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Medicare tries to ensure business with quality doctors and health-care providers, both to help its beneficiaries and for the program’s own well-being. However, in the normal course of medical business, unpleasant things can happen, like billing mistakes and, most alarmingly, Medicare fraud and abuse.
Medicare fraud is the general term for someone, such as a doctor, knowingly billing the Medicare system for a service or supply that a beneficiary didn’t get.
Billing errors are often innocent mistakes 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 fraud.
In order to avoid billing errors, be sure to pay close attention to the payment notice you receive from Medicare or your insurance company. If you suspect a mistake, immediately talk to your doctor or a staff member about it. They’ll either explain to you why the payment notice is correct, or they will fix the error.
Medicare fraud is illegal, so it’s more serious than a billing error. Medicare fraud involves doctors or beneficiaries abusing the Medicare system for their own personal gain.
Medicare billing fraud means knowingly billing Medicare — possibly over and over again — for products and services that were not medically necessary, accurately coded, or for an actual beneficiary. You can help detect Medicare billing fraud by carefully reviewing your payment notice. This is the notice 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 owe.
Also, beware of providers who:
Here are two more examples of Medicare fraud:
Medicare abuse happens when a provider doesn’t follow good medical practices, including performing services that are not medically necessary. It is as serious an offense as Medicare fraud. Medicare abuse, like Medicare fraud, is illegal and punishable to the full extent of the law.
If you suspect Medicare fraud or abuse, you should report it right away. The Centers for Medicare & Medicaid Services (CMS), which administers Medicare, is cracking down on this type of activity. The agency is working with beneficiaries, doctors, and federal agencies — such as the Department of Health and Human Services (HHS), the 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.
To report Medicare fraud or abuse, you can do any of the following:
Please note that the contact information above is only to be used for reporting fraud or abuse.
eHealth's Medicare website is operated by eHealthInsurance Services, Inc., a licensed health insurance agency doing business as eHealth. The purpose of this site is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. eHealth and Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. We offer plans from a number of insurance companies.