Medicare Fraud and Abuse – a Prescription for Increased Premiums

Medicare, the U.S. Government’s health insurance program, provides medical coverage for citizens aged 65 years or older and certain disabled persons younger than 65 years.  With over one billion claims processed annually, Medicare has become the country’s largest managed provider of medical care.  With more than a billion transactions, tens of millions of members, and an increasingly-complex system, Medicare fraud and abuse of the system is inevitable.

The overwhelming majority of health providers, suppliers, and institutions who provide Medicare services do so honestly and by the regulations.  However, unscrupulous individuals have determined how to commit Medicare fraud to the tune of millions of dollars every year.  Those Medicare fraud thefts have the effect of raising Medicare premiums for the honest members.

Most Medicare mistakes are honest ones rather than Medicare fraud.  They are probably transcription errors, typographical errors, and many other types of problems that can occur when humans interact with large amounts of paperwork.  If you see these types of errors, contact the doctor who provided those services and discuss them.  The problem can usually be solved that way.  However, if a provider begins billing you for services that used to be free (or that you know to be free under Medicare), or uses other unusual billing strategies, it might be Medicare fraud.

Medicare fraud can take several forms.  One is to bill Medicare for services and products that were never delivered.  Another is to bill Medicare for more services than were actually provided to the patient.  Overbilling and billing for returned medical equipment are other examples of Medicare fraud.

The government is fighting back against Medicare fraud.  The goal is to ensure that Medicare only does business with reputable and honest medical health care providers, institutions, and suppliers.  The fight against Medicare fraud includes the Centers for Medicare and Medicaid Services (also known as the CMS), those who provide Medicare services (e.g., doctors, hospitals, etc.), those who receive Medicare services (patients), and several federal law enforcement and consumer protection agencies of the U.S. government.

All Medicare members should examine their bills and statements carefully.  They should look for services billed but not provided, extra charges, incorrect Social Security or Medicare numbers, and other discrepancies. 

If you suspect Medicare fraud and your doctor’s office was unable or unwilling to clear up the problem, contact the Medicare provider who reimbursed the doctor for the Medicare claim.  The Office of the Inspector General maintains a hotline at 1-800-HHS-TIPS (1-800-447-8477).  Please retain all pertinent documentation, including notes from any conversations you had with the provider’s office.  Medicare fraud hurts everyone.

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