How to Protect Yourself From Medicare Fraud

10 minute read

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Updated for December, 2019

Just about every week of the year, a person or group of people is found to have committed Medicare fraud. And the fraud doesn’t amount to thousands of dollars—we’re talking millions. Just in November 2018, there were two people in Dallas, Texas who were charged with close to $6 million in fraudulent activity. In that same month, a Detroit clinic owner was sentenced to jail for more than a decade due to a $9 million Medicare fraud scheme. The FBI’s white collar crime unit releases dozens of press releases every year catching doctors and scammers in Medicare fraud, too.

Medicare Costs

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The effects of Medicare fraud impact everyone involved with the Medicare billing process, but most importantly, they affect you, your health, and your wallet. So before we discuss how to identify fraud and how to prevent it, let’s talk about who is affected by Medicare fraud and the scope of how much it can cost you.

It’s difficult to pinpoint exactly how much money is wasted by Medicare fraud, specifically because there’s so much of it. The Council for Medicare Integrity, a non-profit, independent watchdog, predicted that in 2017 Medicare paid out about $36 billion—almost 10 percent of all Medicare payouts—in erroneous payments to medical providers around the country. This number includes billing errors and fraud, because it’s difficult to tell which billing errors were made intentionally or not. For 2018, the error rate was about 8 percent, resulting in about $31.5 billion in waste.

However, there is a team of people who seek out those committing fraud all around the country with the goal of recouping some of the lost billions of dollars paid out to Medicare claims. Medicare’s Fraud Strike Force has teams in major metropolitan areas like Miami, Los Angeles, New York City, and Philadelphia to help stop these schemes. Overall, there are more than a dozen teams that aim to “prevent and combat health care fraud, waste, and abuse,” according to the Strike Force’s website. They primarily focus on people who are intentionally improperly billing for services administered to the elderly, whether it’s claiming you received more services than you did, were prescribed certain drugs that you never filled, or other fraudulent activity.

The Medicare Strike Force Team operates under the Office of Inspector General, which is a branch of the Department of Health and Human Services. This is the same department that the Centers for Medicare and Medicaid Services is under. The Strike Force reports that they have caught more than 4,000 people who have improperly billed for more than $14 billion total since the initiative started in 2007.

Generally speaking, you should be skeptical of all billing. Medicare is there to cover services for you, so if you’re paying exorbitant costs each time you go to the doctor, this could mean that something is wrong.

While it’s important to know how to report fraud if you suspect it or if it actually happens to you, it’s best to know how to prevent fraud in the first place. Generally speaking, you should be skeptical of all billing. Medicare is there to cover services for you, so if you’re paying exorbitant costs each time you go to the doctor, this could mean that something is wrong. It doesn’t hurt to ask questions of all sides, from your medical provider to the Medicare system itself.

Seniors Bills Fraud

Here are some tips you can follow in your medical dealings:

Keep your Medicare card in safe place:

Your Medicare card has vital information on it. While the identification number is changing from your SSN to a randomized 11-digit number, it still has vital information such as your full name, birthday, and coverage. Treat this number like your SSN or bank account information. Only give it to trusted sources such as your primary care physician, people who they refer you to, and Medicare officials.

Keep track of services you received from who and when:

Whenever you visit the doctor or fill a prescription, keep a receipt or invoice of the services or prescriptions you received. The receipt should be detailed to show you what you received, when you received it, and how much you paid for it. If the provider doesn’t offer one—or they make excuses to not give you one—that’s a cause for concern. A receipt will also help timestamp the date of your services, even if you paid for them later.

Confirm exactly what was covered by Medicare and what wasn’t:

If you have to pay for services—which often occurs through coinsurance, copayments, and deductibles—ask the medical provider which parts were covered by Medicare and which parts weren’t. Once the medical provider details that for you, if you suspect an issue or fraud, contact Medicare or your private Medicare insurer to see if the services rendered should have or shouldn’t have been covered. You can view a list of the services, items, and tests are covered under Medicare here.

Don’t give private information over the phone or email:

Never give away your SSN number, your Medicare ID, bank account information, medical records, or any other sensitive information over the phone or email. If the situation described to you—like an update of medical records or the need for an immediate payment or else your coverage will be dropped—sounds dire, then ask for them to confirm multiple levels of information they should know about you, such as as your birthday and full name, before doing anything. From there, you can visit whoever you need to in person to fix the issue, if there actually is one.

Get a second opinion:

If you don’t think you need a certain service being offered, it’s okay to get a second opinion—these are often covered by Medicare, too. You shouldn’t be pressured into getting a procedure you’re not sure you need. A second opinion can help you determine if you should question the first doctor or not.

If you have any questions regarding Medicare fraud, contact the Centers for Medicare and Medicaid Services or the Office of Inspector General.