Healthcare Fraud

Health care fraud, waste and abuse costs American taxpayers nearly $60 billion each year.  Medicare and Medicaid consumers are an essential piece in fraud fighting efforts.  SMP programs provide education and prevention through the media, outreach campaigns, and community events.  Join the fight against fraud!

SMP staff and volunteers assist beneficiaries in resolving potential fraud-related inquiries and issues regarding Medicare, Medicaid, and other health care or related consumer issues.  Referrals of suspected cases of fraud, waste and abuse are made to appropriate investigative entities such as Medicare contractors, state Medicaid Fraud Control Units, Office of the Inspector General, Centers for Medicare and Medicaid and law enforcement.

What is Medicare Fraud?

Fraud occurs when an individual or organization deliberately deceives others in order to gain unauthorized benefit.

Medicare and Medicaid fraud generally involves deliberately billing for services that were not received, or billing for services at a higher rate than is actually justified.

What is Medicare abuse?

Medicare abuse occurs when providers supply services or products that are not medically necessary or that do not meet professional standards.

Examples of Fraud and Abuse

  • Billing for services and supplies that were not provided
  • Obtaining Medicare number for “free” services
  • Billing for equipment not delivered
  • “Upcoding” - improper coding to obtain a higher payment
  • Unneeded or excessive x-rays and lab tests; claims for services that are not medically necessary
  • Billing for excessive medical supplies
  • Using another person’s Medicare card to obtain medical care, supplies or equipment

Prevention Tips

  • Use your Personal Health Care Journal or a calendar to keep a record of the dates of Medicare services received.
  • Review your Medicare Summary Notice (MSN)
  • Did you receive the service or the product?
  • Did the doctor order this service, product or test?
  • Were you billed for the same service more than one time?
  • Is the charge or service related to your condition or treatment?


  • Give out your medicare number except to your doctor or other Medicare provider
  • Accept “free” medical or other services in exchange for your Medicare or Social Security number
  • Give your Medicare number to telephone callers or door-to-door solicitors (Medicare does not call or go door-to-door)

Three Steps to Prevent Health Care Fraud – Protect, Detect, Report!

Protect Yourself from Medicare Fraud and Abuse – Do treat your Medicare card and number like your credit cards, do watch out for identity theft and do be aware Medicare doesn’t call or visit to sell you anything.

Detect Medicare Fraud and Abuse – Use your Personal Health Care Journal or calendar and Review Medicare Summary Notices (MSNs) and other statements. Check for services you did not get and services not ordered by your doctor.  Access your information at

If you have questions, call the provider. Gather information and documentation.  Contact your SMP.  This is a free and confidential service.

Medical Identity Theft

 Medical identity theft is a serious and growing problem.  According to one study, about 1.5 million Americans are victims of medical identity theft each year.  The average cost to fix medical ID theft for someone is more than 20,000 per incident!

But medical identity theft is about more than losing time and money.  Sometimes people are denied a Medicare service or equipment because their records falsely show they already received it, when in fact it went to someone posing as them.

What is Medical Identity Theft?

Medical ID theft occurs when someone steals personal information – such as your name and Medicare number – and uses the information to get medical treatment, prescription drugs, surgery or other services and then bills Medicare for it.

Medicare ID theft is a form of Medicare fraud.  It can affect your medical and health insurance records. Every time a thief uses your identity to get care, a record is created with incorrect medical information about you.  That information might include:

  • A different blood type
  • An inaccurate history of drug or alcohol abuse
  • Test results that are not yours
  • A diagnosis of an illness, allergy or condition that you do not have

Any of these could lead to you receiving the wrong treatment and even being injured or getting sick due to an incorrect treatment.

All types of people, including doctors and medical equipment companies, have been caught stealing people’s medical identities.  There have even been links to the mafia and thieves in other countries. Sadly, about one-third of the people who do it are family members.

How Do People Learn They Are Victims?

 Here are some warning signs that your identity may be stolen:

  • You get a bill for medical services you did not receive
  • You are contacted by a debt collection company for money you do not owe
  • Your insurance company says you’ve reached your limit on medical benefits
  • You are denied insurance for a medical condition you do not have

How to Avoid Medical Identity Theft

  • Review your Medicare Summary Notices (MSN), Explanations of Benefits (EOB) statements and medical bills for suspicious charges.  If you find incorrect information in your records, insist that it be corrected or removed.
  • Protect your Medicare and other health insurance cards in the same way you would protect a credit card.
  • Only give personal information to Medicare – approved doctors, other providers and suppliers; your State Health Insurance Assistance program or SMP program; or Social Security. (Call 1-800-MEDICARE  - 1-800-633-4227) if you aren’t sure if a provider is approved by Medicare).
  • Beware of offers of free medical equipment, services or goods in exchange for your Medicare number.
  • Shred papers with your medical identity before putting them in the trash.  Remove or destroy labels on prescription bottles and packages before you put them in the trash.

How to Respond if You Suspect Identity Theft

  • Ask your health care provider for a copy of your current medical file. If anything seems wrong, write your health plan or provider and ask for a correction.
  • Contact your local Senior Medicare Patrol.  In Virginia, contact 1-800-938-8885.
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