Recognizing Medicare fraud

Medicare fraud and abuse overview

You may be exposed to Medicare fraud at any time, before you enroll in a plan, when you access care at a doctor’s office or a facility or at other times. Learn about common behaviors and actions below that may help you recognize and protect yourself from fraudulent activity.

Billing fraud

If you have Original Medicare, your doctor should not:

  • Charge you for most preventive services
  • Offer tests or other services that you do not need, especially if the doctor says that the more tests you receive, the cheaper they are
  • Routinely waive your coinsurance (providers can waive cost-sharing for patients with great financial need, but not regularly)

Always confirm that you received the services listed on either your Medicare Summary Notice (MSN) or your Explanation of Benefits (EOB). Sometimes this can be hard to do if you received services from several doctors at the same time. If you returned durable medical equipment (DME), your supplier should not continue to charge Medicare for rental fees or maintenance.

To report fraud, you should contact 1-800-MEDICARE (633-4227), the Senior Medicare Patrol (SMP) Resource Center (877-808-2468), or the Inspector General’s fraud hotline at 1-800-HHS-TIPS (447-8477). Medicare will not use your name while investigating if you do not want it to.

Marketing fraud

You are being misled if an agent from an insurance company says that you:

  • Must sign up for a Medicare Advantage Plan to get Medicare drug coverage (you can also keep Original Medicare and enroll in a stand-alone Part D plan)
  • Will pay a higher Part B premium unless you sign up for a certain plan (some plans help pay your Part B premiums or charge additional premiums, but your Part B premium will not increase based on your coverage choices)
  • Must invite a plan representative to your home to get information about the plan or to enroll
  • Can switch back to Original Medicare at any time if you are dissatisfied with the plan, without providing information about enrollment periods
  • Will receive additional benefits that are actually Medicare-covered services
  • Will receive additional benefits, such as dental or vision, that are actually covered by other insurance you have or are eligible for (such as Medicaid)
  • Will lose your Medicaid benefits unless you sign up for a certain plan

Make sure to verify any marketing information you receive in the plan’s benefit manual or by calling the plan directly. Avoid enrolling in error by confirming whether the plan:

  • Provides drug coverage
  • Offers coverage through the coverage gap
  • Has your providers, hospitals, and pharmacies in their network
  • Offers additional benefits, such as vision or dental

Note: Insurance agents and brokers may receive a large fee for getting you to sign up for a Medicare private plan.

Never feel pressured to join any plan. Always make sure you understand what the plan is offering you, and how all your benefits are affected. Ask to receive information about the plan’s benefits in writing. If you suspect that an agent is not following the rules, save documented proof (such as the agent’s business card or marketing materials). Contact your State Insurance Department or State Attorney General Consumer Helpline to report your concerns.

If you find out that your plan has made fraudulent claims about your health or drug coverage, you may be eligible for a Special Enrollment Period (SEP) to disenroll from your plan and switch to another one.