Medicare fraud costs the federal government billions of dollars each year and affects every beneficiary who relies on the program. Fraudulent billing can take many forms, from a provider charging for services you never received to a scammer calling you at home and asking for your Medicare number. Understanding how these schemes work and knowing what to do when you spot one can protect your benefits and your personal information.
Common Medicare Fraud Schemes to Recognize
Fraud can happen anywhere in the health care system, but certain patterns appear again and again. Be alert to these warning signs:
- Billing for services you did not receive. Review every Medicare Summary Notice or Explanation of Benefits you get in the mail. If a charge appears for a test, procedure, or supply you never got, that is a red flag.
- Upcoding. A provider bills Medicare for a more expensive service than the one actually performed. The service may be legitimate, but the billing code is not.
- Unbundling. A provider bills separate charges for procedures that should be billed together as one package, inflating the total cost to the program.
- Free goods or services as bait. Scammers may offer free health screenings, genetic tests, or medical equipment in exchange for your Medicare number. They then use that number to submit false claims.
- Phony phone calls and phishing. Medicare will never call you to sell anything or ask for your bank or credit card information. If someone calls asking for your Medicare number, hang up.
- Kickbacks. A provider may receive money or gifts for referring you to certain services or suppliers, which can lead to unnecessary and costly care.
What to Do If You Suspect Fraud
If you believe you have been the victim of a Medicare fraud scheme, act quickly. You can report suspected fraud to the HHS-OIG hotline at 1-800-HHS-TIPS (1-800-447-8477). Beneficiaries can also call 1-800-MEDICARE to report suspicious charges or ask questions about their statements. Keep copies of any bills, statements, or correspondence related to the suspected fraud, and do not confront the provider yourself.
Protecting your Medicare number is the single most important step you can take. Treat it like a credit card number. Never share it over the phone unless you initiated the call, and only share it with providers you know and trust.
How Whistleblowers Help Stop Fraud
Health care workers, billing staff, and others who see fraud from the inside have a powerful tool to fight back. The federal False Claims Act (31 U.S.C. 3729-3733) allows private individuals, known as relators, to file qui tam lawsuits on the government's behalf. These lawsuits are filed under seal, meaning they remain confidential while the government investigates.
If the government intervenes in the case and recovers money, the relator generally receives 15 to 25 percent of the recovery. If the government does not intervene and the relator pursues the case successfully, the share is 25 to 30 percent. Parties found liable under the False Claims Act can owe up to three times the government's damages plus per-claim civil penalties that are adjusted for inflation each year.
There are deadlines to keep in mind. The general statute of limitations is six years from the violation, or three years from when the government knew or should have known about it, but in no case more than ten years. Anyone considering a qui tam case should understand these time limits before acting.
Protection for Whistleblowers
Fear of retaliation should not stop an honest employee from reporting fraud. Section 3730(h) of the False Claims Act protects employees from being fired, demoted, harassed, or discriminated against because they took steps to stop fraud. Remedies available to a retaliated-against employee include reinstatement and double back pay, along with other damages and litigation costs.
Whether you are a patient checking your statements or a health care worker who sees something wrong, reporting fraud protects the Medicare program for everyone who depends on it. When in doubt, report it.
