Medicare Misconduct: Illustrations and Reporting Strategies
In the ever-evolving world of healthcare, the issue of Medicare abuse and fraud continues to be a significant concern. Here's what you need to know about this issue, its common types, and how to report any suspicious activities.
Reporting Medicare Abuse or Fraud
If you suspect any fraudulent activities related to Medicare, you can report them by contacting 800-MEDICARE (800-633-4227) or reporting online. For Medicare Advantage Plan or Medicare drug plan holders, the Investigations Medicare Drug Integrity Contractor can be reached at 877-7SAFERX (877-772-3379). When reporting, provide necessary details such as your name, Medicare number, the doctor or healthcare professional's name, the service or item in question, the dollar amount approved and paid by Medicare, and the date on the Medicare summary notice or claim.
The Scale of the Problem
In 2022, more than 477 defendants were convicted of fraud-related healthcare crimes. The US Department of Justice estimates that over $100 billion may be lost annually due to healthcare fraud, waste, and abuse. Last year, the DOJ reported that it began more than 800 new criminal healthcare fraud investigations and filed criminal charges in 419 cases involving at least 680 defendants.
Common Types of Medicare Abuse
Medicare abuse involves practices that cause unnecessary costs or services inconsistent with standard medical practice. Examples include billing for services not rendered, upcoding (billing for more expensive services than provided), and falsifying medical records to increase reimbursements.
Examples of Medicare Fraud
Medicare fraud is the deliberate seeking of financial gain when one knows the money does not belong to them, such as billing for services not provided, billing for services different from the care given, or paying for referrals of federal healthcare program beneficiaries. Key types of fraud include double billing, phantom billing, unbundling, upcoding, identity theft or swapping, illegal kickbacks, and prescription fraud.
Recognizing Medicare Abuse
To help recognize Medicare abuse, review your Medicare summary notices, check statements from Medicare Advantage plans, compare appointment dates and services received with statements, and check all receipts and statements for possible mistakes.
Consequences of Medicare Abuse and Fraud
Both Medicare abuse and fraud can expose doctors and other healthcare professionals to civil and criminal liability. These fraudulent activities cause billions in losses annually, endangering patient safety and increasing healthcare costs for all. National law enforcement efforts have led to criminal charges against hundreds of defendants and the seizure of millions of dollars in assets linked to Medicare fraud.
Here are some examples of common types of Medicare abuse and fraud, along with their descriptions and examples:
| Type | Description | Example | |------------------------------|------------------------------------------------------------|---------------------------------------| | Double Billing | Billing multiple times for the same service | Submitting duplicate claims for one procedure[2] | | Phantom Billing | Billing for services never provided | Charging for patient visits that did not occur[2][4] | | Upcoding | Billing for more expensive services than provided | Coding a simple office visit as a complex consultation[2][4] | | Unbundling | Separating procedures for higher overall charge | Billing components of a single procedure separately[2] | | Identity Theft/Swapping | Using someone else’s Medicare info for claims | Filing claims in another beneficiary’s name without consent[2][1] | | Illegal Kickbacks | Paying for patient referrals or services | Conspiring to pay/receive kickbacks in Medicaid claims[1] | | Prescription Fraud | Forged prescriptions, diversion, doctor shopping | Obtaining controlled substances through multiple doctors[2] |
These examples illustrate both abuse (e.g., upcoding, billing for unnecessary services) and outright fraud (e.g., false claims, identity theft) that affect Medicare programs.
This information is sourced from FBI health care fraud data, DOJ enforcement actions, and expert summaries on healthcare fraud and abuse[1][2][3][4].
- In instances of abusive behavior, healthcare professionals might bill for unnecessary services, such as upcoding (billing for more expensive services than provided) or unbundling (separating procedures for a higher overall charge).
- The health insurance sector encompasses various types of insurance, including health insurance and Medicare, with Medicare being a vital part of the United States' healthcare system.
- The wellness of individuals is not only relevant to their personal lives but also to the larger community, as concerns such as Medicare fraud impact the entire health-and-wellness sector, causing billions in losses and endangering patient safety annually.
