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How to Avoid and Report Medicare Billing Fraud and Medicare Abuse

Medicare strives to ensure business with quality doctors and health care providers for not only for the program's own benefit, but for Medicare beneficiaries as well. However, in the normal course of medical business, billing mistakes can happen. In most cases, these are innocent mistakes that are not intended to defraud the Medicare system. For example, a doctor may use the wrong medical code on a claim submitted to Medicare. Even though the service description sounds right, the wrong code could change how much you pay out of pocket. This one-time, innocent mistake is not a case of Medicare Abuse or even Medicare billing fraud.

It helps when you pay attention to the payment notice you receive from Medicare or your insurance company. If you suspect a mistake, talk to your doctor or a staff member about it. They'll either explain to you why it is right, or they will correct the error.

On the other hand, there are individuals, both patients and doctors, who do abuse the Medicare system. Medicare abuse and Medicare billing fraud are illegal. The Centers for Medicare & Medicaid Services (CMS), which administers Medicare, is cracking down. The agency working with patients, doctors and federal agencies - like the Department of Health and Human Services (HHS) Office of Inspector General, the Federal Bureau of Investigations (FBI) and the Department of Justice - to detect and prosecute those who commit Medicare abuse and Medicare billing fraud.

Here's how you can help.

Avoid Medicare abuse

Don't abuse the system and try to keep others from doing so. Do not give your Medicare card or your ID number to anyone other than your health care providers. Only your health care provider should have access to your medical records. Never ask your doctor for medication, products or services that you personally do not need.

Help detect Medicare billing fraud

Medicare billing fraud is the intentional and often recurring billing of Medicare for products and services that were not medically necessary, accurately coded or for an actual patient.

You can help detect Medicare billing fraud by carefully reviewing your payment notice. This is the notice that you get whenever a doctor or health care provider bills Medicare or your insurance company for a health care product or service. The notice identifies the product or service and lists the total amount billed, the amount Medicare or your insurance company paid to the provider, and the amount you will owe. Your doctor or health care provider will eventually bill you for the amount that is your share, unless you already paid it up front. If you suspect Medicare billing fraud, you should report it right away.

Watch for other signs of Medicare billing fraud that are more subtle. For example, be cautious when a medical service is advertised as "free," but be aware that some services may be available to you at no copay.

Also, be cautious of providers who:

  • Tell you that the more tests they perform, the less you pay out of pocket
  • Use telemarketing and door-to-door sales
  • Offer gifts as incentives to use their services
  • Routinely waive copays or who routinely charge copays when your plan makes the service available with no copay
  • Tell you they know how to get Medicare to pay for something that your plan documents clearly outline as not covered
  • Claim that Medicare "endorses" their products or services

How to report Medicare abuse and Medicare billing fraud

  • Call The Medicare fraud tip line at 1-800-HHS-TIPS (1-800-447-8477), TTY: 1-800-377-4950
  • Send up to 10 pages describing the incident to:

    • Email: HHSTips@oig.hhs.gov
    • Fax: 1-800-223-8164
    • U.S. postal service:

      • Office of the Inspector General
      • HHS Tips Hotline
      • P.O. Box 23489
      • Washington, DC 20026-3489
  • Florida residents can call 1-866-417-2078 or email floridamedicarefraud@hp.com.
eHealth Medicare is operated by eHealthInsurance Services, Inc., a licensed health insurance agency certified to sell Medicare products.
Medicare has neither reviewed nor endorsed this information.