Types of Medicare Fraud

Medicare, and many affiliate government departments, as well as private companies and medical professionals are all committed to ameliorating the threat from different types of Medicare fraud. It's a small minority of corrupt individuals and corporations that seek to exploit the cost-savings created through this government service. Whether you are a patient, or an employee of a healthcare institution, it's important to be aware of how this fraud operates, so that you can report suspicious activity and help defend Medicare from untold millions of dollars of damages it incurs every year from exploitation.

Corporate Level

Types of Medicare fraud include criminal activity on both an individual level, and a larger corporate level. Probably one of the most common ways that the system is exploited for private financial gain is by companies that bill Medicare for services that were never received, or never necessary. As an example, in the late 1980s Damon Corp defrauded the Massachusetts Medicare system to the tune of millions of dollars by submitting fraudulent reimbursement claims for blood tests. This single incident cost Medicare, and taxpayers, $25 million dollars. Of course, crime rarely pays, and Damon Corp settled with a $119 million dollar fine.

Individual Level Fraud

Aside from the larger, corporate level—the most malicious types of Medicare fraud may be the kind that occurs on the individual level. This is when an unscrupulous doctor or medical office creates a purposeful misdiagnosis on a patient, in order to bill that patient for a number of tests and dangerous operations. This type of fraud is rare, but predatory medical practices target individuals and can place their lives at risk. To avoid this, pay attention to the reputation of your Medicare Advantage plan (HMO). Follow the star-rating system of HMOs provided at www.medicare.gov and avoid any company with low-ratings.

In addition, as a patient you should be aware of any unusual behavior, or a recent diagnosis that you have second thoughts about. Have a secondary doctor as a backup, who can provide an alternative opinion if you feel uncertain that your primary healthcare provider gave an accurate assessment. Unfortunately, thousands of misdiagnoses occur every year, which includes unnecessary surgical procedures. The majority of these are honest mistakes, but there are still occasionally incidents of deliberate fraud and malicious medical practices, among other types of Medicare fraud.

If you are an employee of a health care provider, you should also be aware of the types of Medicare fraud that are common in the system. Fortunately, Medicare allows anonymous reporting if you are afraid of revealing your identity or being fired. If you suspect there are surreptitious practices happening inside of you medical office, you should not hesitate to make a phone call to a Medicare representative. While misreporting Medicare expenses only wastes taxpayer dollars, a misdiagnosis and an improper medical procedure could cost a patient their health and well-being.

Identity Theft Fraud

Other types of Medicare fraud include identity theft. Just like with your Social Security card or other sensitive personal documents, it's important to guard your Medicare information as well. It's possible that your information could be stolen and used by another person to bill his or her own expenses. For this reason, it's important to check your Medicare monthly statements and look for anything that's not supposed to be there. If you catch an unusual charge, alert a Medicare representative right away, so that they may conduct an investigation.

Drug Pushers Fraud

One of the last types of Medicare fraud to be aware of are the "drug pushers". This is when a private company, such as an HMO, tries to convince a patient to purchase unnecessary services. For instance, an HMO attempts to convince a patient to sign up for a pharmaceutical drug plan with a company that is not covered by Medicare. This will lead to additional, personal expenses that are not covered by the system - which will ultimately profit a private company for typically over-priced drugs that should be billed to your Medicare Plan D.

Another incarnation of this is when a company uses false information to try and coerce you into joining their HMO. Under the recent Affordable Care act through the Obama administration, there is new regulations and pressure to track over-priced, coercive HMOs. As a result, there are now resources available where you can personally track the reputations of private Medicare affiliate companies and ensure that you are not being ripped off by unfair deductibles and premiums. Remember that it's not fraud, or illegal, for a company to set their own prices—but it's illegal to falsify information in order to entice a patient to purchasing their plan.

Through being aware of the different types of Medicare fraud, you will have an advantage in guarding both your well-being, and your wallet. In addition, if you are an employee of a private health practice, you can be aware of how the system is exploited to ensure you are never unknowingly participating in a criminal scheme. Fortunately, fraud is still a rare occurrence, and the vast majority of health professionals work with the government to mitigate fraud wherever possible. For more information, you can visit the official Medicare government website, www.medicare.gov, or speak to your local Medicare representative about additional ways you can be vigilant against deceptive practices.