18 October 2013

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US What is Medicare Fraud How to Prevent Medicare Fraud

US What is Medicare Fraud How to Prevent Medicare Fraud

Medicare fraud is a growing problem that costs American taxpayers billions of dollars a year.

While law enforcement efforts to combat fraud, waste and abuse within the Medicare program have come a long way, criminals are still hard at work trying to find a variety of ways to defraud the government and its U.S. taxpayers.

The Department of Health & Human Services (HHS) established and oversees multiple health care programs, including Medicare and Medicaid. Within HHS is the Office of Inspector General (OIG), whose task is to make sure criminals and fraudsters do not steal your Medicare funds.

What is Medicare fraud?

It is fraud when Medicare is billed for services or supplies you never receive. Medicare loses billions of dollars to fraudulent claims every year.

What are some examples of Medicare fraud?
A healthcare provider bills Medicare for services you never received.

A supplier bills Medicare for equipment you never got.

Someone uses your Medicare card to get medical care, supplies, or equipment.

A company offers a Medicare drug plan that has not been approved by Medicare.

A company uses false information to mislead you into joining a Medicare plan.

Why is it important to stop Medicare fraud?

Medicare fraud results in higher health care costs for everyone. Eliminating fraud cuts costs for families, businesses, and the federal government. It also increases the quality of services for those who need care.

What can we do to stop Medicare fraud?

Stopping fraud requires cooperation from everybody—the federal government, state governments, health care providers, insurers, law enforcement, and citizens like you.

Currently, four key programs are support the effort to crack down on Medicare fraud: 

The Affordable Care Act

 The Act, also known as the health care reform law, includes powerful steps toward fight health care fraud, waste, and abuse. Through its programs, the government has recovered more than $10 billion in the last three years.

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

This joint effort between the Department of Health and Human Services and Department of Justice brings together senior officials to lead Medicare Strike Force teams that raise the fight against fraud to a new level.

Senior Medicare Patrols

The administration has added new funding for Senior Medicare Patrols. These groups of senior citizen volunteers educate their peers to identify, prevent, and report health care fraud.

Public-Private Partnership to Prevent Health Care Fraud

This ground-breaking partnership unites public and private organizations in the fight against health care fraud. The voluntary, collaborative partnership includes the federal government, state officials, several leading private health insurance organizations, and other anti-fraud groups.

What successes have the anti-fraud efforts had so far?  

The government recovered a historic $4.1 billion in 2011, resulting in more than $10 billion recovered since 2008.

In its first year of implementation, the Centers for Medicare and Medicaid’s Fraud Prevention System:

Generated leads for 538 new fraud investigations

Provided new information for 511 existing investigations

Triggered 617 provider interviews and 1,642 beneficiary interviews

 In October 2012, Medicare Strike Force operations in seven cities led to charges against 91 individuals—including doctors, nurses, and other licensed medical professionals—for their alleged participation in Medicare fraud schemes involving approximately $432 million in false billing.

How to Prevent Medicare Fraud?

Protecting your personal information is the best line of defense in the fight against health care fraud and abuse. Medicare and Medicaid lose billions of dollars each year to scam artists. You can make a difference.

Protect your health care benefits

Don’t give your Medicare, Medicaid, or Social Security numbers to strangers.

Remember that Medicare does not call or visit to sell you anything.

Keep records of your doctor visits, tests, and procedures in your personal health care journal

Site exit disclaimer (PDF - 1.8 MB) or calendar.

Save your Medicare Summary Notices and Part D Explanation of Benefits.

Learn to protect yourself against identity theft.

Read Medicare’s lists of Do’s and Don’ts to prevent fraud.

Detect potential errors, fraud, and abuse

Even if you do everything right, there is a chance you could be a target of health care fraud. Keep a close eye on your medical records to quickly detect issues.

 Review your Medicare Summary Notices and Part D Explanation of Benefits for mistakes.

You can access your Medicare account 24 hours a day at

Compare your Medicare Summary Notices and Part D Explanation of Benefits to your personal health care journal Site exit disclaimer (PDF – 1.8 MB) and prescription drug receipts to make sure they are correct.

Look for three things on your billing statement:

Charges for something you didn’t get

Billing for the same thing twice

Services that were not ordered by your doctor

Ask questions. Ask your provider whenever you:
Don’t understand your bill
Don’t think you received a service listed
Feel the service was unnecessary

If you suspect errors, fraud, or abuse—report it

If you suspect errors, fraud, or abuse when you use Medicare—or if someone tries to sell you a product or service you don’t need—report it. Learn what to look for, and get details about preventing and detecting fraud.

What do I need to have to report errors, fraud, or abuse?

Before you report errors, fraud, or abuse, carefully review the facts and have the following information ready:

The provider’s name and any identifying number you may have.
Information on the service or item you are questioning.
The date the service or item was supposedly given or delivered.
The payment amount approved and paid by Medicare.
The date on your Medicare Summary Notice.
Your name and Medicare number (as listed on your Medicare card).
The reason you think Medicare should not have paid.
 Any other information you have showing why Medicare should not have paid.

Where do I report errors, fraud, or abuse?

To report suspected errors, fraud, or abuse, you can contact either:

HHS Office of Inspector General
Call: 800-447-8477
TTY: 800-377-4950
Online: Report Fraud Online
Mail: HHS Tips Hotline
P.O. Box 23489
Washington, DC 20026-3489


Centers for Medicare & Medicaid Services
Call: 800-633-4227
TTY: 877-486-2048
Mail: Medicare Beneficiary Contact Center
P.O. Box 39
Lawrence, KS 66044

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