Medicare Fraud Information for Providers

Features

• There are four components to Medicare--Parts A, B, C and D. Part A covers your inpatient hospital services such as surgery or emergency hospital visits. Part B is outpatient services, such as routine doctor visits or preventive care. Part D refers to the private health care plans that provide prescription drug plans for Medicare recipients.
  
  Finally, there is Part C. Part C is not technically a separate benefit from Part A, B and D, but instead refers to what is known as Medicare Advantage. You can elect to get your Part A and B from a private health care plan, known as a Medicare Advantage plan, instead of through the government, which is typically known as Original Medicare.
  
  

Fraud

• Medicare fraud is when providers such as hospitals or doctors knowingly deceive Medicare into paying for services they should not. Examples include: charging Medicare for procedures and services never performed; charging Medicare for a different procedure that is more expensive than the one actually performed; charging Medicare for equipment that the patient has already returned. There are hundreds of other possibilities. It all boils down to trying to get more money out of Medicare than you are entitled to.
  
  

Spotting Fraud

• Know the rules. If you have Original Medicare, your doctor should not charge a coinsurance for more preventive services, such as pap smears or flu shots; offer test or other services that patients don't need, especially if the doctor says that the more test you receive, the cheaper they are; fail to charge a coinsurance all the time.
  
  Keeping patients informed and aware of the services they are receiving will make them spot Medicare fraud more easily as well. Many fraud cases can be spotted after carefully examining the patients' Medicare Summary Notices or Explanation of Medicare Benefits notices.
  
  

Preventing Fraud

• Treat patients' identification information the same you would as your own credit card number--guard it very carefully. This includes their social security number, their Medicare number, and anything else used to make a claim to Medicare. Finally, learn more about what Medicare covers and what it doesn't. If it sounds too good to be true, it probably is.
  
  

Reporting Fraud

• First, talk to the doctor, hospital or provider in question. Often times, it may just be an honest mistake. If speaking with the provider doesn't clear up the problem, you can report Medicare fraud. You will want to call 1-800-MEDICARE and report the fraud to Medicare directly. They will conduct an investigation, and you may eventually receive a phone call to ask for more information. You can also report fraud anonymously.