Medicare related fraud is on the rise.
According to the Department of Health and Human Services, over $100 billion was lost to “improper payments” across the Medicare and Medicaid programs in 2023. It can raise health insurance premiums, expose you to unnecessary medical procedures, and increase taxes. The FBI is the primary agency for investigating health care fraud for both federal and private insurance programs.
Medicare beneficiaries are often targets of scams designed to acquire personal information that can be used to impersonate you and steal your money. Besides medical identity theft there are several other forms of Medicare fraud. Some examples are:
- Ambulance Fraud – Medicare will cover an ambulance ride to the hospital to diagnose or treat symptoms of an illness in an emergency. However, Medicare will not cover the cost of an ambulance if the reason for using the ambulance is not medically necessary, meaning the ride is not to treat or identify an illness. It will also not be covered by Medicare if other forms of transportation can move you safely or if it is for a ride to your doctor’s office, a community mental health center, or other health care appointments.
- COVID-19 Fraud – As the COVID-19 Public Health Emergency comes to an end, fraudsters are still attempting to bill Medicare for sham tests or treatments and are targeting individuals to illegally obtain money or Medicare numbers.
- Durable Medical Equipment Fraud – Durable medical equipment (DME) and orthotics companies offer a valuable service by providing wheelchairs, surgical supplies, catheters, and respiratory nebulizers as well as nutrition and tube feeding supplies and other health care equipment. DME and/or orthotics are considered medical equipment prescribed by your doctor that can withstand repeated use, serve a medical purpose, and can be used in the home. However, many fraudulent companies across the country are charging Medicare beneficiaries for this equipment without showing the medical necessity and sometimes without even sending the equipment to the beneficiaries.
- Genetic Testing Fraud – Scammers are offering Medicare beneficiaries cheek swabs for genetic testing to obtain their Medicare information for fraudulent billing purposes or possibly medical identity theft. Genetic testing fraud occurs when Medicare is billed for a test or screening that was not medically necessary and/or was not ordered by a beneficiary’s treating physician. Here are several ways genetic testing is advertised:
- Cancer screening/test
- DNA screening/test
- Hereditary cancer screening/test
- Dementia screening/test
- Pharmacogenetics (medication metabolization)
- Parkinson’s screening/test
- Hospice Fraud – Hospice is an important benefit for the Medicare population. Hospice fraud threatens this benefit for all beneficiaries. Scammers are getting beneficiaries to agree to hospice care even though they do not qualify for the benefit. Hospice fraud occurs when Medicare Part A is falsely billed for any level of hospice care or service.
- Nursing Home Fraud – Medicare doesn’t generally pay for long-term nursing home care. However, Medicare Part A covers medically necessary, short-term care in a skilled nursing facility (SNF) within a nursing home under certain conditions. SNFs play a crucial role in providing therapy and rehabilitation after you or a loved one has suffered a debilitating illness or stroke. After a qualifying stay in the hospital, Medicare beneficiaries frequently need some time in a SNF to regain their strength. However, some unscrupulous facilities (even some associated with national chains) have engaged in fraudulent billing.
- Outpatient Mental Healthcare Fraud – Medicare Part B covers outpatient mental health services in places such as a doctor’s office or other health care provider’s office, a hospital outpatient office, or a community mental health center. Medicare only covers visits when provided by a health care provider who accepts the Medicare-approved amount as full payment for any covered service provided. Some examples of this type of fraud are:
- You were picked up by bus or van along with other beneficiaries and taken out for a meal and Medicare is billed for a mental health evaluation.
- You spend all day watching TV or playing games at a facility and Medicare is billed for group therapy.
- You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for mental health services:
- With time spent listed as more than what you received
- That you did not receive
- That were not provided in a health care office or by a licensed professional such as a psychiatrist, psychologist, social worker, nurse specialist, or nurse practitioner
- Pharmacy and Prescription Drug Fraud – Medicare drug coverage (Part D) helps cover the cost of prescription drugs; some prescriptions are also covered under Part B. Pharmacy and prescription drug fraud schemes can happen in both. A common scheme is if someone’s Medicare plan was billed for medication that was not received, or if they were given a different drug than the medical provider ordered.
- Telehealth Fraud – Medicare covers telehealth services (also known as teledoc services or telemedicine). This could include medical appointments, therapy, consultations, and other medical or health services. These services are provided through an interactive, live, two-way communication system with audio and video. Criminals are using telehealth services to steal from beneficiaries and the Medicare program.
- Medicare Marketing Violations and Misleading Marketing – Health insurance companies try to reach people in various ways, like television commercials, radio ads, events, mailings, phone calls, and texts. The Centers for Medicare & Medicaid Services (CMS) has rules for marketing Medicare Advantage plans and Part D plans, though. These rules protect Medicare beneficiaries from aggressive or misleading marketing. For example, without your permission marketers are forbidden to call or text you.
It’s important to know the signs of a Medicare scam so you can protect yourself. To get your personal information, like your Medicare number, scammers may call, text and email saying things like:
- “You need to activate or renew your Medicare card”.
- “We’d like to send you a free genetic testing kit”.
- “Medicare has authorized us to send you a free (knee, back or elbow brace)”.
- “You qualify for a refund on your Medicare costs”.
Remember, never give your Medicare card or number to anyone except your doctor or people you know should have it. And keep in mind that caller IDs and email addresses can be faked, so if you’re not sure who’s calling, call Medicare at 1-800-633-4227, and remember, Medicare will never contact you unless you have contacted them first.
Reduce your risk by:
- Only share your Medicare and Social Security numbers with people you trust.
- Carry your Medicare card only when you need it.
- Keep a record of all your medical visits and procedures.
- Carefully review Medicare statements for mistakes and charges you don’t recognize.
- Trust your instincts and report any suspected fraud.
- Ask for help – If you have questions about how to protect yourself, need to report fraud, or want help determining whether you’ve been a victim, Senior Medicare Patrol (SMP) can help. SMP provides free, unbiased, one-on-one assistance to Medicare beneficiaries, their families, and caregivers. SMP has offices in all 50 states. You can find your local SMP at https://smpresource.org/