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                                                                                                         MEDICARE FRAUD 


  • Medicare is a far-reaching federal health insurance program in the United States for people who are 65 or older, certain younger people with disabilities, or people with end-stage renal disease.

  • Approximately 59 million Americans are enrolled in Medicare.


  • Medicare fraud typically includes knowingly submitting, or causing to be submitted, false claims or making representations of fact to obtain federal healthcare payment for which no entitlement would otherwise exist.

  • It includes knowingly soliciting, receiving, offering, or paying remuneration (e.g. kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by federal health care programs; making prohibited referrals for certain designated health services.

  • Some of the examples of Medicare fraud include:

    • knowingly ordering medically unnecessary items or services for patients

    • billing Medicare for patient appointments they fail to keep

    • knowingly billing for services not furnished or supplies not provided

    • knowingly billing for services at a level of complexity higher than services actually provided or documented in the health records

    • or paying for referrals of federal health care program beneficiaries.

  • As of Q4 2021, the Medicare Fraud Strike Force has 14 offices that work to investigate and prosecute entities and individuals for Medicare fraud violations.


The U.S. Department of Health and Human Services (DHHS) and Department of Justice (DOJ) work to combat the different types of health care fraud through the False Claims Act, Anti-Kickback statue, and the Stark Law.

  • The False Claims Act of 1863 (FCA) imposes civil liability on any person who submits, or causes to be submitted, a false or fraudulent claim to the federal government for payment or approval, either knowingly or due to deliberate ignorance.

  • The Anti-Kickback Statue of 1972 prohibits any person from knowingly or willfully offering, paying, soliciting, or receiving remuneration for making a referral to or inducing business from a federally reimbursed healthcare program, including Medicare and Medicaid.

  • Lastly, the Physician Self-Referral Law of 1989 (Stark Law) prohibits physicians from making referrals to certain designated health services paid for by Medicare or Medicaid.                                   
                                                                                                               FRAUD ALERT 
    Protect Your Patients Against Medicare Fraud During Open Enrollment

  • The risk for Medicare Fraud increases during the open enrollment period. Medicare enrollment fraud can occur when a representative or a plan agent purposefully tricks the person into enrolling in their plan without the plan being right for the person.

  • Watch out for people who:

    • set arbitrary time limits to pressure enrollment in their plan

    • ask for sensitive information like Medicare number, Social Security Number, and/or bank information just to provide you with basic plan information

    • threaten the loss of Medicare benefits for choosing another plan

    • offer gifts in exchange for enrolling in their plan

    • say they represent Medicare

    • demand immediate payment, particularly via gift cards or other prepaid means

  • It is important to confirm everything that a plan agent tells your patient before making a final decision about a plan. Ask for everything in writing and contact current physicians to ensure they are in network for the plan of interest. Never give Medicare information to anyone but trusted health care providers.  

  • If a patient feels a plan or agent has violated Medicare’s marketing rules, they should save all documented proof (when available), such as an agent’s business card, the plan’s marketing materials, and any phone call records. Report the activity to 1-800-MEDICARE or the local Senior Medicare Patrol (SMP). If a patient thinks they were enrolled in a plan without their permission, contact 1-800-MEDICARE or the local SMP to report it and request assistance. They may also contact their State Health Insurance Program (SHIP) for assistance with changing their plan. Medicare allows victims of enrollment fraud to makes changes outside of Medicare’s Open Enrollment Period. 

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