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How to Recognize Medicare Fraud & Abuse

  • Medicare with Melissa

We’ve all heard about Medicare fraud. It can be committed by physicians, other healthcare providers, and program enrollees. But would you know it if you saw it? Millions in taxpayer dollars are lost to Medicare fraud each year.

According to the U.S.Government Accountability Office (GAO), $52 billion in improper Medicare payments were made in fiscal year 2017. Simply put, fraud occurs when a person charges Medicare for a cost they didn’t incur, or they receive more money for a charge than they should. Meanwhile, Medicare abuse is defined as practices that create unnecessary costs to the program.

Original Medicare & Fraud
Do you have Medicare Part A (hospitalization coverage) and Part B (outpatient medical coverage)? If so, your physician should not charge you for the majority of preventative services you seek. Nor should they suggest tests you don’t need. Another red flag is if your provider regularly waives your coinsurance. Each time you receive either an Explanation of Benefits (EOB) or a Medicare Summary Notice (MSN), be sure to confirm you actually received the services that are listed.And if you returned durable medical equipment, confirm the supplier doesn’t keep charging Medicare for either rental fees or equipment maintenance.

Medicare Marketing Fraud
Let’s say you’re speaking with an insurer about signing up for Medicare. Beware if an agent or other company representative states any of the following:

• You have to sign up for a Medicare Advantage plan to get Medicare Part D prescription drug coverage

• You have to invite an agent into your home to receive plan details or sign up

• You will receive “additional” benefits that are, in fact, covered by Medicare

All of the above statements are untrue. For the actual facts, refer to the Medicare plan benefits guide, or call the insurer directly.

Reporting Medicare Fraud
In summary, Medicare fraud costs taxpayers billions of dollars each year. Do your part by contacting the Centers for Medicare and Medicaid Services if you suspect fraud. The main phone number is 1-800-MEDICARE (1-800-633-4227). TTY users may call 1-877-486-2048.

Medicare Advantage plan members can call the Medicare Drug Integrity Contractor, or MEDIC, at 1-877-7SAFERX (1-877-772-3379).

Be sure to have the following information:
• Your name and Medicare number
• Provider’s name and identifying info
• The service or item in question and when it was provided
• Payment amount approved/paid by Medicare
• Date on your MSN or claim

Learn More: Why Does Medicare Have a “Donut Hole” and How Does It Work?

People Also Read: Most Common Medicare Mistakes

Meet Melissa MacCalla

Medicare is not simple and can be hard, frustrating, and downright confusing for most. I love when I get someone on the phone and I am given the opportunity to explain the difference in plans to them and have Medicare make sense. I enjoy talking to clients year after year, hearing about their families growing or them asking about mine.


Oh my gosh!! I was so confused about the Medicare Supplement process. I am turning 65 soon and am retired and have always had insurance thru my former employer. I didn’t know a thing about going on Medicare and was struggling to sort it all out.

A friend of mine recommended contacting Senior HealthCare Solutions, so I did. Melissa was FANTASTIC!! She was professional, responsive, caring and friendly. She explained the steps I needed to take, gathered my information, helped me choose good plans for MY specific needs and took care of my applications over the phone. 1-2-3, eesy-peesy and I was done!! And it didn’t cost me a DIME!!! WOW!!! I HIGHLY recommend Senior Healthcare Solutions for anyone who’s overwhelmed with making the right choices with Medicare Supplemental Insurance and Rx coverage. It’ll take a load off your mind!

Janice W.

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