Preventing Medicare Fraud


Every year, money is taken from the Medicare program through deceptive practices, according to the Centers for Medicare & Medicaid Services (CMS). Medicare fraud is not only a waste of taxpayer dollars, but it hurts the program as a whole, including everyone who receives Medicare benefits. This quick guide reveals how Medicare fraud takes place, why it affects you as a beneficiary, and what you can do to help prevent it.

Defining Medicare fraud and abuse

Simply put, Medicare fraud is when false claims are knowingly made for services or procedures that were never received.

There are many types of Medicare fraud. For instance, it’s fraud when a provider bills Medicare for a medical appointment that didn’t occur. Another example of Medicare fraud is a supplier who charges Medicare for durable medical equipment that’s never been furnished to a beneficiary.

Medicare fraud is different from abuse. According to CMS, Medicare abuse occurs when doctors and health providers give medically unnecessary services or supplies, such as ordering a lab test that isn’t needed or billing Medicare for home health services when the patient isn’t homebound. This can also result in unnecessary costs to the Medicare program, but in a different way.

Why Medicare fraud matters

You may ask, “Why should I care if someone else commits Medicare fraud?” There are at least two main reasons you may want to join the battle against Medicare fraud. One is that Medicare fraud results in higher health-care costs for everyone, both beneficiaries and people without Medicare. Just as a retail store might increase prices to cover the losses of theft, Medicare costs will increase for everyone when fraud occurs.

Secondly, you or your loved one could be the next victim. Anytime you visit the emergency room, pharmacy, or doctor’s office, there’s a risk of Medicare fraud occurring. Someone may steal your Medicare card, or you might encounter a dishonest person working at a doctor’s office or pharmacy. Either way, the burden of proof might fall upon you because the Medicare card and billing information will be in your name.

Looking out for Medicare fraud

Uncovering Medicare fraud is easy if you keep an eye out for suspicious activities. Some red flags to watch out for include providers that:

  • Offer services “for free” in exchange for your Medicare card number or offer “free” consultations for Medicare patients
  • Pressure you into buying higher-priced services
  • Charge Medicare for services or equipment you have not received or aren’t entitled to
  • Charge you for copayments on services that are supposed to be covered 100% by Medicare
  • Use marketing tactics like telemarketing or door-to-door sales
  • Tell you they represent the government or use scare tactics

One way to detect and prevent Medicare fraud is to keep a record whenever you visit a doctor or health provider, including the date you received the service, the provider name, the service or equipment received, and the amount charged. Save all the statements your doctor sends and compare them against your Medicare statements. If you have Original Medicare, you can find your Medicare statements by logging into or checking your Medicare Summary Notice, which is a notice Medicare mails out every three months.

Keep an eye out for discrepancies between your records and your Medicare statements, such as items you never received or if you don’t recognize the provider on a claim.

If you suspect that a provider has committed Medicare fraud, remember the adage “trust, but verify.” You should start by double-checking with the provider to be sure it is not a simple mistake first. Sometimes human and computer errors do occur unintentionally.

However, if so-called “errors” seem to be happening often, then it may be time to investigate further. You wouldn’t want to wrongly accuse your health-care provider, so be sure to approach suspected Medicare fraud with caution.

Reporting Medicare fraud

If you’ve done your due diligence and still believe your provider may have committed Medicare fraud, you should report the incident to Medicare.

Before contacting Medicare, you’ll need to gather all the facts about the incident so you can clearly present your case. Make sure to have the following information on hand:

  • The provider’s information, including name, phone number, address, and type of practice
  • The specific item(s) or service(s) that were billed incorrectly
  • The date that the service or equipment was supposedly given or delivered
  • The amount that was charged and approved by Medicare
  • The date on your Medicare Summary Notice
  • Why you think Medicare was falsely billed

To report Medicare fraud, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you’re a TTY user, call 1-877-486-2048.

Preventing Medicare fraud

Don’t let yourself be a victim of Medicare fraud. The following tips may prevent this from happening to you:

  • Never give anyone your Medicare card number who is not your caregiver or physician.
  • Beware of those who wish to review your medical records when they are not providing medical services to you.
  • Beware of “free” consultations and Medicare services being offered by a clinic or physician.
  • Never allow your provider to request medical services that you do not actually need.
  • Beware of providers that offer to get Medicare to pay for services or items that aren’t covered by Medicare or that you aren’t eligible for.

Most importantly, follow your instincts. If a situation doesn’t seem right, investigate to find the answers. Keep in mind that Medicare fraud may be committed by a person who doesn’t fit your idea of a “criminal”; it can happen with a doctor you think you know and trust.

With this knowledge, you can help fight against Medicare fraud and prevent waste in the Medicare program.

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To learn about Medicare plans you may be eligible for, you can:

  • Contact the Medicare plan directly.
  • Call 1-800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048; 24 hours a day, 7 days a week.
  • Contact a licensed insurance agency such as Medicare Consumer Guide’s parent company, eHealth.
    • Call eHealth's licensed insurance agents at 888-391-2659, TTY users 711. We are available Mon - Fri, 8am - 8pm ET. You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day.
    • Or enter your zip code where requested on this page to see quote.

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