Table of Contents:

  1. Identify Theft
  2. Healthcare Provider Fraud
  3. Other Resources

Medicare fraud is a major problem that is only getting worse. According to the federal government, the program loses around $1,000/year for each Medicare beneficiary. Some experts claim that the true figure is more than double this estimate. The highest estimates approach $300 billion/year. Though the exact figure is unknown, what is certain is that knowing how to protect yourself from Medicare fraud can save you (and American taxpayers) a significant amount of money and headache.

Identify Theft

The most egregious form of Medicare fraud is identity theft. According to AARP, “medical identity theft is when someone uses your personal information, especially a Medicare or health insurance number, to get treatment, prescriptions or medical devices, submit claims, or obtain benefits under your name.” In addition to your Medicare number, fraudsters may attempt to steal your identity by obtaining your Social Security number or other pieces of personal information, such as your date of birth.

There are several warning signs that someone may be attempting to steal your identity. These include: receiving a bill for undelivered medical services, receiving a notice of medical debt from a “debt collector” for a debt you did not incur, or being asked for your Medicare or Social Security number via phone or email from someone you did not reach out to. Oftentimes, these callers will claim to offer a medical service, a reduced rate of insurance, or simply the opportunity to take a survey. In these cases, be careful never to give your information unless you are absolutely certain that you are speaking to an official Medicare representative.

Remember: neither your Medicare plan provider nor your healthcare provider is going to ask you for this information unsolicited. It is always wise to scrutinize those who ask for your Medicare or Social Security number. When in doubt, it is safer not to divulge your personal information.

There are a few red flags to watch out for that indicate you may already be a victim of medical identity theft. These include: noticing healthcare expenses on your credit report for services you did not receive, receiving an explanation of benefits (EOB) from your plan provider that includes services you did not receive, and receiving notice from your plan that you have reached your benefit limit, citing services you did not receive.

Healthcare Provider Fraud

While identity theft is a serious issue, there are other forms of fraud that are subtler and more difficult to detect. These forms of fraud are committed by healthcare providers, or those claiming to provide a health-related service, and can include things such as:

  • Charges for services you did not receive
  • Charges for unnecessary services
  • Duplicate charges
  • Falsified records
  • Inflated charges

Watch out for care providers who charge copays for services that are covered copay-free by your plan or who incentivize using more of their services than you actually need. For instance, if a provider claims that your out-of-pocket expenses will be reduced if you agree to take more tests (regardless of whether these tests are medically necessary), this care provider may be attempting to defraud you — and the Medicare system — for their own personal profit.

Many forms of fraud committed by care providers could masquerade as honest mistakes resulting from accounting or billing errors on the part of medical staff. Regardless of the intention (or lack thereof) behind billing discrepancies, it is important to be on the lookout for such mistakes, so you are not charged unnecessarily. You can do this by asking your insurer at least once a year for a full list of benefits paid in your name, and by checking your credit report for incorrect charges.

Other Resources

To further educate yourself on spotting Medicare fraud, check out this pamphlet. If you are interested in a more in-depth report on Medicare fraud and its various forms, try this report from the CMS.

If you believe you may be the victim of any of these forms of fraud, you can report it here.

Notably, Medicare.gov advises anyone who believes they are a victim of Medicare fraud to first call the office of the healthcare provider from whom they received a suspicious charge. It is possible that billing discrepancies can be solved without involving the authorities, especially in cases where the service giving rise to a concern was actually performed or where the provider made an honest mistake and can easily fix it once notified.

Information adapted from the Centers for Medicare and Medicaid Services and Medicare.gov

Medicare Under Assault from Fraudsters, 2018. AARP

The COVID-19 Epidemic As A Catalyst For Health Care Fraud, 2020. HealthAffairs

Medical Identify Theft, 2020. AARP