Medicare fraud robs America of billions of health care dollars each year. It has been estimated that health care fraud and abuse accounts for 10% of national health care spending. Most Americans feel that it is their duty to report health care fraud. However, many hesitate because they do not feel that they truly know what abuse is.
Medicare fraud is simply any unauthorized use of the program. It can take the form of double billing, billing for services not provided, or unnecessary medical treatment.
Medicare fraud and abuse can happen in any health care setting. This includes:
- Home Health Agencies
- Hospice Programs
- Medical Suppliers
- Nursing Homes
- Managed Care Plans
- Mental Health Services
- Clinical Laboratory Services
- Ambulance Services
Where to Look for Medicare Fraud
The first place to look for Medicare fraud is on your Medicare Summary Notice (MSN). These forms outline the services you were provided and Medicare was billed for. If there are services listed on your summary notice that you did not receive, there is the possibility of Medicare fraud.
Examples of Medicare Fraud
Medicare fraud is when a person or business obtains an unauthorized benefit from the program. These unauthorized benefits can take many shapes. They can also occur in a number of settings. Some examples of fraud at various settings are:
- Home Health Agencies: Home health agencies provide skilled nurses and other therapists for the homebound. These agencies also provide home health aides to help with simple exercises and housekeeping. If you have a home health aide come to your home to help out, but Medicare is billed for skilled nursing, then this is fraud.
- Mental Health Services: Mental health services are provided in many different settings, including nursing homes. If you have a loved one in a nursing home who is in the advanced stages of Alzheimer's, they should not be receiving psychotherapy. This therapy requires that the patient be able to interact and your loved one cannot. This is an unnecessary treatment and an example of Medicare fraud.
- Clinical Laboratory Services: Clinical laboratories perform diagnostic tests for your doctor. Beware of 'mobile labs.' These labs offer free diagnostic tests at senior centers and in malls. All you need to do to receive this free testing is fill out a form. This registration form includes your insurance billing number. With this information, the lab can bill Medicare for tests you never received. This is Medicare fraud.
- Ambulance Services: Ambulances are used to transport patients for a number of reasons. They are often used to take homebound and nursing home patients to treatment facilities. This service is for people who cannot walk to a car or taxi. If an ambulance service transports a person (who is not in a medical emergency situation) who can walk and bills Medicare for it, then this is fraud.
- Pharmacies: Some pharmacies have been sited for underfilling prescriptions. In these cases, when the pharmacist does not have enough medicine to fill your prescription, you are given a partial refill. You are then told to return at a later date. Whether you return or not, Medicare is billed for a full prescription. This is Medicare fraud.
- Hospitals: Often when you are admitted to the hospital, you require X-Rays. Many times only one X-Ray is necessary for diagnosis. If a hospital takes only one view of the area and charges Medicare for multiple views, this is fraud.
- Physicians: Physicians are in charge of your health and your diagnosis. Some conditions and treatments are reimbursed at a higher fee than others. If a doctor writes in a false diagnosis in order to obtain a higher fee from Medicare, this is fraud.
Reporting Medicare Fraud
These are just some of the ways the Medicare program can be abused. There are many more. Each incident of fraud, no matter how small, adds up to a loss in health care dollars. Reporting suspected Medicare fraud is the best way to end the loss and the waste. To report Medicare fraud and abuse, contact the Virginia Senior Medicare Patrol (SMP) at (804) 644-2804 or (800) 938-8885.