Medicare Fraud Reporting

Basics

Medicare fraud usually involves falsified billings, such as those for services that were not provided. For instance, a provider submits a fake bill to Medicare for medical services, drugs, or equipment that were never provided. Additionally, a person might use someone else's valid Medicare card to obtain health care services or equipment.

Significance

The U.S. Department of Health and Human Services (HHS) facilitates the Medicare program. While various federal agencies work with the HHS to minimize Medicare fraud, scam artists continue to game the system, as Medicare fraud often is detected in hindsight. For instance, the HHS discovered that inhalation drugs provided in South Florida were likely tied to fraud due to an extremely high percentage of claims. Two percent of Medicare participants resided in the South Florida area, yet the area accounted for 17 percent of Medicare's total spending on inhalation drugs.

Effects

To prevent fraud, beneficiaries should provide their Medicare card only to their physicians and providers. For instance, Medicare recipients should avoid accepting services that are promoted as "free" after a Medicare Health Insurance Claim Number is provided.

Considerations

Medicare recipients can personally report fraudulent activity. Each beneficiary receives a Medicare Summary Notice that summarizes procedures received. If an unknown procedure is identified, then the HHS suggests that beneficiaries contact their physicians or providers to address concerns. Beneficiaries also can contact the Office of Inspector General confidentially by phone at 1-800-HHS-TIPS, by email HHSTips@oig.hhs.gov, or by mail at P.O. Box 23489 Washington, DC 20026. Helpful information includes the provider's name with identification number, date of service, amount approved, and reason why the amount should not be paid.

Potential

Under the Clinton administration, an incentive reward program was established to address Medicare fraud. For every complaint received that leads to at least a $100 recovery and does not relate to an ongoing investigation, the beneficiary can receive a percentage of the recovered amount. In the United States, Medicare refers to the health care program provided through the Social Security Act for people over 65 years old or with a qualifying disability. Medicare fraud differs from simple clerical errors that a provider accidentally might make. Medicare fraud is intentional, costs billions of dollars each year and, according to the Government Accountability Office, is a pervasive problem.