What constitutes Medicare Fraud, Abuse and Waste?

What constitutes Medicare Fraud Abuse and Waste

Every year millions of dollars are taken from the original Medicare program through deceptive practices resulting in Medicare fraud, abuse and waste. Medicare fraud, abuse and waste not only hurt the original Medicare program as a whole, but everyone who receives original Medicare benefits. Medicare Pathways wants you to understand what constitutes Medicare fraud, abuse and waste and how you can do your part to protect the Medicare program by reporting suspicious behavior with regard to your treatment or items billed to Medicare on your behalf.

What is Medicare fraud, abuse and waste?

Medicare fraud, abuse and waste occur most frequently in the following two methods:

First, Medicare, abuse and waste occurs when false claims are made on behalf of a Medicare beneficiary. For example, you visit a particular physician or medical clinic, they ask for your original Medicare card and give you a certain amount that is due, but then bill original Medicare for more than that amount. The physician or medical clinic then pockets the difference. Another type of Medicare fraud, abuse and waste is when someone bills original Medicare for services or equipment that a Medicare beneficiary never received or for items different from what the beneficiary received.

A second form of Medicare fraud, abuse and waste occurs when a dishonest individual might use the Medicare card of another to receive medical services or to buy equipment. Additionally, an individual may return a form of medical equipment but continue to bill original Medicare for the equipment that they no longer have or need.

While there are other types of Medicare fraud, abuse and waste, the foregoing are the most frequent methods.

Join the battle against Medicare fraud, abuse and waste!

Detecting Medicare fraud, abuse and waste is easy if you keep an eye out for suspicious activities. Beware of providers that offer services for “free” when you have already given them your Medicare card. Also, if a provider offers to waive your co-payments on services routinely without checking to see if your financial situation has improved, you should be leery of this practice.

Other “red flags” to watch for include pressure selling for higher priced services, receiving Medicare bills for services you have not received, so called “free” consultations for Medicare beneficiaries, marketing tactics being used by a provider such as charges for co-payments on services that are supposed to be covered 100 percent by original Medicare. (For more information regarding services that are covered 100 percent by original Medicare visit Medicare Pathways News Blog article regarding preventive services covered by original Medicare at no cost to the Medicare beneficiary.)

What do I do if I suspect Medicare fraud, abuse and waste?

If you suspect that a provider has committed Medicare fraud, abuse and waste, double check with the provider to be sure it is not a simple mistake first. Sometimes human and computer errors do occur, so give your provider the benefit of the doubt from the start. If these “errors” seem to be happening often, then it is time to take action. However, the last thing you want is to wrongly accuse your health provider, so be sure to approach suspected Medicare fraud, abuse and waste with caution.

Before you report a provider for Medicare fraud, abuse and waste be sure you have all the facts. You will need all vital information about the provider including name, phone number, address, type of practice, etc. Also, you will need to gather all the facts about the incident so you can clearly present your case. Write or type a detailed timeline of events, the item(s) or service(s) that were billed incorrectly, the date when this occurred, and any other pertinent information. If you encounter a situation where you believe you or a loved one have fallen victim to Medicare fraud, abuse and waste report it to your local and state Medicare representatives.

You can help prevent yourself or a loved one from falling victim to Medicare fraud, abuse and waste

By adhering to the following steps and precautions you can prevent yourself from falling victim to Medicare fraud, abuse and waste:

  • Never give anyone your Medicare card or claim number who is not your caregiver or physician.
  • Beware of those who wish to review your medical records when they are not providing medical services to you.
  • Beware of “free” consultations and Medicare services being offered by a clinic or physician.
  • Never request medical services that you do not actually need.
  • Beware of providers that offer to get original Medicare to pay for services or items that are usually not covered by original Medicare.

Most of all follow your instincts. If a situation does not seem right, investigate to find the answers. You or your loved one can be safe from Medicare fraud, abuse and waste if you use precaution during every medical situation. Keep in mind that “criminals do not always come in dark clothing with masks on their faces.” Those who commit Medicare fraud, abuse and waste can appear to be normal caregivers or physicians, so keep your guard up any time you give out personal information such as your Medicare card.

Medicare Pathways wants you to be aware and understand what constitutes Medicare fraud, abuse and waste not only to protect yourself but to protect and strengthen the original Medicare program. As noted above, if something does not seem right, check into it to find answers to your questions regarding services provided or billed under your Medicare number. Pay attention to what services are provided at no cost by Medicare, such as certain preventive services, so you know when there is a billing issue. If it original Medicare was billed for services you did not receive bring it to the attention of the physician or medical provider. If this does not resolve the issue, take additional steps to report possible Medicare fraud, abuse and waste.

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