What Is Fraud and What Is Abuse?

Published 03/21/2024

Fraud and abuse of the Medicare Program costs taxpayers millions of dollars each year. Undetected fraud can milk the system of as much as 10 percent of every dollar paid out for health care expenditures. You can do your part by reporting suspected fraud and abuse. Reporting suspected fraud and abuse of the Medicare Program will help keep money in the Medicare Trust Fund and eliminate money spent on fraudulent claims.

What Is Medicare Fraud?
When someone acts in a way that is intended to deceive another person, that's fraud. Here are a few examples of the ways some providers and beneficiaries have intentionally tried to defraud the Medicare program:

  • A clinical psychologist billed Medicare for treatment she never gave to her patient
  • A hospital patient who is not eligible for Medicare coverage used another person's Medicare card to get medical care, supplies and equipment
  • A doctor altered the medical claim form of his patient so that he would receive a larger Medicare payment for his services than he was entitled to by law

What Is Medicare Abuse?
When careless medical and business practices cause unnecessary expenses for Medicare, that's abuse.

Here are a few examples of the ways some providers have abused the Medicare Program:

  • A Medicare patient received medical care from his doctor that was not appropriate for the treatment of his illness
  • Because Medicare payments are higher, a clinical social worker charged her Medicare clients more for the same care she gave to her other clients

How Can You Help?
When you receive your Medicare Summary Notice (MSN) in the mail, please read it carefully.

  • Is your name, address and Medicare number correct?
  • Check the date of service on the statement. Is it the date you visited your doctor?
  • Check the description of the services your doctor billed to Medicare. Were they the services you received during your visit?

If you want help reading your MSN or you find something on it that appears to be wrong, call us at Railroad Medicare 800–833–4455. If you request it, your name will be kept confidential. You may also call the Department of Health and Human Services Medicare Fraud Hotline to report suspected fraud and abuse. Their toll free number is 800–447–8477 or for TTY, call 800–377–4950.

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