Medicare Fraud and Abuse

Medicare Fraud and Abuse

It's important for Medicare beneficiaries to be alert to possible Medicare fraud and abuse incidents, whether they directly affect the beneficiary or not. Every year, the Medicare system loses millions of dollars at the hands of con artists and deceptive medical officials who exploit the Medicare system, typically for monetary gain, and sometimes to the detriment of the patient. You should be aware of some of the common techniques used by disreputable medical professionals, so that you can help to report such incidents if you suspect fraud and abuse.

What is Medicare Fraud?

It should be noted that a complaint about the quality of a healthcare provider, a home health agency, a nursing home or your doctor is not considered Medicare fraud and abuse. While quality issues are a matter that should also be reported to Medicare officials, fraud is more narrowly defined as the exploitation of the Medicare system, or a deceitful act perpetrated for monetary gain.

How Does Medicare Fraud Occur?

One common way Medicare fraud and abuse may occur is when a patient is billed, or told to receive, unnecessary treatment. Be aware of unusual diagnoses and if you suspect something isn't right, seek a second opinion. A misdiagnosis could actually be an intentional move on the part of a disreputable doctor who wishes to extract additional money out of the Medicare system - at a potentially dangerous cost, not only to your personal expenses, but also your health and welfare.

This is why it's important to do this if you suspect an unusual diagnosis was made which could lead to an expensive - and dangerous - medical procedure. Every year, thousands of unnecessary medical operations are performed on patients. And, while the majority of these are honest mistakes, when you are under the umbrella of government sponsorship you should be a little bit extra vigilant to ascertain from an independent vantage point that every procedure is absolutely necessary. The best way is to have another trusted doctor who can provide a secondary opinion.

Also, beware of a company that is offering a Medicare drug plan that has not been approved by Medicare. If a pharmaceutical company is not authorized to work with your HMO, then this is likely a tactic to create additional charges by introducing treatment that Medicare does not cover - and must come out of your pocket. In addition, beware of a company that is attempting to coerce you into joining a Medicare Advantage plan, as another way Medicare fraud and abuse may occur is when a patient is pressured to join an HMO based on false information. You can track the reputation and star-ratings of private Medicare affiliate companies at

There is other ways Medicare fraud and abuse may occur, which you may not be aware of. Sometimes a company will bill Medicare for equipment after it's already been returned, or for equipment that you never received. If you were supposed to be delivered a certain product, and the shipping appears very late, consider tracking down the information about the shipment yourself and verify that the order was placed correctly, and Medicare representatives are aware that you never received the equipment.

Aside from companies, Medicare fraud and abuse may also occur on an individual level. Guard your Medicare card and information closely, as just like any aspect of identity theft, it's possible for people to steal and use your information—and to bill their own Medicare expenses using your identity. If you suspect unusual charges to your Medicare account, first contact your health provide to guarantee it's not an error on your part. If you still cannot justify the charge, be ready to alert a Medicare official or customer service representative to determine the origins of the unknown charges on your Medicare statements.

Medicare fraud and abuse can also occur when physicians and doctors do not follow good practices. Over-charging results in unnecessary costs to the Medicare system, and it ultimately places the entire program in jeopardy. If you are employed, and if you suspect that your employer is exploiting the Medicare system, understand that it's possible to report incidents of abuse completely anonymously. However, by remaining anonymous it becomes more difficult for departments to conduct their investigation as they have no way to reach you.

How Does Medicare Mitigate Fraud?

Fortunately, Medicare works very hard with many other government agencies to mitigate fraud wherever possible - whether on the individual level, or Medicare fraud and abuse perpetrated by large corporations. Ending fraud is critical to maintaining the livelihood of the system, to ensure millions of Americans are given the opportunities provided by Medicare to cut the heavy burdens associated with the health scenarios common among senior citizens.

Most physicians, HMOs, and suppliers are also committed to preventing fraud. It's only a small minority of corrupt physicians and individuals who seek to exploit the government, and would place you in harm's way to do it. Through being aware of the techniques used in Medicare fraud and abuse cases, whether you are a patient or an employee, you can be aware of how the system gets exploited - and you can be ready to report incidents of fraud at a moment's notice. In addition, you may eligible as a Medicare recipient for a cash reward for reporting fraud. See for more information.