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Medicare Fraud - What to Look For

Fraud comes in all shapes and sizes. Fraudulent scams against seniors have become more common over the last decade. In fact, according to the National Council on Aging, senior-targeted scams are now called “the crime of the 21st century”.

Health insurance scams alone potentially count for $300 billion each year, according to the National Health Care Anti-Fraud Association. Because Medicare is such a complex, large program, seniors on the national healthcare program are considered a low-risk target for scammers from all backgrounds.

As a matter of fact, Medicare changed the structure of Medicare ID numbers to help prevent fraud. The numbers used to be your Social Security number, followed by a specific letter. Now the numbers are a completely randomized group of letters and numbers for each person.

There are three main types of fraud seniors on Medicare should look for. The first is identity theft. While identity theft doesn’t always involve taking advantage of the Medicare program, it can be a result of stealing someone’s Medicare information.

The second is Medicare fraud. Medicare fraud is when Medicare is billed for services you didn’t receive. This type of fraud can be done by scammers or medical providers. The third is improper care. When a doctor provides you with medically unnecessary services and bill Medicare for them, it is considered improper care.

Fraud involving scammers and seniors

Scammers have several fronts they can use to steal seniors’ identities and/or money. One of the more popular ways scammers take advantage of seniors is with phone calls. Seniors are used to getting inundated with telemarketer phone calls. While some are extremely cautious and simply don’t pick up the phone, others can be more trusting and engage in conversation with the caller.

Call scams happen year-round, but they are most prevalent during important Medicare enrollment periods, such as the Open Enrollment Period and the Annual Election Period. These scammers will call seniors, impersonate a Medicare representative, and ask for their Medicare ID numbers. If someone ever asks you to give your personal information over the phone, like your Medicare ID number or Social Security number, hang up immediately.

Other forms of scams that fraudsters can pull on seniors are fake mobile clinics and selling fake prescription drugs online. These are less common than phone call scams as they are harder to commit, but they do exist.

Medicare fraud involving medical providers and seniors

While the majority of medical providers are trustworthy, there are some bad eggs that can ruin the trust people have with doctors. Medical providers can commit Medicare fraud and improper care fraud. They can do this by billing Medicare for services they didn’t perform, performing unnecessary services and billing Medicare, falsely diagnosing you and billing for unperformed services according to that diagnosis, prescribing unnecessary prescriptions, or billing for a more expensive version of a specific service performed.

Although you may think this doesn’t happen too often, data reveals that there are more improper claims billed to Medicare by medical providers than there should be. In 2017, there was an estimated nearly $24 billion worth of improper payments paid out by Medicare resulting from medical providers committing Medicare fraud.

The Medicare Fraud Strike Force

Fortunately, Medicare has implemented a team to fight against Medicare fraud. The Medicare Fraud Strike Force was established in 2007, and since then, it has received $7 billion back from Medicare fraud perpetrators. The team has also charged over 2,500 Medicare fraud suspects; some of these suspects were involved in fraudulent claims dating back to 1997. Due to the dedication of the team, The Medicare Fraud Strike Force has a 95% conviction rate.

How to prevent, detect, and report Medicare fraud

Medicare sends out a Medicare Summary Notice to each beneficiary every three months. This notice shows details of the services billed to Medicare during the last three months and how much was paid. Review your notice each time you receive it and look out for services you don’t remember receiving or any payments you don’t remember paying.

Prevent Medicare fraud by treating your Medicare information as if it’s your Social Security number. Don’t give your Medicare information out to anyone over the phone unless you are 100% sure they are a Medicare representative.

To report Medicare fraud, call 1-800-Medicare (1-800-633-4227). They will need your Medicare information, identity information of the suspect, details about the service or payment in question, as well as the date of the Medicare Summary Notice that shows the service or payment in question.

As long as you protect your personal information and only use doctors you can trust, you shouldn’t fall victim to Medicare fraud.

Danielle K. Roberts is a Medicare insurance expert and co-founder at Boomer Benefits, where her team of experts help baby boomers with their Medicare decisions nationwide.