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

Health Care Fraud

Errors & Other Situations That May Not Be Fraud

Here are some examples of the types of errors that might occur or situations that
might simply be confusing to a patient.

Beneficiary claims he or she did not receive service.

  • The service was provided by a health care provider the beneficiary may not have seen: laboratory, pathologist, anesthesiologist, radiologist, etc.
  • The beneficiary may have seen an employee of the physician (i.e., nurse practitioner, physician assistant, physical therapist) even though the claim shows the service was provided by the physician.
  • This may be a billing or processing error where the Medicare number has been miskeyed. The only way to tell this is to contact the office that processed the claim so the original claim can be checked for an error.

Hospital inpatient bill: High or duplicate charges

  • This is often a billing or charging error by the hospital. Because hospital inpatient claims are paid under the Diagnosis Related Group (DRG) system, unreasonably high or duplicate charges do not usually affect what Medicare allows or pays.
  • To research this type of issue, contact the hospital to clarify the disputed charges, or contact the intermediary if the overcharging seems extreme or unusual.

Other examples

  • Billing for medical equipment that was returned
  • Billing for services or supplies different than received