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Understanding Medicare Fraud

  • By: Forman Law Group
  • Published: September 24, 2019

Medicare is a health insurance program designed to provide health care for people who fall into three main categories: age 65 or older, anyone diagnosed with certain disabilities, and anyone who has been diagnosed with end-stage kidney disease. For these individuals, Medicare covers inpatient hospital and facility stays, outpatient care including rehabilitative therapies, and the cost of prescription medications. For many people, the Medicare program is quite literally responsible for saving their life and provides an immense amount of relief to families of loved ones who would otherwise have no way to provide for their loved one’s needs. Unfortunately, there’s a much darker side to the story of Medicare, which has resulted in over one billion dollars’ worth of illegitimate billing to Medicare by medical and health care practitioners and agencies. For this reason, Medicare fraud strike force teams have been deployed all over the country to help identify and put a stop to this fraudulent behavior which not only harms the individual who is utilized by dishonest medical professionals for obtaining profit but also society as a whole.

Consequences of Medicare Fraud

When medical and health care professionals and institutions take advantage of the Medicare system, they effectively steal money from the government, which translates to less money for programs that benefit society as a whole. Consider, for example, that it costs roughly $215 million to fund all programs related to the Violence Against Women Act for an entire year; in 2018 alone, roughly $200 million was stolen from the U.S. government through Medicare fraud by just five medical practitioners. This is just one example of many which illustrates the same point: a single Medicare fraud scheme between a few individuals in power can have an immensely detrimental and large-scale impact on society at large.

Medicare and health care fraud can also affect people on an individual level, even to the point that their health and well-being—things which are supposed to be nurtured by Medicare—are compromised. Consider, for instance, when a healthcare provider decides to perform unnecessary or even unsafe treatments with the sole purpose of increasing the amount for which they can bill to Medicare. Medicare fraud also negatively effects individuals on a financial level by leading to higher premiums and out-of-pocket expenses, as well as lower coverage and limited benefits.

How does Medicare Fraud Occur?

There are many different types of Medicare fraud. The following is a list of some of the most common:

  • Medicare is billed for procedures or treatments that were never delivered to the patient
  • Medicare is billed inaccurately, resulting in higher billing amounts than those associated with the services the patient actually received—a practice which has been coined ‘upcoding’
  • Recommending or performing unnecessary procedures for the purposes of increasing billing amounts to Medicare
  • Prescribing more medication than is necessary for the purposes of increasing billing amounts to Medicare
  • Knowingly making a false diagnosis so as to receive payment for particular procedures or tests
  • Receiving kickbacks, which means receiving money in return for referring patients to certain health care facilities

How to Protect Yourself from Medicare Fraud

One of the most important things an individual can do to protect themselves from Medicare fraud is protect their Medicare card. In much the same way that a person conceals their Social Security number and credit card numbers from the public, they should conceal their Medicare number and all other information associated with it. It can be tough, however, to know when it is truly necessary to provide Medicare information to another agency or individual who requests it. For example, there are many Medicare scams which operate by contacting individuals by telephone and requesting information about their Medicare plan. Under almost all circumstances, such forms of contact are not to be trusted. According to, providing information about a Medicare account over the phone would only be safe if the individual claiming to be calling from Medicare is calling in reference to a specific plan which the receiver is already on, or is returning a phone call that was initiated by the Medicare member. If ever in doubt, an individual should simply call Medicare directly, at (800) 633-4227.

Medicare billings should always be transparent; a patient should never feel left in the dark as to what services are being billed or why, and they should never feel as though they can’t freely ask their medical provider any question they may have about the care they are receiving, the reasons for that care, and how it will appear on their Medicare account. Knowing and using the right to ask these questions goes hand in hand with another way to protect one’s self from Medicare fraud, which is simply to educate one’s self as much as possible in order to understand which types of procedures can be billed to Medicare and which cannot.

Lastly, cross-referencing all Medicare statements with one’s medical record (i.e. record of diagnoses, treatments, appointments, and prescriptions) can prove fruitful in identifying red flags or indications that fraudulent activity is occurring. If at any time something does not add up or make sense, an individual should waste no time in pursuing an answer to their questions.

What if you suspect you’re already a victim of Medicare fraud?

There are three ways for a person to report suspicion or proof of Medicare fraud: call Medicare directly at (800) 633 4227, call the Office of the Inspector General at (800) HHS-TIPS, or go online to file a report with the Office of the Inspector General. Prior to making a report, an individual should have easy access to all of the information pertinent to the situation, including their Medicare policy number, the cost of whatever service or item is in question, the name and address of the provider of that item or service, the date it was billed to Medicare, and why the legitimacy of the service or item should be questioned. If in doubt about how to proceed with a particular issue, an individual should not hesitate to contact an experienced attorney who is well-versed in handling Medicare fraud matters.

Forman Law Group

About the Author Forman Law Group is a dynamic, boutique firm focused
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