SMP Program

 
WHY SHOULD I REPORT SUSPECTED MEDICARE FRAUD?
 

Medicare fraud and abuse affects everyone. Medicare loses billions of dollars to improper claims every year. This affects everyone by wasting billions of taxpayer dollars. This also affects you. False information can end up on your medical records, leading to improper medical care later. You may even be denied services you need and deserve.

Medical Identity Theft

Medical identity theft occurs when a beneficiary’s Medicare number is misused, either by a provider, a supplier, or by someone posing as the real beneficiary in order to receive medical care. Such Medicare numbers are considered “compromised.” A beneficiary whose number is compromised may be affected forever by false claims against his or her Medicare number.

Health Impact

Receiving health care from a fraudulent provider can mean the quality of the care is poor, the intervention is not medically necessary, or worse: The intervention is actually harmful. A beneficiary may later receive improper medical treatment from legitimate providers as a result of inaccurate medical records that contain:

  • False diagnoses

  • Records showing treatments that never occurred

  • Misinformation about allergies

  • Incorrect lab results

Additionally, because of inaccurate or fraudulent claims to Medicare, beneficiaries may be denied needed Medicare benefits. For example, some services have limits. If Medicare thinks such services were already provided, they will deny payment.

Personal Financial Losses

Medicare fraud, errors, and abuse can all result in higher out-of-pocket costs for beneficiaries, such as copayments for health care services that were never provided, were excessive, or were medically unnecessary. Beneficiaries may also find themselves stuck with bills for services from providers who should have billed Medicare but instead billed the beneficiary for the entire cost of that service. 

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WHAT ARE THE DIFFERENCES BETWEEN FRAUD, ABUSE AND ERRORS?
 
Medicare fraud occurs when a person or company knowingly tricks Medicare to intentionally receive inappropriate payment from the program.
Medicare abuse occurs when providers seek medicare payment they don't deserve but they have not knowingly or intentionally done so. Abuse can also involve billing for unsound medical practices.
Examples of Medicare fraud and abuse include:
  • Billing for services, supplies or equipment that were not provided
  • Calling Medicare beneficiaries and asking for their Medicare number, saying it is needed to get a new Medicare card or keep their Medicare benefits
  • Trying to get a Medicare number in exchange for "free" services
  • Billing for services different from those that were actually provided
  • Billing for medically-unnecessary services or supplies
  • Billing for excessive medical supplies or services
If you suspect Medicare fraud or abuse, contact Tennessee SMP at 1-866-836-7677.
Medicare errors are accidents. Sometimes the mistake is a simple error by a coder who entered the wrong billing code—a small mistake that just needs to be fixed. There are people on all ends of the healthcare industry who are there to make sure billing issues are corrected.
If the issue is with the hospital or a medical provider, call them and ask to speak with the person who handles insurance. They can help assist you in correcting the billing issue. Those with Original Medicare (parts A and B) can call 1-800-MEDICARE with any billing issues. If the error is with a private insurer, they should have a claims issue hotline you can call.
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WHAT CAN I DO TO PREVENT FRAUD?
 
There are several simple tips that can help you avoid being the victim of a health care scam. For more tips, read the "DON'T BE A VICTIM. PROTECT YOURSELF FROM HEALTH CARE FRAUD." flyer.
Do:
  • Ask questions. You have the right to know everything about your care, including how much it costs.
  • Keep a record of the dates of Medicare services that you receive. Using your Personal Health Care Journal (available from FTAAAD) is an ideal way to do so.
  • Report suspected instances of fraud to SMP.
  • Review your Medicare Summary Notices (MSNs) and Explanations of Benefits (EOBs)
    • Did you receive the service or product?
    • Did your doctor order this service or product?
    • Were you billed for a service or product more times than you received it?
    • Were the services on your statement related to your medical condition?
Don't:
  • Don't give out your Medicare number to anyone who asks. Only your doctor or your other Medicare providers should need it.
  • Don't give your Medicare number to telephone callers or door-to-door solicitors.
  • Don't accept "free" medical services in exchange for your Medicare or Social Security numbers.
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WHAT INFORMATION SHOULD I HAVE ON HAND WHEN I CALL?
 
If you are calling about information on a medical bill or your Medicare statement, ideally you will need the provider name in question, the date of the service, the location of the service, and the provider phone number.
 
If you are calling to report unsolicited marketing or personal contact by an agent of an insurance company or broker, the name of the company and the person you spoke with (if possible) will enable the SMP staff to take action.
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CAN I CALL ON BEHALF OF SOMEONE ELSE?
 
An SMP representative will be happy to assist you with a family member or friend's Medicare concerns as long as you have their permission.
It may be helpful to have that person available during your call, in case there are additional questions. Otherwise, make sure you have all the information on hand that is referenced in the question above.
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WHERE CAN I GO TO REPORT NON-MEDICARE SCAMS?
 
The Federal Trade Commission protects consumers and ensures competition by preventing anti-competitive, deceptive, and unfair business practices through law enforcement, advocacy, and education.
The FTC WEBSITE features a "Claim Assistant" webpage that walks you through the steps needed to report a consumer scam. At this same location you can report identity theft, add your phone number to the national Do Not Call registry, and report international issues. There is also a "Live Chat" feature in case you have difficulty using the website.
To read about current scams, and how to recognize them, the FTC website also offers a SCAM ALERT page.
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SMP DISCLAIMER
 

SMP:  This project was supported, in part by grant number 90MPPG006, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201.  Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions.  Points of view or opinions do not, therefore, necessarily represent official ACL policy.

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