Medicare Fraud: What They Are and How to Report Them

Medicare fraud can come from anywhere and affect anyone, so it’s a good idea to know what it is and how to report Medicare fraud.

But if you want to know about health insurance scams, you should first know some differences between Medicare and Medicaid.

Medicare is a federal health insurance program for people over 65 and younger people who are disabled.

Instead, Medicaid is a program administered by each state. that provides comprehensive health coverage to eligible low-income individuals under state law.

Once this is clear, we can continue to the main point of our article.

What is Medicare and Medicaid fraud?

Medicare and Medicaid fraud is an illegal practice that seeks to obtain money from the US government health program through fraud in the Medicare or Medicaid payment system.

In other words, profiting through unfairly high payments against programs and benefits that are already government funded.

This fraud can be committed in health centers by managers, doctors, patients and other people who work in complicity to commit crimes.

Overbilling, unnecessary medical tests and benefits of dubious origin; are the most common misdeeds when they try to cheat through the United States government health care program.

Sure, crooks won’t have such an easy time defrauding Medicare; Well, as the Department of Health and Human Services of the United States (DHHS or US Department of Health and Human Service) reviews, the Fraud Control Units against Medicaid will be aware of any strange movement.

The MFCU for its acronym in English (Medicaid Fraud Control Units), are called “Medicare cops – Medicaid” and operate in the 50 states of the Union, the District of Columbia, Puerto Rico and the Virgin Islands of the United States.

Keep reading: What is the difference between Medicaid and Medicare?

How to understand Medicare and Medicaid fraud?

If you want to understand Medicare and Medicaid fraud, you must first be clear that anyone who is directly or indirectly involved with the US government health program can commit this type of crime.

As we mentioned before, they can be doctors, directors or managers of a health center; patients, relatives of patients and even a stranger who tries to impersonate a Medicare beneficiary.


How can they scam Medicare and Medicaid?

Between the frauds most common we have the following:

  • misleading billing of services that were not provided.
  • test or unnecessary exams.
  • Refer a patient or issue fraudulent medical referrals. This is known as ping pong, because they send a patient from one medical unit to another when the situation really does not warrant it.
  • Charge a service separately when it is included in the package rate, this is known as disintegration.
  • abuse or patient abuse.
  • Toast benefits to patients not eligible for Medicare or Medicaid.
  • Introduce illegitimate refund claims.
  • Stealing the identity of a Medicare participant to receive services.

Challenges in Fighting Medicare and Medicaid Fraud

Medicare and Medicaid fraud can represent a multi-million dollar loss to the US government; For this reason, these programs are monitored so acutely and even the slightest bit of deception or traps that could be forged in professional health centers are sought.

Apart from the MFCUs that we already mentioned above, there is also an Attorney General of the Department of Health in each state of the country.

The Attorney General is in charge of ensuring that the health program is working correctly and without corruption stains, in addition to this, his powers are totally independent and external to the Medicare Office of the state where he is exercising his position.

In April 2018, Medicare made the effort to provide new cards to beneficiaries of the health program, among the most relevant changes that were made is the replacement of the social security number with the Medicare identification number.

Without a doubt, all the efforts made to prevent Medicare-Medicaid fraud have not been in vain, since every action taken is for the benefit of the program’s participants and those who really need help.

We could even talk about some special legislation for this type of program:

CARES Act of 2020

On March 27, 2020, President Donald Trump enacted a special law to deal with the health emergency generated by Covid-19 where he allocated US $2,000,000,000,000 (two trillion dollars) in resources to overcome this situation.

This special law was called the CARES Act, which expands the capabilities of Medicare to cover services related to the Covid-19 pandemic.

Among other effects, the CARES Act also offers the following benefits:

  • Flexibility to cover expenses in telehealth services.
  • Authorize and certify the physician assistant services In the home.
  • Increase the Medicare payments for hospital stays related to Covid-19 and durable medical equipment.

Regarding Medicaid, the CARES Act clarifies that non-expanding states can use the Medicaid program to cover services related to COVID-19 for uninsured adults who would have qualified for Medicaid if the state had chosen to expand.

Other populations with limited Medicaid coverage are also eligible for coverage under this state option.

How to report Medicare and Medicaid fraud?

If you suspect fraud against Medicare and Medicaid, you can report it through the following means depending on the situation:

For reports on Medicare and Medicaid (general public and providers)

Can contact the Department of Health and Human Services by calling 1-800-447-8477 and by text message at 1-800-377-4950.

For providers with identity theft problems in Medicare – Medicaid

They must go online to Website of the Center for Medicare-Medicare Services and get information about the Victimized Providers Project.

For people with problems with Medicare (According to plan A, B, C and D)

  • Plans A and B: You can contact Center for Medicare Services – Medicaid at 1-800-633-4227 and by text message at 1-877-486-2048.
  • Plan C: These types of plans offer private companies approved by Medicare, so you should check with your insurance company.
  • Plan D: You can contact Medicare drug plan through 1-877-772-3379.

To report Medicare and Medicaid fraud to an MFCU

  • Telephone: Can contact a Fraud Control Unit at Medicaid by calling 1-877-808-2468.
  • Online: Go to the MFCU website and leave your report with them.

To report fraud against the Children’s Health Insurance Program

  • Online: Find the resources of Children’s Health Insurance Program for your state on the website and then report fraud on the website for your area.

To report fraud in the health insurance marketplace

To report Medicare fraud related to the insurance market you can make a complaint calling the 1-800-318-2596.

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