Home Health Care Fraud Medicare

Medicare Fraud

The types of schemes that can and are being perpetrated against the health care system are as complex as the system itself. Common fraud schemes include efforts to fraudulently obtain and use a person’s Medicare number, as well as scams that specifically target Medicare services and plans. “Scam artists have treated Medicare like an automated teller machine, drawing money out of the government’s account with little fear of getting caught,” said former Sen. Norm Coleman of Minnesota.

Medicare Fraud

Medicare fraud is defined as knowingly and willfully executing, or attempting to execute, a scheme or ploy to defraud the Medicare program, or obtaining information by means of false pretenses, deception or misrepresentation in order to receive inappropriate payment from the Medicare program.

Click here for specific examples of Medicare fraud.

Medicare Abuse

Medicare abuse is defined as incidents or practices of providers that are inconsistent with accepted sound medical, business or fiscal practices. These practices result in unnecessary costs to the program, improper payments, payment for services that fail to meet professionally recognized standards of care or conducting procedures that are medically unnecessary.

Abuse involves improper payments where the provider has not knowingly and intentionally misrepresented the facts to obtain payment. Abuse still needs to be reported and corrected. Inappropriate practices that start as abuse, if unchecked, can evolve into fraud.

Click here for specific examples of Medicare abuse.

Errors & Other Situations That May Not Be Fraud

Providing and billing for health care services involves a lot of complicated steps, which may lead to errors or other situations that may not be fraud. Most Medicare payment errors are simply mistakes and are not the result of physicians, providers or suppliers trying to take advantage of the Medicare system. Also, people often have trouble understanding their bills.

Click here for specific examples of errors and other situations that may not be fraud.

How SMPs Help

SMPs play a unique role in the fight against fraud, abuse and errors. They help beneficiaries when they are unable to resolve concerns on their own. Volunteers and staff also serve as “eyes and ears” in their communities, helping to uncover potential problems.

Because of their training and experience, SMP staff and volunteers have more insight than the average Medicare consumer into the issues of fraud, abuse and error. SMPs also have a formal relationship with Medicare Program Integrity Contractors for the Centers for Medicare & Medicaid Services (CMS). SMPs are able to quickly and efficiently refer beneficiary complaints of potential fraud and abuse directly to these contractors for investigation and resolution.

To find the SMP in your state, click here.

For More Information

• Brochure: Help Prevent Fraud. Simple ways you can protect yourself and Medicare from fraud.
• Brochure: Medicare Coverage of Durable Medical Equipment and Other Devices
• Centers for Medicare & Medicaid Services. CMS is the United States Department of Health & Human Services agency responsible for administering the Medicare, Medicaid, SCHIP (State Children's Health Insurance) and several other health-related programs
• CMS overview page on Medicare Advantage plans, Medicare Advantage prescription drug plans, prescription drug plans and 1876 cost lans with marketing efforts. Send marketing guideline questions to  CMSMarketing@cms.hhs.gov
• Final 2009 Medicare Marketing Guidelines
• Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2009
• Kaiser Website with Health Policy Analyses. A leader in health policy and communications, the Kaiser Family Foundation is a nonprofit, private operating foundation focusing on the major health care issues facing the United States, as well as the U.S. role in global health policy.
• Medicare: A Primer. From the Henry J. Kaiser Family Foundation, this primer explains key elements of the Medicare program, which now provides health coverage to 47 million people -- including 39 million people age 65 and older and another 8 million younger adults with permanent disabilities. It looks at the characteristics of the Medicare population, what benefits are covered, how much people with Medicare pay for their benefits and the program’s overall costs and future financing challenges.
• Medicare, The Official U.S. Government Site for People with Medicare. Comprehensive information on Medicare and related issues, including prescription drugs, billing, appeals, long-term care and enrollment
• Medicare Fraud Estimates: A Moving Target? Article published in The Sentinel, May 2010.
• Medicare Trustees Report. This report discusses both the Hospital Insurance program (Medicare Part A) and the Supplementary Medical Insurance program (Medicare Part B and Prescription Drug Coverage)
• My Medicare Community, a National Council on Aging site dedicated to professionals and volunteers who help people with Medicare
• National Committee to Preserve Medicare and Social Security. A membership organization, the NCPSSM protects, preserves, promotes and ensures the financial security, health and the well being of current and future generations of maturing Americans
• News Release  Medicare Imposes Stronger Protections on Medical Equipment Suppliers. New rule strengthens supplier enrollment standards to help prevent fraud.
• QIOs (Quality Improvement Organizatons). To find a state QIO, click here. For the CMS webpage about QIOs, click here.
• Social Security Online  is the official website of the U.S. Social Security Administration
• State Attorney General. Contact your state attorney general’s office to report scams. The attorneys general serve as counselors to state government agencies and legislatures and as representatives of the public interest. When you click the link, scroll to the bottom of the page to find the map and click on your state.
• State Insurance Department. Contact your state insurance department for insurance company or insurance agent licensing information or to file a complaint against a company or agent.
  Stop Medicare Fraud. The U.S. Department of Health & Human Services and U.S. Department of Justice offer information and resources on a new initiative, HEAT, that is designed to stop Medicare and Medicaid fraud.
• Who Cares offers reliable sources of information on a variety of health topics, including Medicare fraud, medical ID theft, generic drugs and assisted living