How to Avoid Medicare Fraud
Learn how to spot, avoid, and report fraud.
Unfortunately, the simple truth is that anybody can end up victim of a scam. It’s not a matter of being too savvy or too intelligent to fall victim to fraud, rather it’s more often about keeping up-to-date on new scams and learning how scammers tend to operate.
While it’s difficult to say just how a fraudster may try to perpetrate their scam, it can be helpful to understand what information they are commonly after and how they typically use that information.
For example, fraudsters are often after your Medicare number. If successful, they use your Medicare number to bill fake claims in your name.
So, knowing this you would likely become very skeptical of someone calling and asking for it. This skepticism is good! If you receive a call from someone that claims to be from Medicare and is asking for your Medicare number, it is more than likely a scam.
Medicare never conducts uninvited calls in which they ask for personal information.
With this in mind, here are a few important steps for preventing fraud:
Never give out your Medicare number.
Protect your Medicare card.
Keep track of your tests and appointments.
Stay current on scam trends.
Review the Medicare plan rules.
Do not let outsiders review your records.
Let’s look at a breakdown of these important steps, so that you understand how they apply and how you can implement them in your life:
Never give out your Medicare number. Be sure to never give out your Medicare number (or Social Security number), unless to a trusted recipient. Keeping this information safe goes a long way in protecting yourself against fraud.
Protect your Medicare card. You want to treat your Medicare Card like you would your Social Security card or credit card. Protect your Medicare card and share it only with your doctor and trusted recipients.
Keep track of your tests and appointments. Use a recording method, such as a calendar, to keep track of your tests and doctor appointments, so that you can check what care you have received and when. Keeping good records will make it easier for you to spot suspicious claims on your statements.
Stay current on scam trends. Periodically, check to see if there are any new Medicare scams circulating. New scams can pop up and take people by surprise. Staying informed is one of the best tools you have for fighting fraud. Medicare posts notice about recent scams here.
Review the Medicare plan rules. Review your Medicare plan to understand what it can and cannot do. Also, take the time to learn the rules that govern representatives. This way you won’t be fooled by offers that are too good to be true.
Do not let outsiders review your records. Do not allow anyone outside of your doctor and Medicare providers to review your medical records or recommended services. These are the only individuals that need to see this information.
How Do I Spot Medicare Fraud?
One of the best ways to protect yourself against fraud is by diligently reviewing your Medicare Summary Notices.
This is the notice that Original Medicare recipients receive every 3 months detailing the services and supplies that have been billed to Medicare during the past 3 months, what Medicare paid toward the cost, and the maximum amount they might owe the provider.
When you review your Medicare Summary Notice, you want to check for any irregularities or errors.
As we mentioned earlier, it is smart practice to keep a calendar that tracks what services you have received and when you received them. Compare your records with the claim statements from Medicare to make sure everything is correct.
If you are a recipient of Original Medicare your Medicare Summary Notice will list any services received or prescriptions filled. If you have a Medicare Advantage plan, you will receive a similar statement that lists these details, as well.
Also, be sure to review your claim statement sooner than later, so that you can catch anything suspicious and assist in stopping fraud.
If you think that you’ve spotted an incorrect charge but you recognize the provider, try contacting their office about it first. Your provider may be able to refresh your memory or explain the service or supply charge.
It’s also possible that from your call the provider realizes they made a billing error. However, if you don’t recognize the provider on the claim you will want to report the fraud.
How Do I Spot a Scam Phone Call?
While you wont know exactly what a scam phone call will sound like or what it might entail, there are two classic warnings signs that should immediately draw your suspicion.
During the phone call, here are the two warning signs to look for:
The caller creates or conveys a sense of urgency.
The caller asks for information they should already have.
Let’s take a look at both of these warning signs, starting with the first. If you ever receive a phone call in which the caller creates a sense of urgency, such as suggesting that money needs to be sent right away, an immediate red flag should go up.
Remember that reputable and professional organizations do not make demands or threats. If a caller makes demands of you for information or threatens penalties, fines, or other repercussions, hang up immediately. The call is a scam.
No healthcare or insurance provider ever behaves in this manner.
The second warning sign may not stand out quite as clearly as the first but is equally important to look out for. If you find that a caller is asking for personal information that you feel they should already know, this is another red flag.
Of course, the situation is different if you are the one to call them, in that case they may need certain information for verification purposes.
However, if someone calls you and asks for sensitive information it is smart to put your guard up as you don’t know for certain who that caller is.
If you’re ever unsure about a caller claiming to be from Medicare or another provider, offer to call them back. You can look up the number yourself from a trusted resource.
If the call is legitimate, the organization will be able to put you back in contact with your caller.
If you offer to do this and the caller gives an excuse as to why this wouldn’t work, such as that the matter is time sensitive, we refer you back to the first warning sign. It’s a scam!
Protecting Your Medicare Card Against Fraud
There have been some protective steps taken by Medicare in recent years to help secure your Medicare card and information.
For example, the new Medicare card that was mailed out between April 2018 and April 2019 now uses a unique Medicare ID number in place of where your Social Security number was on the old card.
To be vigilant in protecting against fraud, treat your Medicare card and Medicare number as you would your Social Security number, credit or debit card, or other bank account information.
Be careful who you share it with and always err on the side of caution. The only people you should provide with your Medicare information are your doctor, pharmacist, healthcare provider, insurance provider, or a trusted companion that assists with your healthcare.
If you believe that your Medicare card or personal information is being misused, immediately contact one of these departments for assistance:
FTC ID Theft Hotline: 1-877-438-4338
Department of Health & Human Services Fraud Hotline: 1-800-447-8477
How Do I Report Medicare Fraud?
If you suspect that you are the victim of Medicare fraud be sure to report the incident to Medicare as soon as possible.
Doing so will assist your own case and could also benefit many others. Here’s how you can report your case:
If you are a recipient of Original Medicare, call Medicare at 1-800-633-4227.
If you have a Medicare Advantage plan, call the Medicare Drug Integrity Contractor at
When you report your fraud, be sure to have the following information available to you, as it will likely be requested:
Your Medicare number.
The name of your provider.
The name and date of the service or item in question.
The amount approved and covered by Medicare.
The date on your Medicare Summary Notice or similar statement.
For more reporting options, the Center for Medicare Services (CMS) has a helpful resource page to guide you in reporting your fraud case.
Understand Medicare Plan Rules to Help Avoid Fraud
As we mentioned earlier, if you take the time to understand the rules surrounding Medicare plans, what can and cannot take place, you will put yourself in a better position to spot fraud.
Here, we’ll go over the rules that Medicare plan representatives must follow and what the rules are for meeting with an agent.
For starters, be aware of the fact that any person representing a Medicare plan is not allowed to ask you for personal information over the phone. This information includes your Medicare number, Social Security number, and credit card or bank account number.
The only time this is allowed to take place is when that information is needed to determine your eligibility, process your enrollment request, or verify your plan membership.
Here are some other things Medicare plan representatives are not allowed to do:
Ask for online payments or payments over the phone (plans are required to send bills).
Visit your home uninvited to sell their plan.
Call you on the phone (unless you are already a plan member).
Try to sell you their plan during an educational event or conference.
Try to sell you a non-health related product while pitching their plan.
Offer cash, free meals, or gifts (under $15 gifts are allowed) to join their plan.
In addition to this, if you are meeting with an insurance agent that works with Medicare plans, there are rules that the agent must follow.
The agent is allowed to provide plan options, plan materials, and enrollment forms. The agent can also collect your completed enrollment form and provide you with business cards for passing on to others.
Once the meeting is complete, the agent can call you to discuss other plan options. Additionally, any plan that you enrolled in will contact you to confirm that you understand how the plan works and that you want to join.
Here are some of the things that the agent is not allowed to do:
Charge you an enrollment processing fee.
Use misleading information or claims about their plan to influence your opinion.
Pressure you into joining a plan or ask you to sign an enrollment form before you are certain.
Talk to you about plan options that you haven’t previously agreed to discuss.
Ask for the contact information of other family members or friends.
Closing Thoughts: Fight Medicare Fraud
To recap and to close, protecting yourself against Medicare fraud takes vigilant education and effort. Remember these important points about Medicare, so that you are always prepared to spot any fraud effort that confronts you.
Medicare will never:
Attempt to sell you anything.
Visit your home.
Enroll you over the phone (unless you contact them for this purpose).
Contact you for your Medicare number (unless you have given them permission to be contacted).
Keep these facts in mind and be sure to always review your Medicare Summary Notice and other claims and statements for suspicious billings. And if you believe you are the victim of Medicare fraud, be sure to report it.
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