How To Report Medicare Fraud, Abuse, and Waste


Medicare fraud is a serious issue that you need to report. The Center for Medicare and Medicaid Services says fraud can cost taxpayers billions of dollars. It can also interfere with the health of Medicare beneficiaries. That’s taxpayer money that’s going into the hands of unethical providers.

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How to Report Medicare Fraud?

You can call the Medicare fraud hotline or report the fraud by contacting one of these organizations:

  • Department of Health and Human Services (HHS) Office of Inspector General (OIG) Medicare fraud hotline at 1-800-HHS-TIPS
  • Contact the HHS by mail at HHS Tips Hotline, PO Box 23489, Washington, DC 20026-348
  • Centers for Medicare and Medicaid Services at 1-800-MEDICARE
  • Contact CMS by mail at Medicare Beneficiary Contact Center, PO Box 39, Lawrence, KS 66044
  • You can report it by calling the CMS report hotline or submit the information online.

What Documents Do I Need to Report Medicare Fraud?

If you’re reporting Medicare fraud, it’s helpful to have some of your information ready.

  • Medicare number
  • Provider information
  • Information about the service that was supposedly provided
  • and the reason you think fraud was committed

If a reported Medicare fraud leads to the recovery of funds, Medicare may provide a reward. If you or someone you know suspects fraud, waste, or abuse, report it immediately.

The Center for Medicare and Medicaid Services (CMS) states that Medicare fraud is:

  • Intentionally billing Medicare for a service not provided
  • Billing Medicare at a higher rate
  • If a provider pays for referrals of Medicare beneficiaries

Medicare fraud is severe; it’s not human error, it’s highly illegal, and it involves doctors or beneficiaries abusing the system for their own benefit. Report Medicare fraud as soon as possible.

What is Considered Medicare Fraud?

When your doctor or healthcare worker finds loopholes to receive payment when they normally wouldn’t, they commit fraud. If a doctor ever says one of these things to you, report it immediately:
  • The more tests that are done, the less you pay out-of-pocket
  • Offers you a gift to get you to use their services
  • Waives a copayment or says the co-payment is higher on a no-copay plan
  • States you can receive coverage on a non-covered service
  • The service or product Medicare endorses

If you have Medicare, you can look through your Medicare Summary Notice and compare your statements and receipts from your providers.

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So, you noticed a bill for a product or service not applicable. Contact the office to be sure of the mistake. If an error occurred, that’s Medicare abuse.

What is Considered Medicare Abuse?

When a provider doesn’t follow proper medical practices and unnecessary tests, they are committing Medicare abuse. Practices that result in unnecessary costs to Medicare are considered abusing the system. Medicare abuse is a serious crime, and violators will be prosecuted.

Abuse can be found when billing for unnecessary services or services that aren’t medically necessary occur. If you’re overcharged for services or supplies, then you’re a victim of Medicare abuse. However, if a provider misuses billing codes to increase reimbursement, the doctor commits Medicare abuse.

Medicare won’t use your name during the investigation of Medicare fraud, waste, or abuse; if you don’t want them to, you can remain anonymous.

What is Considered Medicare Waste?

Some examples of waste include:
  • Prescribing more medications than necessary for one specific condition
  • Ordering excessive lab tests
  • Conducting excessive office visits

If you know of someone misusing resources, understand that this is a serious offense. Any violators will be prosecuted because it costs taxpayers billions of dollars when waste occurs.

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Penalties for violating the laws against fraud, waste, and abuse include: 

  • Civil prosecution
  • Civil monetary penalty
  • A criminal conviction, fines, or both
  • Imprisonment
  • Loss of professional license
  • Exclusion from all Federal health care program participation

As a Medicare beneficiary, looking at your bills to check for fraud is your responsibility. If you think there may be an error, contact the doctor’s office.

If you think the error is intentional or the doctor admits to an error, you’ll need to report it. An error, intentionally or unintentionally, is Medicare waste.

Differences between Medicare Fraud, Abuse, and Waste

  • Fraud requires intent to obtain payment and knowing the action is wrong
  • Abuse creates an unnecessary cost to the Medicare Program, without knowledge
  • Waste may involve intent or knowledge but could also be unintentional

CMS Efforts to Stop Fraud, Waste, and Abuse

Medicare creates the Program Integrity Enhancements to the Provider Enrollment Process rule to end fraud, waste, and abuse. Basically, Medicare expects providers and suppliers to meet specific standards to remain in the Medicare program.

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Program rules include providers and suppliers:

  • Are unable to come back into the program under a different name
  • Can’t bill from a non-compliant location
  • No outstanding overpayment debts to Medicare
  • Can’t abuse ordering of Part A, B, or D items

Applicants that submit false or misleading information risk being unable to participate in the Medicare program for up to 3 years. CMS has the ability to block up to 10 years. Second-time offenders can expect up to 20 years’ ban from the Medicare program. CMS hopes these measures will prevent bad actors from stealing tax dollars. In addition to the new rules, CMS is working hard on transparency initiatives.

FAQs

Is there a reward for reporting Medicare Fraud?
Under the False Claims Act, whistleblowers get between 15 to 25% of what’s collected from the federal government based on the submitted report. Compensation is heavily based on the whistleblower’s report. To get the money, whistleblowers must hire an attorney to file a lawsuit against the facility or healthcare provider that is committing the fraud. 
Who investigates Medicare fraud?
The FBI is responsible for exposing and investigating health care frauds for federal and private insurance programs. As the primary agency, it partners with local, state, and federal agencies to review all cases. It is a collaborative effort since these types of crimes can sometimes be complicated.
What is the punishment for Medicare fraud?
Health care fraud is a federal crime with serious consequences. If convicted you could serve up to 10 years in federal prison and pay hefty fines of up to $250,000. If you cause serious bodily harm/injury to someone, 20 years could be added to your sentence. However, if death is involved, you could face life in prison.
What are the major types of healthcare fraud and abuse?
The five common types of health care fraud are medical identity fraud, billing for unnecessary services or items, billing for services or items not furnished, upcoding, unbundling, and kickbacks.

How To Report Medicare Fraud

Reporting Medicare fraud is as simple as making a phone call. If you know Medicare fraud, waste, or abuse that's happening, it’s vital that you report the incident. As citizens, it’s our job to be courageous and prevent injustice from occurring again. Besides, sometimes there is a reward available to the person that reports Medicare fraud, waste, or abuse.

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

17 thoughts on “How To Report Medicare Fraud, Abuse, and Waste

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