AdvancingSmartly

Investigations into potentially improper payments from Medicare and Medicaid continue to be reported.  Investigations reveal that an enormous amount of fraud is taking place. The National Center for Policy Analysis estimates the amount of Medicare fraud to be about $33 billion dollars.

Medicare has investigated the above average percent of fraudulent claims submitted for laboratory tests, durable medical equipment, hospice and hospital outpatient test billings.  On the Medicaid side, nursing home charges have been investigated.  All of this activity will cause changes in how Medicare and Medicaid operate, which will impact you.

Any claim submitted for one of these higher risk services will receive greater scrutiny by Medicare or Medicaid before it is paid.  This may mean you will see more claims denied.  If so, protect yourself by making sure the service you are going to be responsible for paying was in fact provided.  If you were told by the provider that a service would be covered by Medicare or Medicaid, and it is not, you may have a defense to the provider's request for payment in full from you.

According to Medicare, the following activities are suspect and can be reported to the Fraud tip-line:

• Providers who advertise free testing or screening;

• Offers of free medical equipment or supplies;

• Providers who offer to waive co-payments and deductibles;

• Offers of free groceries (or any substitute) in exchange for your Medicare number or your Explanation of Benefits statement;

• Door to door or telephone solicitations offering free or discounted Medicare services;

• Advertisements that read: "Call 1-800-NUMBER; this item is approved by Medicare; No out-of-pocket expenses;"

• When your Part B Medicare Explanation of Benefits statement shows items or services that you did not receive;

• Suppliers provide more expensive equipment than is medically necessary, for example, motorized wheelchairs, electric beds, etc.;

• Suppliers that provide lower cost equipment while billing Medicare for higher cost equipment;

• Medical justifications for equipment, items or supplies signed by a doctor who does not know you;

• Medical suppliers that accept Medicare assignment but charge you more than the Medicare approved charge;

• Suppliers that bill Medicare for home medical equipment while you are in the hospital or nursing home; and

• Suppliers that refuse to pick up rental items and continue to bill Medicare after you no longer need them.

Medicare also offers the following tips to protect yourself from becoming involved in a fraudulent Medicare claim:

• Read your Explanation of Medicare Benefits statement carefully and look for:

• Duplicate payments for the same service;

• Ambulance services you are not aware of;

• Payments for home medical equipment while you were in a Medicare approved hospital or nursing home;

• Dates of service on the Explanation of Medicare Benefits statement which differ from the dates you really received services; and

• Items or services you do not recall receiving.

• Never allow anyone to convince you to ask your physician to request an item you do not need;

• Never allow anyone, other than legal representatives or advocates, to review your medical records or prescription medications without your physician's approval; and

• Never give your Medicare number to telephone or door to door solicitors.

If you suspect Medicare fraud, you can call Operation Restore Trust's confidential tip-line at (800) 447-8477.  Be ready to give them the following information:

1.  Provider's name and identifying number;

2.  Item or service you are questioning;

3.  Date being shown as to when the service was furnished;

4.  Amount approved and paid by Medicare;

5.  Date of the EOMB statement;

6.  Name and Medicare number of the person who supposedly received the item or service; and

7.  Reason you believe Medicare should not have paid.

You can also send this information to Medicare by mail, to the Medicare Fraud Unit address provided on your EOMB.  Using the Internet, you can provide the same information on suspected fraud to: Htips@os.dhhs.gov.

[Back to Top]