or visited by an uninvited party selling Medicare plans
• lied to about the services or benefits you will receive under your plan

What to do if you’ve been a victim of Medicare abuse

If you believe that you have been a victim of Medicare abuse or fraud, here’s what you’ll need to have on hand to file a report:

• your name
• your Medicare number
• your provider’s name
• any services or items that are questionable or seem fraudulent
• any information on the bill related to payment
• the date for the claim in question

Once you have this information ready, you can call Medicare directly at 800-MEDICARE (800-633-4227). You’ll be able to speak directly with a Medicare agent who can help you file a Medicare fraud report.

If you’re enrolled in a Medicare Advantage plan, you can call 877-7SAFERX (877-772-3379).

You can also report suspected Medicare fraud to the Office of the Inspector General by calling 800-HHS-TIPS (800-447-8477) or filing an unclassified report online. To file a physical report, you can also write to the Office of Inspector General at P.O. Box 23489, Washington, DC 20026 (ATTN: OIG HOTLINE OPERATIONS).

After a report is filed, a variety of agencies will investigate the claim to determine whether Medicare fraud has been committed.

Ultimately, individuals who are convicted of healthcare fraud can receive up to 10 years in prison. This sentence is far more severe if the fraud has resulted in patient injury or death.

Who investigates Medicare abuse?

Federal and civil legislation is in place to prevent healthcare fraud like Medicare abuse.

For example, the False Claims Act (FCA) makes it illegal to submit false claims to the federal government, such as overcharging on medical services or supplies.

Additional laws, such as the Anti-Kickback Statute, Physician Self-Referral Law (Stark Law), and Criminal Health Care Fraud Statute, are intended to discourage acts that may be considered healthcare fraud.

Under these laws, multiple agencies handle cases of Medicare abuse. These agencies include:

• The U.S. Department of Justice (DOJ). The DOJ is responsible for enforcing the laws that prohibit healthcare fraud, like Medicare abuse.
• The Centers for Medicare & Medicaid Services (CMS). The CMS oversees the Medicare program and handles claims related to Medicare abuse and fraud.
• The U.S. Department of Health & Human Services (HHS). The HHS oversees the Office of Inspector General and the CMS.
• The HHS Office of Inspector General (OIG). The OIG helps to detect healthcare fraud by conducting investigations, imposing penalties, and developing compliance programs.

Once Medicare fraud has been identified, each agency plays a role in investigating and charging Medicare abuse to the fullest extent of the law.

The takeaway

Medicare abuse is a form of healthcare fraud that costs taxpayers and the government billions of dollars each year.

Common practices of Medicare abuse include billing for unnecessary or different procedures, ordering unnecessary supplies or tests, or even stealing another individual’s Medicare information to submit false claims.

If you suspect that you are a victim of Medicare abuse, call 800-MEDICARE (800-633-4227) to speak to an agent for more information on what to do next.