Friday, July 12, 2024

How To Prevent Medicare Fraud

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Handle Identity Cards Carefully

Medicare & You: Preventing Medicare Fraud

Healthcare identity theft is rampant. Carefully handle your insurance, Medicare, and social security cards. Dont give them to anyone other than your doctor or Medicare provider. Protect them as you would your credit cards. If they fall into the wrong hands your entire medical history could be compromised.

Report Medicaid Fraud & Patient Abuse

Report Medicaid provider fraud or patient abuse to the Attorney Generals Medicaid Investigations Division at 881-2320. You can also report fraud or abuse online HERE.

Fraud by Medicaid recipients such as fraudulent eligibility or transfer of assets should be reported to the North Carolina Division of Health Benefits or to your Local County Department of Social Services.

Addressing Documentation Coding And Billing Processes To Avoid Misconduct

While a compliance program is the foundation for healthcare fraud and abuse prevention, providers should also consider improving their medical billing and coding processes.

Clinical documentation is the basis upon which payers reimburse providers for their services. Inaccurate and inappropriate coding can lead to potential healthcare fraud and abuse investigations.

Common clinical documentation and coding issues include billing for the following:

  • Services that were not rendered
  • Medically unnecessary procedures
  • Services performed by an improperly supervised or unqualified employee
  • Procedures or tests of such low quality they are deemed worthless

CMS has advised providers to be particularly mindful of upcoding, or requesting a higher reimbursement rate for services that do not merit that level of compensation. Providers may upcode claims in order to maximize their claims reimbursement.

“Providers should be proactive in evaluating their billing data and comparing it to similar providers locally, regionally and nationally.”

Providers should also benchmark their medical billing data against industry standards, Michael J. Bittman, a Broad and Cassel law firm partner, advised in a 2016 Orlando Business Journaleditorial.

To avoid illegal kickback schemes with investment partners, the federal agency recommends that providers ask the following questions:

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Falsifying Records Or Claims

Falsifying Records or Claims

Doctors perform a procedure that isnt covered by your health plan, so they bill us for a different service thats covered by your plan. For example, they perform a tummy tuck but bill us for a hernia repair.

Doctor Shopping

Health care professionals arent the only ones capable of abusing the system. In this case, a member decides to visit many doctors, pharmacies or emergency rooms to get multiple prescriptions for the same medicine.

Using Brand-Name Drugs

A doctor prescribes a brand-name drug when theres a lower-cost generic option that works exactly the same way.


Say youre not feeling well and you head to the doctors office. When you get there, only a nurse is available to see you. Upcoding happens when your doctors office lies and bills the insurance company as if you saw the doctor, which is a more expensive service.


This ones interesting because the services are covered, but theyre billed separately so the practice can make more money. For example, a doctor bills the insurance company for several different tests as if they were done separately when you really just had one comprehensive test done.

Poor Care Coordination

False Premiums

Some dishonest health insurance agents or brokers may take advantage of you and pocket the money theyre supposed to be sending the insurance company for your monthly payments.

Billing for Services You Never Had


Fraudulent Practice #: Unbundling

How to avoid becoming a victim of Medicare fraud

This occurs when a provider bills separately for each item that occurred within one procedure, to purposely inflate the cost of the procedure. Lets say you had a hysterectomy. Instead of billing for a hysterectomy the practitioner breaks the operation down into all of its different parts and bills for each part separately. Unbundling can easily double the cost of a procedure!

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Protect Your Medicare Number

Your Medicare Number is similar to your social security or credit card numbers. You are at risk for identity theft if it gets into the wrong hands. But unlike credit cards, your Medicare card offers no consumer protection. To safeguard yourself, be cautious of sharing your Medicare card or number with anyone. Exceptions include your doctor, close family members or other Medicare providers that you trust. If you are unsure whether to give someone access to your number, call Medicare first to check.

Remember that your Medicare Number also appears on your medical records and statements. Do not share these documents with anyone. When disposing of old statements, shred the paperwork so the number is illegible.

Learn How To Recognize Report And Protect Yourself From Health Care Fraud And Abuse

Health care fraud and abuse refers to deceptive practices in the health industry that lead to undeserved profit. These schemes cost the nation billions of dollars each year and result in higher health insurance premiums and out-of-pocket expenses for consumers.

Health care fraud is a deliberate deception or misrepresentation of services that results in an unauthorized reimbursement.

Health care abuse refers to practices that are inconsistent with accepted medical, business, or fiscal practices.

These practices can take many forms, the most common including:

The Consumer Protection Division of the Office of the Attorney General aims to help educate consumers on how to recognize fraud and abuse and how to file a complaint with the appropriate agency.

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Incentivized To Process More Patients

Current reimbursement models incentivize physicians to engage in behaviors designed to game the system based on expectations for productivity that can compete with physicians presumed obligations to provide patients with high-quality care. For example, corporate protocols or reimbursement restrictions can limit or at least affect physicians prescribing of certain tests, procedures, or medications. Based on independent medical judgment, a physician might believe a diagnostic test or certain medication is medically necessary for a patient, only to find that the insurance company denies coverage or to be notified, for example, that a clinically preferred suture thread, skin graft, or preoperative prep solution will no longer be made available due to cost. Couple these externally imposed protocols and internally mandated efficiencies with performance-based compensation models tied to relative value units , and quality metric-guided physicians can find themselves pulled in 2 conflicting directions. In response, some physicians argue that overcoding and overbilling are not fraudulent but rather reflections of responsible, quality care.10

Although most physicians oppose outright fraud, the marketplace is rife with behaviors that inflate health care system costs, produce inefficiencies, and harm patients.

Check Your Medicare Claims And Statements

How To Avoid Medicare Fraud

Whether you have Original Medicare, a Medicare Advantage Plan, or a Medicare Supplemental Plan, youll receive regular statements outlining the services used. If you have Original Medicare, a Medicare Summary Notice comes every three months by mail or every month by email . For Medicare Advantage Plans, the statement frequency varies by plan.

Compare your MSN or statement and any processed claims to your calendar and receipts. Take time to verify the dates of service, the providers seen, and the amount charged. If the statement comes at an odd time or any of the details are incorrect or suspicious, contact Medicare or your insurance company immediately.

Whether you have Original Medicare, a Medicare Advantage Plan, or a Medicare Supplemental Plan, youll receive regular statements outlining the services used. If you have Original Medicare, a Medicare Summary Notice comes every three months by mail or every month by email . For Medicare Advantage Plans, the statement frequency varies by plan.

Compare your MSN or statement and any processed claims to your calendar and receipts. Take time to verify the dates of service, the providers seen, and the amount charged. If the statement comes at an odd time or any of the details are incorrect or suspicious, contact Medicare or your insurance company immediately.

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Healthcare Fraud: Why Its Happening

The simple answer is greed of course, but its more complex than that. Part of the problem is the opportunity. Total healthcare spending is over $2.7 trillion a year in America or 17% of our Gross Domestic Product. With so much money flowing through the healthcare system the opportunities, and temptations, for fraud are almost limitless. The healthcare fraud industry is so enormous that crooks are constantly able to devise new ways to grab a piece of the pie.

Healthcare Fraud: Irresistible To Crooks And Providers Alike

Alarmingly, the healthcare fraud industry has become so alluring that criminals from all sorts of other illegal enterprises are jumping on the bandwagon. Drug dealers reportedly like that the financial rewards are greater and the punishments less severe than their previous line of work. Mafia and gangs from many large cities are getting involved. Fraud detectives busting bogus clinics often find stockpiles of weapons.

Fueled by a growing epidemic of prescription pill addiction, pill mills have been popping up across the country. In this scam, a clinic or doctors office becomes a prescription writing factory and/or takes prescription pills and resells them on the streets. In Florida, the undeniable capital of healthcare fraud, its believed that pill mills were responsible for seven deaths a day in 2010! Pain Management Clinics proliferated and over 900 existed in Florida in 2010, that number dropped to 367 in 2014 due to a statewide pill mill crack down.

Healthcare fraud cases involving pharmacies have quadrupled in the past five years. From billing Medicare for more expensive drugs than those that are actually provided, to bribing healthcare workers for leftover pills to resell, pharmacists are getting in on the action.

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Stopping Healthcare Fraud Waste And Abuse

Healthcare fraud is a serious issue that contributes to the skyrocketing cost of medical care. It’s estimated that Medicare and Medicaid fraud costs $70 billion to $200 billion each year, according to the National Health Care Anti-Fraud Association.

Anyone can commit fraud. That includes doctors, hospital employees, billing services, medical equipment suppliers, patients, and caregivers. Violators can be prosecuted under civil and criminal laws. And preventing fraud is everyone’s job.

Santa Clara Family Health Plan has established a comprehensive Fraud, Waste, and Abuse Program to prevent, detect, and correct fraud, waste, and abuse by employees, members, employers, brokers, providers, contractors, and subcontractors of SCFHP. Under this program, SCFHP works to promote a sense of integrity and vigilance by means of comprehensive anti-fraud education for such individuals and entities. This program also provides procedures for prevention, detection, auditing, monitoring, investigation, and follow-up.

Implementing A Compliance Program To Identify And Prevent Healthcare Fraud

How to Avoid Medicare Fraud

Developing a strong compliance program is key to preventing healthcare fraud and abuse activities.

A strong compliance program should establish a culture within a hospital that promotes prevention, detection and resolution of instances of conduct that do not conform to Federal and State law, and Federal, State and private payer healthcare program requirements, as well as the hospitals ethical and business policies, the HHS Office of the Inspector General stated in official compliance guidance geared towards the hospital setting.

The OIG also suggested that providers implement the following components:

Additionally, OIG recently a resource for hospitals and providers to evaluate the effectiveness of their compliance programs. The resource explains how healthcare organizations across the size spectrum can evaluate standards and policies, administration, stakeholder screening and assessments, training, internal reporting system monitoring, non-compliance discipline, and investigations and remedial measures.

“To get a little bit deeper, you’re going to take a look at the compliance program and see how was it designed, how was it structured, and was it what they call a paper compliance program or a real compliance program.”

To get a little bit deeper, you’re going to take a look at the compliance program and see how was it designed, how was it structured, and was it what they call a paper compliance program or a real compliance program.

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Individual Effects Of Medicare Fraud

For starters, its simply maddening to think that individuals who commit these types of offenses are bringing in much more than the typical, hard-working family earns just to survive. For instance, Money reports that the median real income is $54,635 for households in Michigan and $57,259 for a household in Ohio.

Based on these numbers, the physicians and CEO in the previously discussed case fraudulently received roughly 727 times that amount . And they did so solely by billing the governments healthcare system for services not rendered and taking kickbacks along the way.

The NHCAA adds that these fraudulent activities hit individual Americans financially as well. How? Because, added together, this type of fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage, according to the NHCAA. In other words, the losses that occur due to these fraudulent activities have to be made up for somewhere. Sadly, that somewhere is often from the individuals receiving coverage.

The NCHAA further says that Medicare fraud can result in negative physical consequences for patients as well. This occurs when healthcare professionals and agencies perform unnecessary or unsafe medical procedures just to increase their billing amounts. Depending on the procedures, the damage to the individuals involved can be devastating.


Request A Fraud Waste And Abuse Presentation

Does your organization have what it takes to effectively prevent Medicaid and Medicare fraud, waste and abuse? Find out by requesting an FWA presentation from ClarisHealth, where a member of our team will discuss your specific needs. Learn more about the ClarisHealth 360-degree solution for payment integrity and FWA, Pareo Fraud: Case Management and Detection powered by A.I. here.

Learn more about the ClarisHealth 360-degree solution for payment integrity and FWA, Pareo Fraud: Case Management and Detection powered by A.I. here.

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Medicare Fraud: Protecting Yourself Begins By Protecting Your Card

According to, you should always treat your Medicare card like its a credit card. In other words, dont give the number out to just anybody, because theres a chance it could be used to open up a fraudulent claim.

Granted, it isnt possible to hide your number from your healthcare provider because he or she will need it for billing purposes. However, you dont want to give it out to anyone else, even if they offer you something of value in exchange for free medical care.

But what if someone calls you saying theyre from Medicare and then requests your personal information over the phone? says there are only two instances in which this agency will ever call you and request this type of information:

  • The first is if theyre from a Medicare plan that youre already a member of, which automatically rules out anyone who calls you about a plan that youre not currently on.
  • The other is if you called them and left them a message and they are calling you back.
  • Its also important to realize that between April 2018 and April 2019, all Medicare recipients will receive new identification cards. These red, white, and blue cards will automatically be sent to you at the address listed on your Social Security account, so there is no need to call and request it. Also, the number on the card is different than your Social Security Number, which better protects your identity.

    Report Medicare Fraud And Abuse

    How To Avoid Medicare Fraud & Scam

    If you suspect Medicare fraud or abuse, you should report it right away. The Centers for Medicare & Medicaid Services , which administers Medicare, is cracking down on this type of activity. The agency is working with beneficiaries, doctors, and federal agencies such as the Department of Health and Human Services , the Office of Inspector General, the Federal Bureau of Investigations , and the Department of Justice to detect and prosecute those who commit Medicare abuse and Medicare billing fraud.

    To report Medicare fraud or abuse, you can do any of the following:

    • Fax your report to 1-800-223-8164.
    • Mail the report to Office of the Inspector General HHS Tips Hotline, P.O. Box 23489, Washington, DC 20026-3489.

    Please note that the contact information above is only to be used for reporting fraud or abuse.

    Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealths Medicare related content is compliant with CMS regulations, you can rest assured youre getting accurate information so you can make the right decisions for your coverage. Read more to learn about our Compliance Program.

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    Healthcare Fraud: What To Look For

    There are many types of healthcare fraud, but the most common and costly is fraud committed by dishonest service providers. Who are they? Doctors, nurses, equipment providers, pharmacists, etc., anyone who orders or provides healthcare services, supplies or treatments. Thats right, the doctors that we depend upon and trust are often the culprits responsible for these types of crimes. Anyone can be a victim, thats why our tips for avoiding healthcare fraud later in this post are so important for you to read and follow.

    There are many ways unscrupulous service providers commit fraud. Heres some of the most common illegal practices:

    What Needs To Be Done

    CMS has additional opportunities to strengthen the enrollment system, including adopting a more flexible screening approach, tailoring screening measures to fraud risks, and classifying reenrolling durable medical equipment and home health providers as “high risk” when appropriate. CMS should also focus enrollment scrutiny on providers such as independent diagnostic testing facilities and comprehensive outpatient rehabilitation facilities , as OIG found that IDTFs and CORFs did not comply with basic Medicare requirements to maintain open and accessible physical locations as reported to and on file with CMS. In addition, CMS should consider instituting temporary enrollment moratoria for certain types of providers in geographic areas at significant risk for fraud, such as home health providers in Florida and Texas.

    The Department should continue to collect and maintain more robust data sets, particularly for State Medicaid programs, as well as further facilitate law enforcement’s access to data. OIG and the Department must also ensure that OIG has the capacity to handle the volume of new fraud referrals that can be expected from CMS’s expansion into predictive modeling and that CMS and OIG coordinate closely on such referrals. CMS should also strengthen fraud and abuse prevention efforts by issuing regulations for mandatory provider compliance plans under sections 6102 and 6401 of the ACA.

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