About Medicare Fraud and Abuse

Medicare fraud and abuse refer to illegal activities aimed at exploiting the Medicare system in the United States.

1. Medicare Fraud: This involves knowingly submitting false information or making false claims to Medicare for payment. It can take various forms, including:

   • Fraudulent billing: Billing Medicare for services or items that were not provided, such as a back brace that was never provided to the patient.
   • Phantom billing: Billing Medicare for fictitious patients or services.
   • Upcoding: Charging for a more expensive service than what was actually provided.
   • Kickbacks: Receiving payments or kickbacks for referring patients or prescribing certain treatments or medications.
   • Hacking: A person may steel a Medicare Number or card and use it to submit fraudulent claims in the patient's name.
   • Insurance fraud: Offering a Medicare drug plan that Medicare hasn’t approved, or attempting to bill Medicare without Ordering and Referring Privileges, or while currently under CMS Office of Inspector General (OIG) sanction. CarePrecise includes the current Ordering and Referring Report ("in PECOS") listing, and flags providers who are currently ineligible to bill Medicare in many of its data packages.
     

2. Medicare Abuse: This refers to practices that are inconsistent with accepted medical, business, or fiscal practices, resulting in unnecessary costs to Medicare. While not kin every case illegal, these abuses can still be harmful to the Medicare program and its beneficiaries. Examples include:

   • Overutilization of services or unnecessary medical procedures on the part of the patient or provider.
   • Providing services that are not medically necessary, on the part of the provider.

Both fraud and abuse can lead to significant financial losses for the federal Medicare program and taxpayers, and they can also harm patients by providing unnecessary or substandard care. The government, through agencies like the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS), actively investigates and prosecutes instances of fraud and abuse to protect the integrity of the Medicare program. The Federal Bureau of Investigation (FBI) may become involved in investigating illegal Medicare activities, and may make arrests and gather evidence towards prosecution.

CarePrecise supplies data and services to law enforcement in the mitigation of Medicare fraud, including the FBI and other agencies of the federal government. A CarePrecise-maintained system for tracking eligibility to bill Medicare, as well as provider sanctions, over time, the Physician Sanctions, Reinstatements, Deactivations and Reactivations (SRDR) database, is available for use in private industry's efforts to curtail abuse, Recovery Audit Programs, and similar tracking of eligible Medicare billing.

CarePrecise does not offer legal advice, and nothing on this page or elsewhere on our website may be construed as legal advice.