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Everything You Need To Report To the Medicare Fraud Department

Medicare fraud steals funds from taxpayer money. When Medicare reimburses money for services for which the claimant isn't entitled, then it's considered fraud. Fraudulent actions collect money from the Medicare program illegally, essentially scamming the US taxpayer and reducing future access to government funding for vital programs. If you suspect Medicare fraud, always report it. Here's everything you need to report to the Medicare Fraud Department.

Medicare fraud billing - doctor's hand on a computer with a stethescope

Fraud is a serious crime and the US government loses millions of dollars each year as a result.

Where to Report It and How

You can report Medicare fraud by calling the phone number below or reporting it to the Office of the Inspector General.

  • 1-800-MEDICARE (1-800-633-4227)
  • Report Fraud Form, Office of the Inspector General, U.S. Department of Health & Human Services

All complaints are confidential. Public disclosure is restricted by the Privacy Act. You may also provide a complaint anonymously if you prefer. It's easy to submit a claim and reporting fraud is the right thing to do. It's also a good idea to consult with an attorney before submitting a claim to ensure you have enough evidence for a solid case against those committing fraudulent actions. 

What Information Do I Need?

You will need the following information:

  • The provider's name
  • Any identifying number
  • The date of service
  • The item given or delivered (even if service was not provided)
  • The payment amount Medicare approved and paid
  • The date on your MSN
  • Your name (if you wish)
  • Your Medicare number
  • The reason why Medicare should not have paid
  • Any other information

You may feel more comfortable consulting an attorney if the fraud is pervasive and has been going on several years.

Here is additional information on the types of Medicare fraud, how to spot Medicare fraud and where to report it.

Types of Medicare Fraud

Common types of fraud include phantom billing, patient billing, and upcoding and unbundling.

Phantom billing is where the medical provider bills for services not rendered or for medically unnecessary procedures. You may be told that you need to have blood work for a condition when blood work is not part of the usual medical procedure for that condition. Without a keen eye, that blood work billing may go unnoticed, and that particular office may commonly bill for services not necessary.

Patient billing is when the patient is also in on the scam and provides his or her Medicare number in order to receive financial kickbacks or other rewards. The medical provider, in this case, bills Medicare for a procedure and the patient is told to agree that that procedure was performed.

Upcoding and unbundling incorrectly inflates bills when the medical provider bills for individual services instead of the correct bundle. For example, in unbundling, the office may charge for the doctor's visit, for the inpatient surgery, and for closing the surgical opening; however, in reality, from the consultation to closing the wound with sutures is part of one, single procedure and should be bundled together. When the office tries to bill for every line item, it's fraud.

The provider may also upcode, which is billing for a more expensive procedure when a less expensive one was provided. There are examples where a patient was billed for an upscale, expensive wheelchair, for instance, and then a lesser model was provided to the patient with the office keeping the added bonus money - but this case is fraud too.

How to Spot Medicare Fraud

As a patient, you should review any Medicare claims for errors. If you suspect anything suspicious, report it. If it has gone on undetected for years (or even months), and you've just discovered it, you may want to consult a trusted attorney.

When you receive any services, record the dates on a calendar, save any receipts, and statements from providers and check for mistakes. Compare the dates of your procedures with the statement dates. Make sure each service is listed and all details are correct. You should receive a Medicare Summary Notice (MSN) or you can log into MyMedicare.gov or call 1-800-MEDICARE (1-800-633-4227).

If any claims are listed for which you have no record, or you're billed for items you don't think you received, you may be a victim of fraud. If you think the charge is incorrect, you can call your provider and ask about it; they may be able to explain the services you received and confirm it was correct, or they may realize they made a billing error. If the provider sounds suspicious, or you suspect it's part of a larger problem, report the fraud with the help of an attorney and do not contact your provider.

If you work for a medical provider and you suspect that the office is guilty of fraud, contact an attorney immediately, and they will advise you on how to gather specific, actionable evidence to bring a case against the business.

Don't worry. In both scenarios, you are protected under the False Claims Act and the Whistleblower Protection Act. You cannot legally be threatened, lose your job, or suffer any consequences as a result of your actions. Your attorney can help you understand the laws and provide the necessary protection for you.

Compensation for Reporting Fraud

You may be eligible to receive up to $1,000 for reporting Medicare fraud; however, if the fraud is more pervasive, an attorney can help you win up to 10% of the money recovered. Some relators (whistleblowers) have received thousands to millions for their heroic acts. Reporting fraud is a complicated task to do alone. It's both brave and noble, for the good of the country, but those in the wrong won't thank you for reporting them; they'll want to defend themselves, so legal council can protect you and your rights. 

For more information and everything you need to know about Qui Tam and whistleblowing lawsuits, download our free guide which explains the different types of whistleblowing, how to report fraud and how you can stay protected. Click on the button below.

Download our Whistleblower eBook

Disclaimer: This blog is intended as general information purposes only, and is not a substitute for legal advice. Anyone with a legal problem should consult a lawyer immediately.

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