The National Consumer Protection Technical Resource Center: The Center of Service & Information for SMPs
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 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 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.
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 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.
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