What Is Medicare Fraud, Waste, and Abuse | Medicare Plan Finder

What is Medicare Fraud, Waste, and Abuse?

Anastasia Iliou Medicare

Medicare Fraud, Waste, and Abuse

The government loses millions each year due to Medicare fraud, waste, and abuse, causing prices to rise. Medicare fraud, waste, and abuse come from a series of laws designed to protect all parties involved in Medicare and Medicaid. The laws promote healthy relationships between agents, carriers, and clients and prevent the insurance industry from becoming profit-based, instead of care-based. Your coverage should be more important than profits.

Penalties for committing Medicare fraud can reach nearly $100,000 and result in extraction from all government health care programs.

What Is Medicare Fraud?

  • Knowingly making false claims or misrepresenting data
  • Knowingly giving or receiving rewards for goods and services
  • Promoting one health service over another
  • Billing Medicare for appointments that never happened or for more than what actually happened

What Is Medicare Waste and Abuse?

Waste and Abuse surrounds unnecessary costs or fees. Some examples are:

  • Billing for unnecessary services
  • Excessive supply purchases
  • Misusing codes

What Are The Laws?

  • False Claims Act (FCA) – Protects the government from being overcharged on goods or services. No proof of intent is required.
  • Anti-Kickback Statute (AKS) – Agents cannot knowingly reward referrals for health care programs.
  • Physician Self-Referral Law (Stark Law) – Doctors cannot make referrals to health care companies in which they have an interest.
  • Criminal Health Care Fraud Statute – Cannot defraud; bill for unnecessary medical goods and services (like drugs that are not needed or wheelchairs for those who are not impaired).
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What Can You Do?

Don’t become a victim! If you aren’t sure about a health agent’s validity, find your agent through a field marketing organization (or FMO) like Senior Market Advisors. FMOs contract with trained, certified agents.

To help fight Medicare fraud, waste, and abuse report any suspicious activity to 1-800-HHS-TIPS (1-800-447-8477). You can also describe the incident in up to ten pages and email it to HHSTips@oig.hhs.gov.

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