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How To Report Suspected Medicare Fraud

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Report Scams To The Federal Government

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You can report scams to the federal government. Your report may keep others from experiencing a scam. Government agencies use reports of scams to track scam patterns. They may even take legal action against a company or industry based on the reports. However, agencies usually dont follow up after you report, and can’t recover lost money.

Do not use the agency contact information included in scam messages. Use contact information in the federal agency directory to report other government imposters.

Report Disaster and Emergency Scams

Report coronavirus scams and other scams about disasters and emergencies.

Report Most Common Scams

The Federal Trade Commission is the main agency that collects scam reports. Report the scam to the FTC online, or by phone at . The FTC accepts complaints about most scams, including these popular ones:

  • Phone calls
  • Demands for you to send money
  • Student loan or scholarship scams
  • Prize, grants, and sweepstakes offers

The FTC also collects reports of identity theft. Report identity theft online at or by phone at .

Report Online and International Scams

Report IRS or Social Security Imposter Scams

Scammers often pretend to work for the Social Security Administration or Internal Revenue Service . Common signs include:

How To Report Medical Billing Fraud

This article was co-authored by wikiHow Staff. Our trained team of editors and researchers validate articles for accuracy and comprehensiveness. wikiHow’s Content Management Team carefully monitors the work from our editorial staff to ensure that each article is backed by trusted research and meets our high quality standards. This article has been viewed 69,075 times.Learn more…

The medical billing process in the United States is complex for both doctors and their patients. Medical procedures are never cheap, and the cost of a doctor or hospital visit may surprise many patients. However, unethical medical professionals may also try to get extra money out of patients. For example, doctors may bill patients for procedures or tests that the patient never received. If you believe that you have been fraudulently billed, first try to sort the bill out with the doctor or hospital. It may have been an honest mistake. If they refuse to correct the charges, contact your health insurance provider.

What Are Medicare Scams

Medicare scams are different from Medicare fraud and abuse. Scams typically involve someone pretending to be a healthcare provider or insurance agent. The person uses deceit to collect your personal information.

For example, if someone calls you and asks for your Medicare number or your Social Security number to activate your Medicare ID card, this is a Medicare scam. Your Medicare ID card is automatically activated, and the person on the phone is not a Medicare representative.

If you receive a call from someone asking for any personal information, hang up! Medicare representatives will never call you, or ask for personal information over the phone unless youve given them permission in advance.

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What You Should Know:

  • Medicare fraud involves knowingly misbilling the Medicare system for medical services or items or engaging in incentive schemes to get patient referrals.
  • To prevent Medicare fraud, always review your Medicare bill and statement of benefits.
  • Report suspected Medicare fraud immediately to the appropriate government agency.
  • Health care providers can avoid accidentally committing Medicare fraud with diligent billing practices and by keeping their licenses current.
  • Medicare fraud occurs when a practitioner knowingly bills the Medicare system for products or services that were not used by the beneficiary, is involved in reward schemes for such products or services or makes illegal referrals for designated health services. To combat fraud and abuse, its important to know what Medicare fraud looks like, how to protect yourself and how to report Medicare fraud.

    Medicare Fraud: What It Is And How To Report It Anonymously

    How to Report Medicare Fraud: 10 Steps (with Pictures)
    • Medicare fraud costs billions of dollars each year. Learn how to spot Medicare fraud, how to protect yourself and how to anonymously report Medicare fraud to the proper authorities.

    Every year, tens of billions of dollars of improper payments are issued by the Medicare program. And much of this waste can be attributed to Medicare fraud.

    Fraud is illegal and should be reported by anyone who suspects it. If you suspect Medicare fraud, call 1-800-MEDICARE . TTY users may call 1-877-486-2048.

    You may also call the U.S. Department of Health and Human Services Office of Inspector General at 1-800-HHS-TIPS . TTY users may dial 1-800-377-4950.

    You may also file an online Medicare fraud complaint. Or you can send an email to [email protected] or send a fax to 1-800-223-8164.

    If you suspect fraud taking place related to a privately sold Medicare Advantage or Medicare Part D Prescription Drug plan, you should call the Medicare Drug Integrity Contractor at 1-877-7SAFERX .

    Before you call, have these items ready:

    • Your Medicare number
    • The name of the person, facility or company you suspect of fraud
    • The service or item in question and when it was administered or delivered
    • The payment amount of the transaction in question
    • The date given on your claim or Medicare Summary Notice that includes the transaction

    Your report will be kept anonymous, and youll be protected from the suspected source that you are reporting.

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    Be Prepared To Step In

    At appropriate times, Shenkman said, CPAs could offer to take control of bill payment in situations where people who are cognitively impaired aren’t able to discern the many frauds and scams that exist.

    About 25% of the U.S. population lives with a form of disability, and the average American life expectancy is 78.6 years, up from 70.8 years in 1970, according to the U.S. Centers for Disease Control and Prevention. That means people are living longer, and more are in need of help from professionals like CPAs to keep them safe from health care scams.

    Though helping clients handle their health care bills may sound simple, not many CPAs currently provide this service, Shenkman said.

    What Fraud Looks Like

    Most providers who commit Medicaid fraud fall into one or more of these categories:

    • billing for patients who did not really receive services,
    • billing for a service and/or equipment that wasnt provided,
    • billing for items and services that the patient no longer needs,
    • overcharging for equipment or services,
    • concealing ownership or associations in a related company,
    • paying a kickback in exchange for a referral for medical services or equipment,
    • billing more than once for the same service,
    • using false credentials such as diplomas, licenses or certifications, or
    • ordering tests or prescriptions that the patient does not need.

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    Report Medicaid Fraud And Abuse

    Healthcare fraud and abuse affects all of us. Healthcare fraud significantly impacts the Medicaid program by using up valuable public funds needed to help vulnerable children and adults access health care. Everyone can take responsibility by reporting fraud and abuse. Together we can make sure taxpayer money is used for people who really need help.

    Examples of Medicaid Fraud

    • Billing for medical services not actually performed
    • Providing unnecessary services
    • Billing for more expensive services
    • Billing for services separately that should legitimately be one billing
    • Billing more than once for the same medical service
    • Dispensing generic drugs but billing for brand-name drugs
    • Giving or accepting something of value in return for medical services,
    • Falsifying cost reports
    • Lies about their medical condition
    • Forges prescriptions
    • Sells their prescription drugs to others
    • Loans their Medicaid card to othersOr When a Health Care Provider Falsely Charges For:
    • Missed appointments

    The following information is preferred when reporting suspected fraud or abuse:

    • Nature of the complaint
    • The names of those involved in the suspected fraud and/or abuse, including their address, phone number, Medicaid identification number, date of birth , and any other identifying information if available/applicable

    Fighting Fraud Can Pay Up to $1,000

    You may be eligible for a reward of up to $1,000 if all of these 7 conditions are met:

  • You are not an excluded individual.
  • If You See A Name You Don’t Know On Your Medicare Statement

    HOW TO READ A BILL: Medicare Summary Notice PART A (1 of 3)

    Most of us recognise our doctors name, so its not unusual to be concerned if you see a name you dont recognise on your Medicare statement.

    If this happens, consider whether you might have had a service, such as an eye test, pathology, or diagnostic imaging, from someone other than your usual provider.

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    How To Report Medicare Fraud Anonymously

    Medicare fraud costs US taxpayers approximately $60 billion a year in the form of abuse, fraud, and waste. Thats money that goes to unethical and dishonest medical care providers and comes straight out of the pockets of taxpayers hard-earned paychecks. Furthemore, the patients who depend on the medical services are swindled out of getting the services they need as resources are diverted by greedy, unscrupulous parties looking to cash in at the expense of others.

    If you are a doctor, nurse, pharmacist, or employee of a medical provider or insurance company, you may well have seen Medicare fraud practices up close, carried out by co-workers, administrators, superiors and so on. For those who have the courage and loyalty to their fellow citizens, there are ways to report Medicare fraud to prevent injustice from occurring, and you may even report Medicare fraud anonymously. In addition, monetary rewards may be available to you in return for reporting Medicare fraud.

    How Confidential Is A Medicare Fca Claim

    When an FCA Claim is filed it is sealed by the U.S. Circuit Court. The Whistleblowers identity will remain anonymous as the Government investigates the validity of the claimants accusations. This should only take 60 days but could take longer if the Government needs more time.

    “You can discuss the situation with your qui tam attorney confidentially who will help ensure YOU are protected…”

    The U.S. Attorneys Office will complete their review of the case and decide whether or not to assist in the prosecution of the case. If they decide to assist, the whistleblowers reward will be reduced to 15%-25% of the total recovery – but the weight and resources of the government are brought into the investigation. If the Government decides against further action, plaintiffs can still proceed on their own.

    The whistleblower reward from a stand alone action is 25%-30% of the recovered sum.

    Remaining an anonymous whistleblower may not be possible once the case is unsealed and made public. However, the False Claims Act provides protection to people who blow the whistle on healthcare fraud via the Department of Labor and the Department of Justice.

    At any point in the FCA process legal counsel can be retained. Finding a qui tam lawyer with experience in healthcare fraud and FCA claims is recommended. Lawyers will consult on these type of cases for free and work on a contingency basis pending the strength of the case.

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    What Reward Is Available To Medicare Fraud Whistleblowers

    To encourage whistleblowers to file lawsuits that expose fraud against Medicare and other government programs, the FCA awards such relators up to 30% of any money the government recovers as a result of their litigation.

    What is Medicare, anyway? How does Medicare fraud typically work?

    Medicare is a government health insurance program for people aged 65 years or above people below 65 years of age living with certain disabilities and people of all ages with end-stage renal disease. It includes hospital insurance, medical insurance, and prescription drug coverage.

    In the simplest terms, Medicare fraud occurs when healthcare providers bill the government for services or supplies that have not been provided. Such fraud is rampant, costing taxpayers hundreds of billions of dollars each year, according to some estimates.

    What are some common fraudulent practices?

    If you work in a hospital or medical practice, you may have witnessed one or more of the following illegal activities:

    What laws govern Medicare fraud and abuse?

    Both federal and state statutes may apply to Medicare fraud, which may be treated as both a criminal and a civil matter. The most prominent federal laws that may create liability include:

    What You Need For Report Health Care Fraud

    How to Report Medicare Fraud: 10 Steps (with Pictures)

    The Health Care Fraud Unit is an enforcement entity at the Division of Professional Licensure supported by three investigators and three attorneys. The mission of the HCFU is to combat fraud committed by health care professionals and facilities licensed by the Board of Registration of Chiropractors and the Board of Registration of Allied Health . Among other things, the HCFU inspects health care clinics investigates and prosecutes fraud complaints negotiates and implements agreements imposing discipline assists initiatives of the boards of registration and services requests by public protection agencies and private insurers. Here, licensees are disciplined for deceptive practices such as excessive or false billing improper referral relationships charging for services not rendered selling or sharing provider numbers offering incentives to beneficiaries and making false claims about credentials, diagnosis codes, and medical conditions, care, and results.

    If you are aware of any illegal or improper activity being committed by a DPL licensee, please do not ignore it. Report it immediately!

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    What Happens When You Report Medicare Fraud

    After you report Medicare fraud, OIG staff review the complaint and send it to the right department for further investigation. The complaint resolution process may take six months or more.

    The OIG does not provide information about ongoing investigations, so until the complaint is resolved you wont be able to find out exactly how the investigation is going.

    How To Report Medicare Fraud Abuse

    Patients often need to know how to report Medicare fraud abuse in order to protect themselves and their health care. In some cases, reporting fraud can even result in financial benefits for the patient. If you suspect that someone is cheating on their Medicare claims, there are steps that you can take to protect yourself and your patients.

    The first step is to gather as much evidence as possible. This includes documenting conversations with the patient, copies of medical records, and any other relevant information. Next, contact the Office of the Inspector General or your states Medicaid Fraud Control Unit. These organizations can provide you with resources and support as you pursue your case.

    If you are filing a complaint on behalf of a patient, it is important to be familiar with the rights that they have. For example, patients have the right to an attorney if they are being questioned by authorities. Additionally, they have the right to remain silent during investigations and may not be required to provide any information that could incriminate themselves. Finally, patients have the right to receive notification of any decisions made related to their case.

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    Fraud Committed By Patients And Other Individuals

    • Bogus marketing: Convincing people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan
    • Identity theft/identity swapping: Using another persons health insurance or allowing another person to use your insurance
    • Impersonating a health care professional: Providing or billing for health services or equipment without a license

    Choose Between Confidentiality And Anonymity

    SMP The Mission

    There are two ways you can go about speaking up about a Medicare compliance violation : confidentially or anonymously. Confidentiality means that the compliance officer knows who you areand in turn, you receive legal protection for coming forward.

    According to the joint document, confidentiality provides the best protection and is accomplished by making the report official rather than attempting to report without disclosing your identity. Anonymity, on the other hand, means that you keep your identity hidden, which is not only challenging to accomplish, but also potentially risky. If you are found out, you are not eligible for protections under the applicable federal and state whistleblower laws.

    That said, ultimately, the decision on how to come forward is yours to make, and if youre ever in doubt about the best way to handle a specific situationor your personal liability in the matteryou may wish to speak to a healthcare attorney before doing anything at all. Those conversations will be protected under attorney-client privilege.

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    Report Scams To Third Parties

    You may want to report the scam to organizations outside of the government. Third parties may be able to get your money back or remove fraudulent charges.

    Report a scam that happened with an online seller or a payment transfer system to the companys fraud department.

    If you used your credit card or bank account to pay a scammer, report it to the card issuer or bank. Also report scams to the major credit reporting agencies. Place a fraud alert on your credit report to prevent someone from opening credit accounts in your name.

    Tips For Protecting Yourself From Medicare Fraud And Abuse

    Is your provider pressuring you to get services you dont think you need, or promising that these services are covered? This could be a sign of Medicare fraud or abuse. Be wary of any provider offering additional services, or pushing you to get services that dont sound medically necessary.

    For example, if your provider tells you that a service is covered by Medicare, always check with Medicare or your provider before agreeing to the service. If the service isnt covered, your provider may be committing Medicare fraud.

    And, as we mentioned, make sure to review your information. Keep a tally of the appointments youve had and take notes while youre there. Use that information to double check what your doctors and providers report to Medicare in your name. This is a good practice even if youre not looking for fraud remember, honest mistakes do happen, and keeping an eye on your Medicare Summary Notice is a good habit for any beneficiary. For those guarding against Medicare fraud and abuse, its the first line of defense.

    What extra benefits and savings do you qualify for?

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