4 Types of Medicare Fraud and How to Protect Yourself From Them
With more than 4 million Medicare claims processed every day, instances of Medicare fraud can easily get buried in the shuffle. And if your provider is forced to pay out on a fraudulent claim, that could result in your premiums going up through no fault of your own. That’s why you must know how to spot potential Medicare fraud and what to do about it if and when you find something suspicious.
Sometimes Medicare fraud is relatively easy to spot. For instance, if someone else uses your name and insurance information to get prescription drugs, you will most likely notice immediately. But in some cases, Medicare fraud isn’t so blatant, like when a care provider bills Medicare for procedures or equipment that were not used (also known as Phantom Billing). So, to help you understand what to look for, here is a quick guide to Medicare fraud.
Types of Medicare Fraud
There are many different types of Medicare fraud. Some instances of fraud come from simple mistakes and clerical errors, whereas others might be intentional. Here are four of the most common types of Medicare fraud:
Phantom Billing - Any instance in which your provider bills Medicare for a procedure that was never performed or equipment that was not used or needed.
Upcoding – Your care provider intentionally uses an incorrect code on your bill, indicating that you needed more expensive treatments or procedures than necessary.
Repeat Billing – Billing patients more than once for the same procedure, supplies, or medicine.
Length of Stay Overcharge – Patients are charged for extra days in a hospital or other medical facility.
How to Spot Medicare Fraud
Spotting Medicare fraud might require extra alertness and diligence on your part, but if it saves you money and protects you from fraud, it will be well worth it. Here are a few steps you can take to make sure you don’t fall victim to fraudsters:
Record the dates and save your receipts any time you receive care or services.
Once you get your statement from Medicare, compare the dates and services on your statement to the dates and receipts you saved to ensure all the details are correct.
If you notice any items or services listed in your claims that don’t look familiar, it’s possible that you, or Medicare, may have been billed for things you did not need or receive.
Check your claims as soon as possible. The sooner you notice and report errors, the better. You can view your claims as soon as they're processed by logging into MyMedicare.gov or calling 1-800-MEDICARE (1-800-633-4227).
How to Report Medicare Fraud
If you've contacted your provider and still suspect fraud, you can report it by calling 1-800-MEDICARE (1-800-633-4227) or contacting the Office of the Inspector General at 1‑800‑HHS‑TIPS (1‑800‑447‑8477). TTY: 1‑800‑377‑4950.
Before you call to report fraud, make sure you have the following information handy:
Your name and Medicare Number
The provider's name
The service or item you find suspicious
The date that the service or item was supposedly given or performed
The payment amount approved and paid for by Medicare
The date on your Medicare statement
Reporting fraud helps protect yourself and others from unnecessary bills and expenses, and if your report is successful, you might be eligible for a reward of up to $1,000. So, stay alert, keep track of your dates and statements and always be on the lookout for potential Medicare fraud.
What’s the Big Deal?
You may be thinking right about now, “this isn’t my problem, though, right? These people committing Medicare fraud are stealing from Uncle Sam’s deep pockets, and the government has it coming to them. I would argue that Medicare fraud creates a ripple effect and impacts everyone. Medicare Fraud Strike Force estimated Medicare fraud cost American taxpayers approximately $10.8 billion in 2017. It’s not just the government’s pockets getting pick-pocketed — it’s yours too. Whether you have government-sponsored insurance or not, Medicare fraud will ultimately drive up the cost of health care for everyone.
Luckily, the hospitals you trust with your health are also taking action and cracking down on scammers. Not only are they putting confidential, anonymous hotline reporting solutions into place, as ETHIX360 offers, but they also require downstream vendors like ETHIX360 to pass stringent audits. As the Chief Compliance Officer of ETHIX360, one of my most important responsibilities is to ensure all employees, from the CEO to entry-level, have taken all the required compliance training, such as Fraud, Waste, and Abuse, and reviewed all applicable policies. The healthcare community understands that Medicare fraud is everyone’s responsibility, and they are doing their part, as should you.
The ETHIX360 blog brings you weekly updates on all things human resources and compliance.
MEET THE AUTHOR
Stephanie Farmer is a seasoned ethics and compliance (E&C) professional. She has earned an MA in both Business and Professional and Applied Ethics and is a graduate of The Ethics & Compliance Initiative Managing Ethics in an Organization Program. Prior to and during her E&C career, Stephanie served in the United States Marine Corps Reserves and the North Carolina Air National Guard.
ABOUT ETHIX360
At ETHIX360, our goal is simple: to provide an affordable, flexible, and comprehensive answer to employee communication, policy management, corporate training and case management on issues related to corporate ethics, code of conduct, fraud, bribery, and workplace violence.
