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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.

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.

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.

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.

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.

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

  1. I was prescribed a select combo 2 tens unit when I had sergury. Medicare is paying $104.00 a month for 13 months on average as rent to own. I called Medicare and told them I could buy the unit myself for $110.00. All they would tell me it medicares policy.

  2. I worked in an acute care hospital where the norm for the 8 minute rule was to count any time spent tracking down or talking to nurses or doctors about the patient and time spent checking back in with nurse or collaborating with other healthcare team members as long as it was related to the patient. Does this constitute as fraud since billed time included non-direct patient contact?

  3. I have been working for a company that I have recently ran into problems with and that deals with medical billing. We are told to at least finish each chart-whether it is completed-progress note or not with applying the diagnosis codes and the procedure codes so the days patients can be billed. I am not sure how this can be not considered inappropriate. I have been threatened with being fired if I do not comply. Well, due to how I chart-I do not cut and paste like the others in the clinic it takes a little longer to chart. Long story short, they let me go due to an error with the payroll. When I offered to complete my some 50+ notes that need some kind of finishing touches they told me to not worry about it. That’s 50+ notes not completed, but billed, how is that right? I think they may have just brought over the old codes from past charts for the ones I had not placed codes on. Is this considered Medicare/insurance fraud? If not, how do I get someone to go in and audit the records of this poorly run business? Something is not right here…

    1. Hi Leslie! Something does sound fishy. I would report it to Medicare for sure. There should be a link in our post somewhere to their contact info.

  4. My wife and I delayed Social Security until age 70 and have paid for Medicare Part B using direct debit from our bank. When my wife started SS there was no method of coordinating with Medicare so Medicare drew the May payment from our checking account and Social Security also deducted her May payment from her first benefit check. We were told that Medicare will reimburse the overpayment but they only do that quarterly and by send her a paper check. 1. Medicare and Social Security should be able to communicate when someone currently paying Medicare directly starts SS. 2. You have been drawing Medicare payments from my bank electronically for five years. It is possible to reimburse her electronically immediately. Waiting for the quarterly reconciliation and mailing a paper check is a waste of my tax dollars and qualifies as waste and abuse. I started SS this month and attempts to coordinate with Medicare so I don’t double pay and have to wait for the quarterly reimbursement check in the mail failed miserably. After much frustration I came away with the instructions to contact my bank to block the extra payment… A simple fix is a better communications between SS and Medicare, and reimbursing overpayments can easily be made electronically. Creating a paper check and mailing it is considerably more costly to the Government than a direct deposit to an existing bank account.

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

  5. 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?

  6. 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.

  7. 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.

  8. 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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