Most providers handle Medicare properly, but some purposely engage in fraud.
In the United States, people over age 65 or disabled may qualify for health insurance through the federal government's Medicare program. However, cases of fraud riddle the program. Criminals may get away with cheating the government partly because there are many types of Medicare fraud that agents have to catch.
Types of Fraud
In general, providing any purposely-inaccurate information to a patient or Medicare representative constitutes Medicare fraud. Specifically, Medicare fraud may involve charging for new or expensive services or items, when the provider actually provided used or cheap items. It also can involve billing for services or medications never provided, performing unnecessary or inappropriate procedures, and billing for hours never worked by medical employees. Medicare fraud also includes waiving copayments without checking the patient's ability to pay, and billing multiple times for the same procedure or medication. Additionally, it can include using a different billing/diagnostic code for higher reimbursement, inserting additional billing/diagnostic codes into reports when those codes are not applicable, and using separate codes when a code "bundle" is more appropriate.
Importance
Any time a person commits Medicare fraud, the burden of the fraud falls onto the 46 million Americans who use the program. Because the Medicare program must try to make up for its loss, Medicare representatives end up charging higher premiums.
Impact
A report by CBS "60 Minutes," claims criminals take away as much as $60 billion dollars annually from the Medicare program. In some areas, In terms of revenue, Medicare fraud is comparable to other criminal activity, such as trafficking drugs. Florida is an area hit particularly hard by Medicare fraud.
Signs
You should suspect Medicare fraud if a provider claims a test, procedure or medication is free but still wants your Medicare number, according to the Medicare website. You also should suspect fraud if the provider indicates doing more tests will be cheaper, or offers payments or gifts if you go to a clinic or hospital. Medicare fraud may be happening if someone claims to represent Medicare and is not your physician.
Reporting Fraud
If you suspect Medicare fraud has happened or is occurring, report it right away to the inspector general by phone, fax or mail. Give the representative the provider's name and identification number, the item or service in question, the date of service, the amount paid by Medicare, the date of the summary notice, the name and Medicare number of the person who received the service and the reason you believe fraud has occurred. Any other proof you may have to support your case is beneficial.
Office of the Inspector General
HHS TIPS Hotline
P.O. Box 23489
Washington DC 20026
800-447-8477
