Medicare fraud has been around as long as Medicare has, since 1965, and it is one of the most rampant forms of financial fraud in the United States. Medicare loses an estimated $60 billion each year due to fraud, errors and abuse. When thieves steal from Medicare, less money is available for the health care people really need.

“Medicare fraud has a negative impact on both beneficiaries and the Medicare program,” said Ryan Kibby, Oregon Senior Medicare Patrol project director.

Fraud costs Medicare beneficiaries in time, stress, money, and even their health. It costs families, friends and caregivers in worry and lost work when helping their loved ones recover from falling victim to Medicare fraud.

The Senior Medicare Patrol (SMP) is a federal grant-funded project with offices in all 50 states plus the District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands. SMPs provide free, unbiased one-on-one assistance to Medicare enrollees, educating and empowering them in the fight against health care fraud. In Oregon, the SMP is part of the Oregon Department of Human Services (ODHS), Office of Aging and People with Disabilities (APD).

Medicare Fraud Prevention Week is a great time to familiarize yourself with how Medicare fraud works, what to look out for and how you can help prevent it. It’s always the week of June 5, or 6/5, because most people become eligible for Medicare when they turn 65.

Examples of Medicare fraud

Your Medicare ID number is the key to most Medicare fraud. Once scammers have it, along with other personal information, they can bill Medicare for supplies, tests and other health care services. The scammers get a steady stream of money from these claims, while the patient/beneficiary usually receives nothing. When Medicare doesn’t cover the full amount of the claim, they will bill the unsuspecting patient for the remainder.

Durable medical equipment (DME)

One of the most common Medicare fraud scams involves durable medical equipment, or DME, which refers to items such as wheelchairs, scooters, braces, CPAP machines, hospital beds, prosthetics, etc. – medically necessary items patients use at home.

For example, state and federal authorities are investigating an ongoing national DME scheme involving urinary catheters. Scammers are targeting Medicare enrollees via phone calls, internet ads and text messages with offers of free services, medical equipment, or gift cards upon confirming their personal information and eligibility for specific Medicare services. The scammers often tempt the person by saying they are “qualified” for items “at no cost” or “free.” Once the scammers obtain the enrollee’s personal information, they will begin monthly billing to Medicare for medically unnecessary urinary catheters that may or may not actually be sent to the enrollee. The Department of Health and Human Services Office of Inspector General (HHS-OIG) issued this consumer alert April 30.

Another recent investigation into DME fraud is “Operation Brace Yourself” – a widespread fraud ring involving back, shoulder, wrist and knee braces that cost Medicare more than $1 billion.

Learn more about DME Medicare fraud here.

Other types of Medicare fraud

• Medical identity theft – Once the scammer has a patient’s Medicare ID and other personal information, they can steal the patient’s identity. Report medical identity theft here.
• Providers that bill Medicare for services or supplies they never gave you or that you don’t need. They may also charge Medicare twice for a service or item that you got only once.
• Genetic testing scams – Scammers offer Medicare enrollees screenings or tests for diseases such as cancer, dementia or Parkinson’s, including DNA testing to screen for hereditary predisposition for such conditions, among others.
• COVID-19 scams – Fraudsters continue to bill Medicare for sham tests or treatments and target individuals to illegally obtain money or Medicare ID numbers.
• Ambulance fraud – Ambulance companies may intentionally or unintentionally charge Medicare for transport that is not medically necessary or with inflated mileage, or the vehicle does not meet certain safety standards.
• Telehealth fraud – Due to the recent expansion of telehealth services and the ease in which this fraud can be committed, criminals are exploiting this new technology for fraudulent purposes.
• Nursing home care fraud – Some unscrupulous facilities (even some associated with national chains) fraudulently bill Medicare for services or therapies that weren’t provided or weren’t medically necessary, for example.
• Hospice fraud – Scammers get beneficiaries to agree to hospice care even though they do not qualify for the benefit.

A longer list of common Medicare fraud schemes can be found here.

Learn more about the financial cost of Medicare fraud here.

What you can do

There are three pillars to fighting Medicare fraud – Prevent, Detect, Report!

Prevent

• Learn about the Medicare Summary Notice (MSN) you receive in the mail, including how to read it and what to look out for. You can also sign up to receive MSNs via email here. (If you are enrolled in a Medicare Advantage Plan, you will receive an Explanation of Benefits, or EOB.)
• Protect your Medicare card like a credit card. Do not carry it on you unless you are going to a new doctor’s appointment, for example.
• Do not give your Medicare ID number to anyone other than a health care professional, in-person. Never give out the number over the phone for any reason.
• Call your SMP or go to their website to learn how to best protect yourself and your loved ones from health care fraud, errors or abuse.
• Become an SMP volunteer in your community (see below for details).

Detect

• When reviewing your MSN or EOB, look for services, products, or equipment you didn’t receive, double charges, or items your doctor didn’t order.
• Request and use a My Health Care Tracker booklet from your SMP to compare appointment information you recorded with what is printed in your MSNs and/or EOBs.
• If you find items of concern on your MSN or EOB, call the doctor or company in question and ask them about potential mistakes. Call Medicare or your Medicare Advantage Plan if you still have questions.

Report

• If you believe that you have experienced Medicare fraud, errors, or abuse and you are not comfortable calling the provider or plan, or if you are not satisfied with their response, call or email your local SMP, and/or report the event here. You can also call 1-800-Medicare, or report directly to the HHS-OIG Hotline: 1-800-HHS-TIPS (800-447-8477).
• If it’s determined that your tip led to uncovering fraud, you may qualify for a reward.

Become an SMP volunteer

SMP volunteers and staff serve as “eyes and ears” in their communities, educating beneficiaries/enrollees to be the first line of defense. Volunteers take pride in working to protect the Medicare program and its beneficiaries. In 2020, the SMP project nationwide had a total of 5,720 total active team members who conducted 9,870 group outreach and education events, reaching an estimated 425,103 people.

“We teach people how to avoid experiencing Medicare fraud,” Kibby said. “By preventing fraud from happening, this program helps individuals and protects the Medicare program for generations to come.”

SMP volunteer team members are trained to:

• Promote community awareness of health care fraud, errors and abuse.
• Teach beneficiaries how to prevent Medicare fraud through presentations, health fairs, and other community events.
• Provide counseling, and when needed, serve as consumer advocates to resolve billing disputes/issues.
• Make appropriate referrals to state and federal partners for suspected cases of Medicare fraud, errors, and abuse for further investigation.

Learn more about becoming an SMP volunteer in your community here. You can also call Oregon SMP at 855-673-2372; or send an email.

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