Did you know that irritating things like Medicare fraud and abuse can happen in the medical business? Well, it does happen and in this article you will learn what Medicare fraud and abuse are so you can avoid and report it. So, what is Medicare fraud and abuse? And what can you do to protect yourself from it?
Well if your doctor intentionally bills the Medicare system for a service or supply that you didn’t get, that is Medicare fraud. This can happen vice-versa being that the beneficiary can abuse the Medicare system. This is illegal and is punishable by law.
Medicare billing errors – Why they are not Medicare Fraud
Billing errors are often innocent mistakes and are not a case of Medicare fraud. For instance, a doctor may use the wrong medical code on a Medicare claim, resulting in a billing error. The wrong code could change how much money you pay out of pocket even if the service description sounds right. This should only happen one-time (and at most, a few times) and is not a case of Medicare fraud.
How to avoid it:
Pay close attention to your payment notice from your insurance company or Medicare. If you feel that there is a mistake, immediately talk to your doctor or a staff member about it. They will either fix the mistake or describe to you why the payment notice is correct.
What is Medicare fraud and how can you avoid it
Medicare fraud is when a doctor or a beneficiary abuse the Medicare system for their own personal gain. This is illegal and it is more serious than a billing error.
If the products or services that you received were NOT:
- Accurately coded
- Medically necessary
- For you as the beneficiary
And if a doctor or health provider happens to bill you over and over again for their personal gain. It is by definition: Medicare billing fraud.
How to avoid it:
Carefully review your payment notice so you can identify Medicare billing fraud. Whenever a health care provider bills Medicare or your insurance company for a health care product or service, you will get a payment notice. This notice will tell you the total amount billed for every product or service, the amount you owe, and the amount Medicare paid to the provider.
Also, be skeptical of providers who:
- Claim that Medicare endorses their products or services.
- Offer gifts as incentives to use their services.
- Charge copays or waive copays, even though your plan makes the service available with no copay.
- Use door-to-door sales and telemarketing.
- Tell you that you will pay less out of pocket if they perform more tests.
- Tell you they know how to get Medicare to pay for something that’s not in your plan.
Here are two examples of Medicare fraud from a beneficiary standpoint:
- You ask your doctor for medication, products or services that you don’t need yourself.
- Someone besides you uses your Medicare card to receive products or services. Never give your Medicare card to anyone except your health care providers.
What is Medicare abuse and how can you avoid it
Medicare Abuse describes practices that may result in unnecessary costs to the Medicare Program. An example of abuse is a provider performing services that are not medically necessary. Medicare abuse is illegal to the full extent of the law and it is as serious an offense as Medicare fraud.
Report Medicare fraud and abuse
If you feel there is Medicare fraud or abuse, you should report it immediately. The Centers for Medicare & Medicaid Services (CMS), which handles Medicare, wants to eradicate this type of activity. The agency is working with doctors, beneficiaries and federal agencies to crack down on those who commit Medicare abuse and fraud. The federal agencies they are working with include the Department of Health and Human Services (HHS), the Federal Bureau of Investigations (FBI), the Office of Inspector General, and the Department of Justice.
To report Medicare fraud or abuse, you can do any of the following:
- Email: You can also send up to 10 pages describing the incident to HHSTips@oig.hhs.gov.
- Call the Medicare fraud tip line at 1–800-HHS-TIPS (1–800–447–8477). The TTY number is 1–800–377–4950.
- Mail the report (up to 10 pages) to the Office of the Inspector General HHS Tips Hotline, P.O. Box 23489, Washington, DC 20026–3489.
- Fax your report (up to 10 pages) to 1–800–223–8164.
- Florida residents only can call 1–866–417–2078 or email floridamedicarefraud@hp.com to report abuse or fraud. This agency investigates and prosecutes those who purposefully defraud or abuse the state of Florida’s Medicare system.
Please note that the contact information above is only to report fraud or abuse.