Your Guide to Reporting Medicare Fraud, Waste, and Abuse

Last updated 3 months ago. Our resources are updated regularly but please keep in mind that links, programs, policies, and contact information do change.

Protecting Medicare Together

Medicare is a cornerstone of healthcare for millions of Americans. Protecting its integrity is a shared responsibility that safeguards not only taxpayer dollars but also the health and financial well-being of every beneficiary. Fraud, waste, and abuse within the Medicare system divert critical funds from legitimate patient care, drive up healthcare costs for everyone, and can expose individuals to unnecessary or harmful medical services.

This guide helps you understand what constitutes Medicare fraud, waste, and abuse, how to identify suspicious activities, the official channels for reporting concerns, what to expect after making a report, the protections available to those who report, and valuable resources like the Senior Medicare Patrol (SMP) program designed to assist beneficiaries.

Understanding Medicare Fraud, Waste, and Abuse: Definitions and Examples

Understanding the differences between fraud, waste, and abuse is the first step in identifying potential problems within the Medicare system. While these terms are sometimes used interchangeably, they have distinct meanings according to official government sources like the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services Office of Inspector General (HHS OIG).

Defining the Terms

Fraud: Medicare fraud involves intentional deception or misrepresentation that an individual or entity knows to be false, or does not believe to be true, made with the knowledge that the deception could result in unauthorized benefit or payment from the Medicare program. The key elements are intent and knowledge. Medicare fraud is considered a criminal act.

Waste: Waste is generally defined as the overutilization of services or the misuse of resources, resulting in unnecessary costs to the Medicare program, even if not caused by criminally negligent actions. It often relates to mismanagement, inefficient practices, or poor clinical judgment rather than deliberate deceit.

Abuse: Abuse includes actions or practices that are inconsistent with accepted sound fiscal, business, or medical practices, resulting in unnecessary costs to Medicare, reimbursement for services that are not medically necessary, or services that fail to meet professionally recognized standards of care. Unlike fraud, abuse does not necessarily require proof of intent to deceive; it can involve providers seeking Medicare payment for items or services when beneficiaries were not legally entitled to them.

Illustrative Examples

Concrete examples help clarify these definitions:

Examples of Fraud:

• Knowingly billing Medicare for appointments the patient never kept or for services/items (like medical equipment) that were never provided.
• Knowingly billing for more expensive services or procedures than were actually performed (often called “upcoding” with intent).
• Falsifying patient diagnoses or medical records to justify tests, surgeries, or other procedures that aren’t medically necessary.
• Using a patient’s Medicare number without their knowledge or consent to submit fraudulent claims (medical identity theft).
• Paying or receiving kickbacks (money or other valuables) in exchange for patient referrals for services or items reimbursed by Medicare.
• Operating sham medical facilities, such as hospice centers that enroll patients who are not terminally ill to bill for services.

Examples of Waste:

• A doctor ordering excessive or duplicative laboratory tests beyond what is needed for diagnosis or treatment.
• Conducting more frequent or lengthy office visits than medically required for the patient’s condition.
• Prescribing significantly more medication than necessary for treating a condition.
• Widespread use of very expensive medical products (like certain skin substitutes) when less costly, equally effective alternatives might be available, or when the efficacy of the expensive product is not well-established.

Examples of Abuse:

• Billing for services that are not medically necessary based on the patient’s condition.
• Charging Medicare or beneficiaries far more than the reasonable cost for services or supplies.
• Misusing billing codes on a claim to inappropriately increase reimbursement (this can be abuse even if intent to defraud isn’t proven).
• Providing healthcare services that fail to meet professionally recognized standards of care.

The Gray Area: Errors vs. Intent

Distinguishing between intentional deception (fraud), improper practices (abuse), inefficiency (waste), and genuine billing errors can be challenging for beneficiaries reviewing their statements. A charge for a service not received might be deliberate fraud, or it could be a simple clerical mistake. This complexity and the potential overlap between the categories can create uncertainty.

Individuals might hesitate to report something suspicious for fear of wrongly accusing a provider or misunderstanding a complicated bill. However, it is not the beneficiary’s responsibility to determine intent or definitively categorize the issue. The crucial step is to report suspected problems. Official bodies like CMS and the HHS OIG have established processes and trained investigators to analyze reports, gather evidence, and determine whether an error, waste, abuse, or fraud has occurred.

Often, contacting the provider’s billing office directly can clarify confusion or resolve simple mistakes quickly. If concerns remain after contacting the provider, escalating the report through official channels is the recommended course of action.

Key Laws Underpinning Enforcement

Several major federal laws form the backbone of efforts to combat Medicare fraud, waste, and abuse, primarily by defining prohibited conduct for healthcare providers and establishing penalties:

The False Claims Act (FCA): Makes it illegal to knowingly submit false or fraudulent claims to Medicare or Medicaid. “Knowingly” includes acting in deliberate ignorance or reckless disregard of the truth. Penalties can include substantial fines per claim plus triple the amount of damages sustained by the government.

The Anti-Kickback Statute (AKS): A criminal law prohibiting knowingly and willfully offering, paying, soliciting, or receiving anything of value (remuneration) to induce or reward referrals for items or services paid for by federal healthcare programs. This aims to prevent medical decisions from being corrupted by financial incentives.

The Physician Self-Referral Law (Stark Law): Prohibits physicians from referring Medicare or Medicaid patients for certain “designated health services” (like lab tests, imaging, or therapy) to entities with which the physician (or an immediate family member) has a financial relationship, unless a specific exception applies. This is a strict liability statute, meaning intent does not need to be proven.

While these laws focus heavily on the actions of providers and suppliers, their effective enforcement directly benefits beneficiaries by protecting them from unnecessary or inappropriate care, ensuring the accuracy of their medical records, and preserving the financial health of the Medicare program upon which they rely. The consequences of violating these laws ripple through the system, impacting taxpayers who fund the program and the beneficiaries who depend on its services.

The High Cost of Fraud, Waste, and Abuse

Medicare fraud, waste, and abuse impose a staggering financial burden on the U.S. healthcare system and taxpayers, diverting billions of dollars each year from legitimate patient care. These activities not only drain taxpayer funds but also drive up overall healthcare costs, potentially leading to higher premiums and out-of-pocket expenses for beneficiaries. Furthermore, they can directly harm beneficiaries by subjecting them to unnecessary medical procedures, compromising the accuracy of their health records, or leading to the theft of their medical identity.

Understanding Improper Payments vs. Fraud

It is important to distinguish between “improper payments” and “fraud.” Government agencies track improper payments, which are defined as any payment that should not have been made or was made in an incorrect amount (including overpayments and underpayments) according to statutory, contractual, or administrative requirements. Improper payments can stem from intentional fraud, waste, or abuse, but they can also result from unintentional errors, such as mistakes in documentation, coding errors, or administrative oversights.

Crucially, estimates of improper payments are not estimates of fraud. While all fraudulent payments are improper, many improper payments occur without fraudulent intent. Understanding this distinction is vital for accurately interpreting government reports on program integrity.

Recent statistics illustrate the scale of improper payments:

• In Fiscal Year (FY) 2024, the total estimated improper payments for the Medicare program (across Fee-for-Service, Medicare Advantage Part C, and Part D) amounted to $54.3 billion.
  • Medicare Fee-for-Service (FFS) had an improper payment rate of 7.66%, totaling $31.70 billion.
  • Medicare Advantage (Part C) had an improper payment rate of 5.61%, totaling $19.07 billion.
  • Medicare Part D (Drug Plans) had an improper payment rate of 3.70%, totaling $3.58 billion.
• The Government Accountability Office (GAO) reported that combined Medicare and Medicaid improper payments exceeded $100 billion in FY 2023, representing 43% of the government-wide total.

Analysis of the reasons behind these improper payments reveals that issues often lie within administrative processes rather than solely deliberate deception. For traditional Medicare (FFS) and Part D in FY 2024, “insufficient or no claim documentation” was the leading cause of improper payments. For Medicare Advantage, “medical record discrepancies” were the primary driver.

The prevalence of documentation-related errors suggests that systemic factors, such as complex billing requirements, administrative burdens on providers, or inadequate oversight, contribute significantly to the improper payment figures. Addressing these large sums requires not only targeting intentional fraud but also improving processes, clarifying rules, and supporting providers in meeting documentation standards.

Specific Costly Examples and Recovery Efforts

While overall fraud costs are difficult to pinpoint precisely, specific examples and enforcement results highlight the financial impact:

• The HHS OIG found that diagnoses reported only on Medicare Advantage Health Risk Assessments (HRAs) and related chart reviews, without support from other service records, led to an estimated $7.5 billion in potentially improper risk-adjusted payments in 2023.
• Government enforcement actions do yield significant recoveries. The Health Care Fraud and Abuse Control (HCFAC) program recovered $3.4 billion across Medicare and Medicaid in FY 2023, demonstrating a positive return on investment for enforcement efforts. Settlements and judgments under the False Claims Act exceeded $2.9 billion in FY 2024, with over $1.67 billion related to the healthcare industry.
• GAO has noted that implementing its recommendations has led to billions in savings, such as nearly $2 billion over five years from improved automated payment prevention in Medicare.

However, the billions recovered through enforcement actions are substantially less than the tens of billions estimated in annual improper payments. This gap underscores the challenges in detecting and successfully prosecuting fraud compared to addressing errors and waste. It strongly suggests that relying solely on after-the-fact enforcement is insufficient. Robust prevention strategies—including beneficiary education, provider training, clear program rules, and proactive system safeguards—are essential to significantly reduce the overall financial losses to the Medicare program.

Impact on Beneficiaries

Beyond the financial costs to taxpayers, fraud, waste, and abuse can directly harm Medicare beneficiaries. Fraudulent billing can lead to errors in a patient’s medical history, potentially affecting future care decisions. Beneficiaries might undergo unnecessary tests or procedures, exposing them to physical risks. Their benefits might be depleted for services never received, leaving them without coverage when they genuinely need it. In some cases, if Medicare denies fraudulent claims after initially paying, beneficiaries could potentially be held responsible for the cost. Furthermore, the theft and misuse of a Medicare number for fraudulent purposes—medical identity theft—is a serious crime that can have long-lasting consequences for the victim.

How to Report Suspected Medicare Fraud, Waste, and Abuse

Reporting suspected fraud, waste, or abuse is a critical step in protecting the Medicare program and its beneficiaries. Several official channels are available for submitting reports. Knowing where to direct your concerns depends on the nature of the issue and the type of Medicare coverage involved.

Primary Reporting Channels

HHS Office of Inspector General (OIG) Hotline: This is the central hub for reporting suspected fraud, waste, abuse, and mismanagement across all Department of Health and Human Services programs, including Medicare and Medicaid. It accepts tips from the general public, beneficiaries, and providers. However, the OIG clarifies that its hotline should not be used for routine billing inquiries, coverage questions, or appeals; those should be directed elsewhere, primarily to 1-800-MEDICARE.

1-800-MEDICARE: This is the primary contact number for beneficiaries enrolled in Original Medicare (Part A and Part B). Beneficiaries can call this number to ask questions about their Medicare Summary Notices (MSNs), report billing errors, or voice concerns about services received or billed under Original Medicare.

Investigations Medicare Drug Integrity Contractor (I-MEDIC): If the suspected issue relates to a Medicare Advantage Plan (Part C) or a Medicare Prescription Drug Plan (Part D), reports can be made to the I-MEDIC. Beneficiaries can also contact their specific Medicare Advantage or Part D plan directly to report concerns or suspected fraud.

Senior Medicare Patrol (SMP): SMP programs are a key resource specifically designed to help beneficiaries prevent, detect, and report Medicare fraud, waste, and abuse. They offer education and one-on-one assistance.

The existence of these different reporting avenues reflects the structure of the Medicare program itself, with separate administrative pathways for Original Medicare versus private Medicare Advantage and Part D plans, alongside the overarching oversight role of the HHS OIG. While this structure allows for specialized handling of complaints, it can also create confusion for individuals unsure of the most appropriate contact point. The following table consolidates the contact information for the primary reporting entities to provide a clear and accessible reference.

Official Medicare Fraud, Waste, and Abuse Reporting Contacts

Note: URLs are subject to change. Always verify contact information directly on official government websites like Medicare.gov and OIG.HHS.gov.

The continued availability of traditional reporting methods like toll-free phone numbers and mail, alongside online portals, is crucial. This multi-modal approach ensures accessibility for all individuals, including older adults or those in areas with limited internet access, reflecting the diverse needs of the Medicare population.

Other Reporting Avenues

In specific situations, other agencies may be relevant:

• If suspected fraud involves Medicaid alongside Medicare, or solely Medicaid, the state’s Medicaid Fraud Control Unit (MFCU) is a key reporting entity. A directory is available on the HHS OIG website.
• General healthcare fraud or related identity theft can also be reported to the Federal Bureau of Investigation (FBI).

Gathering Information for Your Report

When you suspect Medicare fraud, waste, or abuse, providing detailed and accurate information significantly increases the likelihood that investigators can effectively assess and act on your report. Vague allegations are difficult to pursue. Investigators rely on specific, actionable leads to initiate and conduct successful inquiries.

Key Information to Collect

Based on guidance from the HHS OIG and other official sources, try to gather as much of the following information as possible before submitting your report:

Your Information (Optional but helpful): Your name, contact information (phone, email, address), and Medicare number. You can choose to report anonymously, but providing contact details allows investigators to follow up if they need clarification.

Subject of Complaint (Who): The name and contact information (address, phone number, etc.) of the healthcare provider, supplier, company, or individual you suspect of wrongdoing. Include any identifying numbers if known (like a provider number).

Description of Activity (What): A clear, detailed narrative explaining the specific activity you suspect is fraudulent, wasteful, or abusive. Describe the service, item, bill, or behavior in question. Crucially, explain why you believe it is improper.

Timing (When): The specific date(s) when the service or item was supposedly provided or billed. Include the overall timeframe during which the suspicious activity occurred.

Location (Where): The place where the service was supposedly rendered (e.g., specific clinic name, hospital, home address).

Discovery (How): Explain how you became aware of the potential issue (e.g., reviewing your MSN, receiving an unsolicited item, a suspicious phone call).

Corroboration (Witnesses): The names and contact information of any other individuals (e.g., other patients, staff members) who might have witnessed the activity or can help verify your report. The ability to provide independent verification can significantly strengthen a complaint, potentially giving it higher priority amidst the large volume of reports received by oversight agencies.

Supporting Documentation

Include copies (never send originals, as they won’t be returned) of any documents that support your allegation. This evidence helps investigators understand and verify your complaint. Useful documents include:

• Medicare Summary Notices (MSNs) or insurance Explanation of Benefits (EOBs) with the questionable charges clearly marked or highlighted.
• Bills, invoices, or receipts received from the provider or supplier.
• Your own notes from appointments, including dates, times, and services discussed or received.
• Relevant emails, letters, flyers, or advertisements related to the suspicious activity.
• Photographs, if applicable (e.g., of unsolicited equipment received).

The level of detail requested underscores that investigations are evidence-based. By actively tracking appointments, carefully reviewing statements, and gathering supporting documentation, beneficiaries transform themselves from passive recipients of care into active participants in safeguarding the integrity of the Medicare program.

What Happens After You File a Report?

Submitting a report about suspected Medicare fraud, waste, or abuse is an important action, but it’s also helpful to understand the process that follows and manage expectations regarding communication.

Initial Review and Triage

Once a complaint is received, for example, by the HHS OIG Hotline, analysts review it to determine its relevance, completeness, and credibility. Due to the high volume of tips received, not every complaint automatically triggers a full-scale investigation. Agencies prioritize allegations based on factors such as the potential risk to beneficiaries, the financial impact on Medicare, the credibility of the information provided, and whether the OIG or another agency is the only viable path for addressing the issue.

This prioritization means that even valid concerns might not be investigated immediately, or at all, if they don’t meet the threshold for action based on available resources and competing priorities. This reality reinforces the value of providing detailed, well-documented reports (as discussed in Section V) and highlights the importance of proactive prevention efforts.

Investigation Process

If a decision is made to pursue the complaint, several actions might occur:

Further Investigation: OIG investigators or investigators from other relevant agencies (like CMS contractors or the Department of Justice) may gather additional evidence. This can involve interviewing witnesses (including patients and provider staff), conducting data analysis of billing patterns, issuing subpoenas for records, or even visiting provider offices.

Referral: The complaint might be referred to another entity better suited to handle it. This could include referral to CMS for administrative action (like payment suspension), to the Department of Justice (DOJ) for potential civil or criminal prosecution, to a state Medicaid Fraud Control Unit (MFCU) if Medicaid is involved, or to internal OIG components for an audit or inspection.

Complexity and Duration: Healthcare fraud investigations can be complex and lengthy, sometimes taking months or even years to complete, depending on the scope of the allegation, the amount of evidence, and the cooperation of involved parties.

Communication with the Reporter

It is essential for reporters to have realistic expectations about communication after submitting a complaint.

Potential Contact: If you provided your contact information, an investigator may contact you for additional details or clarification.

No Status Updates: However, agencies like the HHS OIG generally do not provide status updates on investigations or even confirm receipt of a complaint. This policy is in place to protect the integrity of investigations, maintain confidentiality, and comply with privacy laws.

Lack of Contact ≠ Inaction: It is critical to understand that a lack of communication does not mean your report was ignored or that no action is being taken. Your information may still be valuable, contributing to a larger investigation or identifying trends even if it doesn’t lead to immediate, visible action on your specific report.

Limited Medicare Follow-up: In certain specific situations, such as if you called 1-800-MEDICARE and left a message, or if you previously filed a report, a representative from Medicare (not necessarily an investigator) might call you back. Be cautious, however, as Medicare rarely makes unsolicited calls.

The investigative process is largely opaque to the person who filed the initial report. While this lack of feedback is necessary for legal and operational reasons, it can sometimes diminish a reporter’s sense of impact or closure. Understanding this “black box” nature beforehand helps manage expectations.

Potential Outcomes

If an investigation substantiates wrongdoing, a range of outcomes is possible, including:

• Administrative actions by CMS or OIG, such as warnings, provider education, recovery of overpayments, suspension of payments, or exclusion of providers from participating in federal healthcare programs.
• Civil monetary penalties and lawsuits under the False Claims Act to recover funds and impose fines.
• Criminal prosecution by the DOJ, potentially leading to fines and imprisonment for individuals involved in fraud.
• Recommendations for changes in policies or procedures within HHS programs to prevent future occurrences.

Protections for Reporters: Whistleblower Rights

Concerns about confidentiality and potential retaliation can deter individuals from reporting suspected wrongdoing. Fortunately, federal laws and agency policies provide significant protections for those who come forward.

Confidentiality and Anonymity

When reporting to agencies like the HHS OIG, individuals often have options regarding their identity:

Anonymous Reporting: You can choose to submit a report without providing your name or contact information. In this case, your identity remains unknown even to the OIG. The drawback is that investigators cannot contact you for clarification or additional information.

Confidential Reporting: You can provide your name and contact information but request that your identity be kept confidential. The OIG is required by the Inspector General Act to protect your identity from disclosure outside the OIG, unless the Inspector General determines that disclosure is unavoidable during the investigation (e.g., if only a very small number of people could possess the reported information). OIG endeavors to protect confidential sources and may attempt to contact you before any necessary disclosure. Choosing confidentiality allows investigators to follow up with you if needed. State hotlines may also offer confidentiality to the extent permitted by law.

Anti-Retaliation Protections

Federal laws specifically prohibit retaliation against individuals who make “protected disclosures” about waste, fraud, abuse, mismanagement, or substantial dangers to public health and safety. Retaliation can include actions like being fired, demoted, harassed, denied promotions or benefits, or receiving other adverse treatment because of the disclosure.

Who is Protected: These protections generally cover employees of federal agencies (like HHS), as well as employees of federal contractors, subcontractors, grantees, and subgrantees who report misconduct related to federal funds or programs.

What is a Protected Disclosure: To be protected, the disclosure must generally be based on a reasonable belief that wrongdoing occurred and must be made to an authorized person or entity. Reporting to the relevant OIG Hotline is always considered an authorized channel. Other authorized channels vary depending on the reporter’s employment status (e.g., supervisors, Congress, GAO). Importantly, disclosing classified information through unauthorized channels is not protected, even if it pertains to wrongdoing.

Key Laws: Protections are established under laws such as the Inspector General Act of 1978, specific statutes protecting contractor and grantee employees (like 41 U.S.C. § 4712), and the Whistleblower Protection Act and its subsequent enhancements.

The False Claims Act (FCA) Qui Tam Provisions

A distinct and powerful avenue for whistleblowers, particularly those with inside knowledge of significant fraud against the government, is the qui tam provision of the False Claims Act.

How it Works: This allows private individuals (known as “relators”) to file lawsuits on behalf of the U.S. government against entities that have submitted false claims to programs like Medicare. The government investigates the allegations and decides whether to intervene and take over the case.

Financial Incentives: If the lawsuit is successful and the government recovers funds, the relator is typically entitled to receive a percentage of the recovery, usually ranging from 15% to 30%. This financial incentive encourages individuals with direct knowledge of fraud to come forward.

“First-to-File” Rule: The FCA generally bars subsequent lawsuits based on the same underlying facts as the first-filed qui tam action. This means that only the first whistleblower to properly file the claim stands to receive a share of the recovery, making timeliness crucial.

Complexity: Filing a qui tam lawsuit is a formal legal process that typically requires experienced legal counsel to navigate the procedural requirements, protect the relator’s interests, and maximize the chances of success. This pathway is distinct from making a report to the OIG Hotline, involving higher stakes and greater legal complexity.

Reporting Retaliation

If an individual believes they have suffered retaliation for making a protected disclosure, specific channels exist for reporting this:

HHS OIG Whistleblower Protection Coordinator: HHS established this role (formerly Ombudsman) to educate employees about their rights and remedies regarding retaliation. While the Coordinator cannot act as a legal representative, they can provide information and guidance. Contact: [email protected]. Employees of HHS grantees and contractors can also submit reprisal complaints to the HHS OIG.

U.S. Office of Special Counsel (OSC): Federal employees may be able to file retaliation complaints with the OSC.

Navigating whistleblower protections involves understanding specific legal definitions (like “protected disclosure” and “authorized audiences”) and procedures that can vary based on one’s employment status. The complexity suggests that individuals facing potential retaliation may benefit significantly from seeking specialized advice, whether from the OIG Coordinator or legal counsel, particularly if considering a qui tam action under the FCA.

Help is Available: The Senior Medicare Patrol (SMP)

Navigating the complexities of Medicare and identifying potential fraud, errors, or abuse can be daunting for beneficiaries and their families. Fortunately, a dedicated nationwide program exists to provide free, personalized assistance: the Senior Medicare Patrol (SMP).

SMP Mission and Role

SMPs are grant-funded projects supported by the federal Administration for Community Living (ACL), with programs operating in every state, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. Their core mission is clear: to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report healthcare fraud, errors, and abuse. SMP staff and volunteers act as trusted resources and serve as the “eyes and ears” within their local communities, forming a crucial part of the front-line defense against Medicare losses.

How SMP Helps Beneficiaries

SMPs fulfill their mission through three main types of activities:

Education and Outreach: SMPs conduct presentations for senior groups, community organizations, and faith-based groups; exhibit at health fairs and other events; and distribute informational materials. They educate beneficiaries on topics like how to read their Medicare statements (MSNs and EOBs), how to protect their Medicare number, common healthcare scams, and the difference between fraud, errors, and abuse.

Counseling and Assistance: SMP staff and trained volunteers work one-on-one with beneficiaries who have questions or concerns about their Medicare bills or services. They can help individuals understand complex Medicare information, review their MSNs and EOBs for accuracy, identify potential billing errors or suspicious charges, and guide them through the process of resolving issues or reporting suspected fraud. This personalized support serves a vital “translator” function, bridging the gap between the often-intimidating healthcare billing system and beneficiaries who need help navigating it. SMPs make the process less confusing and more accessible.

Receiving Complaints and Making Referrals: Beneficiaries can bring their complaints directly to their local SMP. SMP staff assess the situation to determine if fraud, error, or abuse is suspected. When fraud or abuse appears likely, the SMP refers the case to the appropriate state or federal agencies (such as the HHS OIG, CMS contractors like I-MEDIC, or state MFCUs) for formal investigation.

Volunteer Engagement: SMPs rely heavily on dedicated, trained volunteers from the community to extend their reach and provide peer support. While this model allows for broad community presence, it may mean some variation in resources across locations. The SMP National Resource Center plays a key role in providing training, technical assistance, and standardized materials to support consistency and quality across all state programs.

Finding Your Local SMP

Connecting with your state or territory’s SMP program is easy:

• National Toll-Free Number: Call 1-877-808-2468 to be connected to the SMP program in your area.
• Online SMP Locator: Visit the national SMP website’s locator tool at smpresource.org/Locator/ to find contact information for your local program.

Recognizing and Preventing Medicare Fraud: Tips for Beneficiaries

Being informed and vigilant is the best defense against becoming a victim of Medicare fraud, waste, or abuse. Knowing common scam tactics and practicing simple preventive measures can protect your identity, your benefits, and taxpayer dollars.

Common Fraud Schemes and Red Flags

Fraudsters are constantly devising new ways to exploit the Medicare system and its beneficiaries. Many schemes prey on beneficiaries’ trust in the Medicare name or take advantage of confusion surrounding benefits and billing. Be aware of these common tactics:

Billing Schemes:

• Charges for doctor visits, tests, procedures, medications, or medical equipment/supplies that you never received.
• Billing for more complex or expensive services than were actually provided (Upcoding).
• Billing related services separately to get higher reimbursement instead of using a required bundled code (Unbundling).

Unnecessary Services/Items:

• Providers ordering tests (like genetic tests), equipment (like back or knee braces, wheelchairs, scooters, urinary catheters), or services that are not medically necessary for your condition. Often, these are marketed as “free” or “covered by Medicare.”
• Specific Scams: Be wary of unsolicited offers for genetic testing (cardiac or cancer screening), durable medical equipment (DME) you didn’t request or need, unnecessary ambulance rides, or enrollment in hospice care when not terminally ill. Recent alerts highlight scams involving urinary catheters.

Identity Theft:

• Someone stealing your Medicare number (and possibly other personal information) to submit fraudulent bills in your name.

Kickbacks and Inducements:

• Offers of cash, “free” groceries, gift cards, or other items of value in exchange for your Medicare number or agreement to receive certain services.
• Providers routinely waiving required copayments or deductibles to attract business (waivers are only allowed based on genuine financial hardship assessed individually).

Marketing Violations and Scams:

• Unsolicited phone calls, text messages, emails, or door-to-door visits trying to sell Medicare plans or medical items. Remember, Medicare rarely calls beneficiaries uninvited.
• High-pressure sales tactics or scare tactics (e.g., threatening loss of benefits) to get you to enroll in a plan or provide personal information.
• Callers falsely claiming you need a “new” plastic or updated Medicare card and asking for your number to issue it. Medicare automatically mailed new cards without Social Security numbers; you don’t need to request one unless yours is lost or stolen.
• Fake offers of refunds or rebates requiring you to provide bank account or Medicare details.
• Marketers misrepresenting plan benefits or using official government logos (like the Medicare logo) improperly in advertisements.

Pharmacy Fraud:

• Pharmacies billing Medicare for prescriptions never picked up or dispensed, dispensing expired drugs, or providing fewer pills than billed (shorting).

Practical Prevention Tips – The “4 Rs” and More

Medicare and its partners recommend following the “4 Rs” and other practical tips to protect yourself:

Record: Keep a log or calendar of all your doctor’s appointments, hospital stays, tests, and other medical services you receive. Note the dates and the provider’s name. SMPs often provide free “My Health Care Trackers” for this purpose.

Review: Carefully read your Medicare Summary Notice (MSN) if you have Original Medicare, or your Explanation of Benefits (EOB) if you have a Medicare Advantage or Part D plan. These statements arrive by mail (typically quarterly for MSNs, more often for EOBs) or you can access them online sooner through your secure account at Medicare.gov. Compare the dates, provider names, services, and charges listed on the statement against your own records. Look specifically for:

• Services, supplies, or equipment you didn’t receive.
• Double billing for the same service.
• Services that were not ordered by your treating physician.

This review process is arguably the single most effective detection tool available to beneficiaries, transforming you into an active monitor of your own healthcare billing.

Report: If you spot errors or suspicious activity on your MSN/EOB or encounter questionable behavior, report it promptly. First, consider calling the provider’s office directly, as it might be a simple billing error they can correct. If you’re not satisfied with their explanation or suspect intentional wrongdoing, contact the appropriate official channels listed in Section IV (1-800-MEDICARE, HHS OIG Hotline, I-MEDIC, or your local SMP).

Remember/Guard: Treat your Medicare card and number with the same level of protection as your credit cards or Social Security number.

• Do not share your Medicare number with anyone who contacts you unexpectedly by phone, email, text, or in person, especially if they offer “free” items or services in exchange.
• Only give your Medicare number to your doctors, pharmacists, other trusted healthcare providers, your insurer, or official Medicare representatives (like SHIP or SMP counselors) whom you have contacted or have a legitimate reason to interact with.
• Hang up on unsolicited callers asking for your Medicare number.

Additional Prevention Tips:

• Do not accept medical equipment or supplies (like braces, test kits, or catheters) that are delivered to your home unless they were specifically ordered by your doctor who treats you. If unsolicited items arrive, refuse the delivery or return them to the sender. Keep a record.
• Be skeptical of offers for “free” medical services, consultations, or genetic tests advertised on TV, online, or through unsolicited calls.
• Never sign blank medical or insurance forms.
• Rely on your own trusted physician for medical advice and treatment decisions, not on telemarketers, door-to-door salespeople, or people approaching you at health fairs or in public places.
• Do not allow anyone except your doctors or other legitimate providers to review your medical records.

Quick Guide: Medicare Protection Do’s and Don’ts

By staying informed and taking these proactive steps, every Medicare beneficiary can contribute significantly to protecting themselves and preserving the integrity of the Medicare program for current and future generations.

Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.