Medicare Abuse

Medicare abuse is the process where illegal practices lead to unnecessary billing costs for the insurance program. There are many types of Medicare abuse. There is though no precise measure of health care frauds but those who exploit Federal health care programs can cost taxpayers billions of dollars while putting beneficiaries’ health and wellbeing at risk. These risks magnify as Medicare serves a growing number of beneficiaries.

Medicare places lots of trust in the valuable and ethical contribution of physicians. Like Medicare other Federal health care programs also rely on physician’s medical judgement to treat patients with appropriate, medically necessary services and to submit accurate claims for Medicare-covered health care items and services.

One can play a vital role in protecting the integrity of the Medicare program. To combat fraud and abuse one must know how to protect one’s organization from engaging in illegal and abusive practices and violations of civil or criminal laws.

The healthcare professionals exploiting Federal healthcare programs for illegal, personal or corporate gains create the need for laws that combat fraud to ensure appropriate, quality medical care.

Physicians encounter on a frequent basis following types of business relationships that may raise fraud and abuse concerns:-1.Relationships with payers.

2.Relationships with fellow physicians and other providers.

3.Relationships with vendors.

What is Medicare Fraud?

Medicare fraud typically includes any of the following:-

1.Submitting knowingly false claims or making misrepresentations of facts to get a Federal health care payment for which no entitlement would otherwise be there.

2.Soliciting,receiving,offering or paying remuneration knowingly(like kickbacks, bribes or rebates) to induce or reward referrals for services reimbursed by Federal Health Care programs.

3.Making prohibited referrals for certain designated health services.

Healthcare frauds can be committed by anyone. The fraud schemes range from solo ventures to widespread activities by an institution or group. Even organized crime groups infiltrate the Medicare Program and operate as Medicare providers and suppliers.

What is Medicare Abuse?

Medicare abuse is an act that results in unnecessary costs directly or indirectly to the Medicare program. It also refers to an action or practice that fails to offer medically necessary services to people. The most common types of Medicare abuse include:-

1.Billing for services that are not medically necessary

2.Overcharging for services or supplies

3.Using billing codes improperly to increase reimbursement

Difference between Medicare abuse and Medicare fraud

Medicare fraud is a condition when a person tries to acquire financial gains knowing that the money does not belong to them. A medical fraud occurs when a person tries to get money or similar compensations for services or items for which they get Medicare reimbursement or on making banned referrals.

Individuals and groups can both commit Medicare fraud. The involved people, directly or indirectly can include doctors, other health providers, suppliers, and Medicare beneficiaries.

Medicare abuse or fraud can expose doctors and health care providers to civil and criminal liability.

Examples of Medicare Fraud

There are many ways to commit Medicare Fraud. Some of them are-

1.A doctor or other healthcare provider bills Medicare for services not provided.

2.A doctor bills for services different from the care that has been given to patients.

3.A doctor pays for referrals of Federal healthcare program beneficiaries.

Some other Medicare fraud types include when a person does these acts—

1.He/she continues to bill Medicare for rented, durable medical equipment(DME) after their return.

2.He/she advises people that Medicare will pay for a service or supply when it is not a true fact.

3.He/she uses a stolen Medicare number to submit fraudulent claims.

4.He/she bills for a doctor’s appointment that a person did not attend.

Commonality of Medicare fraud

The Fraud schemes range from single person attempts to a wide range of activities committed by large institutions. Sometimes organized crime groups can falsely represent themselves as Medicare providers or suppliers. According to the National Health Care Anti-fraud Association, the U.S spends more than $3.6 trillion on healthcare every year and the estimated health care fraud costs billions of dollars annually.

How to recognize a Medicare Abuse

There are many ways to commit Medicare abuse or fraud.One can prevent this by following basic steps which are—

1.Reviewing all Medicare Summary Notices for errors and reporting out anything which looks wrong or suspicious to Medicare.

2. Checking statements from Medicare Advantage plans as they should show all the person’s services and prescriptions.

3.Comparing appointment dates and the types of health services got with the statements received from Medicare.

4.Checking all receipts and statements for possible mistakes.

A person can call their doctor or other health providers to discuss the possible mistakes and check facts before reporting it to Medicare.

How to report Medicare abuse?

If a person thinks he/she has noticed Medicare abuse or fraud they can report it in 3 ways-1.Call Medicare at 1-800-633-4227 or 1-877-486-2048.

2.Contact the Senior Medicare Patrol(SMP) resource center at 877-808-2468

3.Contact the Inspector General Fraud hotline at 1-800-447-8477

To make a call a person needs to gather some information like—

1.Name and Medicare number.

2.The doctor or healthcare provider’s name and other identifying information.

3.The service in question and the date when it was provided.

4. The dollar amount approved and paid by Medicare.

5.The date on the Medicare Summary Notice or claim.

If a person is enrolled in a Medicare Advantage Plan and suspects of a Medicare abuse or fraud, then they can call the Medicare Drug Integrity contractor at 1-877-772-3379.


Medicare abuse and fraud are unlawful practices that result in unnecessary costs billed to the insurance program.

People can help to prevent Medicare abuse by checking whether the information is correct on any Medicare or Medicare Advantage plan summary notices, statements and receipts. To report a Medicare abuse or fraud, a person can contact 1-800-MEDICARE or 1-800-633-4227.

Published by ambikajha

I am Ambika Jha.I like to write on different topics.I feel life is too short for anything.So let us work our best in the given time and let life's music be in rhythm and rhyme.So be your best and never stop to learn and write.

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