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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.

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.

Documents 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 very serious, 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.

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 as well as receipts from your providers.

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.

How to Identify and Report Medicare Abuse

When a provider doesn’t follow proper medical practices and issues of 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, then the doctor is committing 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.

How to Identify and Report 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.

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 in an effort to end fraud, waste, and abuse. Basically, Medicare expects providers and suppliers to meet specific standards to remain in the Medicare program.

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.

How To Report Medicare Fraud, Abuse, and Waste

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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Lindsay Engle

Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

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

      1. Thank you for operating this very informative website. I wasn’t able to find that information with several internet searches.

  1. Our lab has recently discarded over $6000 dollars in expired test kits and will discard another several 1000 soon. This costs our patients, insurance providers, and the company. Our company, Providence health, had sent in a lean team to train our lab to have no more than 2 months supply of all supplies that would of prevented this horrible waste. Our lab director is not interested in meaningful change and extraordinary waste will certainly continue. Local efforts for change have been fruitless. Is this a reportable offense to Medicare? Are there any protections from the likely retribution?

  2. I am a patient with an Anthem Blue Cross Medicare Advantage Plan, but my medical provider Brown and Toland has repeatedly charged me with large co-payments for preventive care (i.e., blood tests and cat scans ordered by my doctor) that, according to the rules outlined in my Anthem Blue Cross plan should involve no copayments whatsoever. I have repeatedly called these incorrect and I believe fraudulent billings to the attention of Brown and Toland several times but they have repeatedly ignored my complaints,.

    1. Hi Steven! Unfortunately, Medicare Advantage plans do come with many out of pocket costs which include copays for preventative care services. This is how they keep your monthly premium low or zero. That’s one of the biggest downsides to these types of plans. I would reach out to your carrier to confirm that your doctor was correct in charging the copays. The guidelines you see in the coverage summary does not include every single service that you could receive. You may be confusing one preventative test for another.

  3. I am unsure if I am dealing with a situation of Medicare Waste or not.. Our Utilization Review/Care Management Team is downgrading inpatient claims to outpatient claims when a Medicare Advantage Plan denies the inpatient admission as not medically necessary to admit and does not authorize the stay. In some cases they have submitted appeals to the MA plans and when denial for inpatient claim is upheld they are then changing the claim to bill outpatient observation or outpatient services instead of billing a Part B (121 claim) inpatient claim (which is paid at higher rate than a part B claim). The MA plans we are contracted with indicate they follow CMS billing and UM guidelines yet claims and patient status are being changed to be billed as outpatient instead of inpatient when patient is enrolled in a Medicare Advantage Plan and there is no physician order prior to the patient being discharges. This is all being done well after discharge. I have brought my concerns to management only to be told this is okay if our Care Management Team tells us so. Since we are not billing CMS Medicare but a Medicare Advantage Plan, I am unsure of this would be considered abuse or waste with Medicare. I am responsible for submitting the new claim to the MA plan so I want to make sure this is not waste or abuse with Medicare.

  4. Have been frustrated with diabetes monitoring supply provider US Med. Been dealing with them for several years. Approximately every 3 months when I order refills, I receive supplies I did not request or even explicitly denied when I placed the order! Each item is of little cost. E.g. batteries or control solution for monitor. However, if they “overserve” other customers in this way, US Med may receive a significant chunk of change from Uncle Sam. I do not support this business ethic. I’ve sent several emails to US Med, but they evidently don’t wish to change. FYI…


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