Medicare Fraud: How to Identify and Prevent

By Western Berks Physical Therapy on October 8th, 2019

Medicare Fraud

Preventing Medicare Fraud

Just about every week of the year, a person or group of people is found to have committed Medicare fraud. And the fraud doesn’t amount to thousands of dollars—we’re talking billions. The Department of Health and Human Services Office of The Inspector General, along with state and federal law enforcement partners, participated in the largest health care fraud takedown in history in June 2018. More than 600 defendants in 58 federal districts were charged with participating in fraud schemes involving about $2 billion in losses to Medicare and Medicaid. The latest estimates from the Center for Medicaid and Medicare Services (CMS) indicate that the government’s exposure to fraud and abuse within the Medicare program is over $100 billion annually.

The effects of Medicare fraud impact everyone involved with the Medicare billing process, but most importantly, they affect you, your health, and your wallet. So before we discuss how to identify fraud and how to prevent it, let’s talk about who is affected by Medicare fraud and the scope of how much it can cost you.

Common Types of Medicare Fraud

The annual Medicare Open Enrollment period begins on October 15 and continues until December 7. With this in mind, following are two common types of health care fraud with descriptions.


  • False Claims – deceiving insurance companies and state worker’s compensation programs by falsifying injuries
  • Medical Identity Theft – using another’s medical benefits to obtain services personally
  • Physician Shopping – moving between doctors to obtain multiple prescriptions


  • Kickbacks – accepting kickbacks for patient referrals
  • Phantom Billing – billing for services that were never performed
  • Pharmacy Fraud – dispensing less than the prescribed and charged amount of a prescription
  • Providing Unnecessary Care
  • Unbundling – charging separately for procedures that are actually part of a single procedure to increase the reimbursement
  • Upcoding – charging for a more expensive service than what was actually performed

Fraud perpetrated against the Medicare system directly drains taxpayers. Medicare is funded through a payroll tax on both the employer and employee. As more funds are needed, taxes are raised. Thus, everyone employed is affected. If your organization has a company-rated healthcare plan, fraud affects your claims history which will directly affect your rating and corresponding premium amounts. For self-insured plans, fraudulent claims directly steal from you.


The DO’s and DON’Ts  of Medicare Fraud

Medicare fraud results in higher health care costs and taxes for everyone. There are con artists who may try to get your Medicare number or personal information so they can steal your identity and commit Medicare fraud. Read our DOs and DON’Ts below to learn how you can help fight and protect yourself from fraud.


DO protect your Medicare number and your Social Security Number. Treat your Medicare card like it’s a credit card. Don’t ever give it out except to your doctor or other Medicare provider. Never give your Medicare number in exchange for free medical equipment or any other free offer. Dishonest providers will use your numbers to get payment for services they never delivered.

DO remember that nothing is ever “free”. Don’t accept offers of money or gifts for free medical care.

DO ask questions. You have a right to know everything about your medical care including the costs billed to Medicare.

DO educate yourself about Medicare. Know your rights, and know what a provider can and can’t bill to Medicare. Read your “Medicare & You” handbook, or visit to learn more about your rights and different covered services.

DO use a calendar to record all of your doctor’s appointments and what tests or X-rays you got. Then check your Medicare statements carefully to make sure all the details are correct.

DO be wary of providers who tell you that the item or service isn’t usually covered, but they “know how to bill Medicare” so Medicare will pay.

DO make sure you understand how a plan works before you join.

DO always check your pills before you leave the pharmacy to be sure you got the correct medication, including whether it’s a brand or generic and the full amount. If you don’t get your full prescription, report the problem to the pharmacist.

DO report suspected instances of fraud. See the end of the blog post to find out who to call.

DO review your “Medicare Summary Notices” or other statements from your plan for errors. These notices show what services or supplies were billed to Medicare, what Medicare paid, and what you owe. Make sure you and Medicare weren’t billed for health care services or medical supplies and equipment you didn’t get. If you spend time in a hospital, make sure the admission date, discharge date, and diagnosis on your bill are correct.


DON’T allow anyone, except your doctor or other Medicare providers, to review your medical records or recommend services.

DON’T contact your doctor to request a service that you don’t need. Don’t let anyone persuade you to see a doctor for care or services you don’t need.

DON’T accept medical supplies from a door-to-door salesman. If someone comes to your door claiming to be from Medicare or Medicaid, remember that Medicare and Medicaid don’t send representatives to your home to sell products or services.

DON’T be influenced by certain media advertising about your health. Many television and radio ads don’t have your best interest at heart.

DON’T give your Medicare card, Medicare number, Social Security card, or Social Security Number to anyone except your doctor or other Medicare provider.


If you suspect Medicare fraud:

  • Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
  • Call the fraud hotline of the Department of Health and Human Services Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477). TTY users can call 1-800-377-4950.
  • Visit to file a report online.


For additional resources, click here. This link will take you to an in-depth booklet explaining:

  • How to protect yourself and Medicare from fraud
  • How to identify and report billing errors and concerns
  • What to do if you suspect Medicare fraud
  • How to protect your personal information