What is Medicare Fraud?

Medicare fraud occurs when a hospital, nursing home, doctor's office, hospice care facility, ambulance service, pharmacy, rehabilitation center, or any other type of healthcare provider overbills Medicare.

Medicare fraud is big business. The Medicare system is large and complicated, and that makes it an easy target for abuse. The types of fraud seen in Medicare vary from overbilling, all the way to complex schemes that involve fake patients, fake doctors, and ghost services. It can be a small-scale crime or a multi-million dollar operation that goes on for years.

Many of the people on Medicare fail to look at their itemized bills from doctors, home-health service companies, pharmacies, or medical product providers. It is this disconnect that often leaves the abuse uncovered. If the patient cannot see that they were charged for test that never happened, it can be difficult to stop the abuse. . Fraud can also be as simple as a healthcare provider ordering unnecessary tests in order to pad the bill. What other types of fraud happen, and what’s being done to address it?

Common Schemes

The most common type of Medicare fraud is overbilling. It is estimated that there is over $10 billion in fraudulent overbilling every year. Some of the largest judgments in favor of Medicare have come from suits against providers who have been caught overbilling. Overbilling can be achieved by charging for tests that are never performed or diagnosing patients with more costly conditions simply to gain greater reimbursements from Medicare.

There are other kinds of Medicare fraud that revolve around medical supplies and equipment. Medical equipment or supplies might be billed as brand new when they are actually used. Or, equipment is billed but never actually ordered or delivered. 
Providers of services and equipment have been caught double billing as well. They may use the coded system provided for Medicare providers to increase their reimbursements by using codes that are meant for more complex, expensive series of tests in place of simple codes for single tests. 

Finding Fraud

There has been progress made if breaking up criminal organizations that prey upon Medicare. In the 2010 Patient Protection and Affordable Care Act, or ACA, the U.S. government has put into place more manpower to detect fraud. They have employed new tactics to step up oversight on new healthcare providers who want to become Medicare providers. They may now undergo background checks.

Mental health providers will have to serve at least 40% of non-Medicare patients to crack down on companies that bill solely to Medicare. The legislation also requires all healthcare agencies within the U.S. government to share information in hopes of catching fraud sooner. In addition, Medicare no longer has to pay any provider’s claim if they have been credibly accused of fraud. Payment will only come after an investigation clears the provider.

With new measures in place to protect the system, it is hoped that Medicare will be around to serve more Americans as they age. There are always going to be ways to game the system, but it is hoped that these new measures will make it harder to defraud the American taxpayer. 

Do You Have Information Regarding Medicare Fraud? Report it Here.

You can stop abuse of government funds by becoming a Medicare fraud whistleblower and get a substantial reward for your information. Our attorneys have a lot of experience representing those who expose fraud in the healthcare industry. To get a consultation with a lawyer free of charge, you may fill out the secure and confidential form on this page, or contact us at 1-866-648-5223.