Reporting Medicare Fraud

Guide to recognizing and reporting Medicare fraud and abuse. Contact information and what info you need to provide when reporting it. Did you know you may qualify for a reward?

We’ll give an introduction to how Medicare fraud is defined, how to report it, information to report, and what happens when fraud is reported. Basically everything that applies to Medicare fraud discussed here also applies to Medicaid fraud.

What is Medicare Fraud?

Medicare fraud and abuse typically falls into three categories:

  • False Claims
  • Kickbacks and Paid Referrals
  • Self Referrals

False Claims
The False Claims Act establishes civil and criminal penalties for anyone that submits claims to Medicare for services that were not performed or medical supplies that were not provided. This also includes items or services that are substandard. An example of false claims is when a provider submits a Medicare claim for medical services or equipment that was not provided to the patient. Fines imposed for violating the False Claims Act can be up to 3 times the damages caused to the government.

Deliberately altering claims to receive a higher payment would also be considered a false claim. Other examples would be listing diagnosis and treatment codes and modifiers that are not accurate in order to receive a higher payment and excessive charges for medical services and supplies.

Medicare fraud may range from a small practice to a large organized effort by an organization, institution, or group practice.

Kickbacks
Kickbacks are a form of Medicare fraud which involves paying or soliciting someone for referrals of medical services or items that are then reimbursed by Medicare. There is an anti-kickback law that makes it a criminal offense to solicit, pay or receive any payments for referrals of services or items that are reimbursed by a Federal healthcare program - such as Medicare or Medicaid. Penalties for violating the Anti-Kickback law can include fines, prison, or both.

Physician Self Referral
A law called the Stark Law was created to prevent a physician from referring a patient for health services to an organization in which he or she has an interest. This interest could be ownership or partial ownership by the physician or a family member, an investment interest, or a compensation arrangement.




Reporting Medicare Fraud - Contacts
Here is the contact information for reporting Medicare or Medicaid fraud.

If you are a Medicare Beneficiary (Insured by Medicare):

CMS Hotline: 1-800-MEDICARE (1-800-633-4227)

For Medicare Managed Care or Prescription Drugs: 1-877-7SafeRx (1-877-772-3379)

If you are a Medicare Provider:

    Office of Inspector General Hotline

    Phone: 1-800-HHS-TIPS (1-800-447-8477)

    Fax: 1-800-223-8164

    E-mail: HHSTips@oig.hhs.gov

    http://oig.hhs.gov/index.asp


Mailing Address:

    US Department of Health and Human Services

    Office of Inspector General

    Attn: OIG Hotline Operations

    P.O. Box 23489

    Washington, DC 20026


Or you can report through your Medicare Administrative Contractor (MAC) - your local contractors who administer Medicare.


If you are a Medicaid Provider or Insured:

OIG Hotline

    Phone: 1-800-HHS-TIPS (1-800-447-8477)

    Fax: 1-800-223-8164

    E-mail: HHSTips@oig.hhs.gov

    http://oig.hhs.gov/index.asp


Mail:

    US Department of Health and Human Services

    Office of Inspector General

    Attn: OIG Hotline Operations

    P.O. Box 23489

    Washington, DC 20026


You may also report to your Medicaid State Agency Fraud Unit which you can search for here.

What Info to Provide When Reporting
When reporting Medicare fraud, the U. S. Government recommends having the following information before you report:

  • Provider name
  • Provider ID numbers you may have
  • Your name and Medicare ID number
  • Specific service or procedure in question
  • Date of service or when item was delivered
  • Amount paid by Medicare
  • Date of MSN (Medicare Summary Notice)
  • Reason(s) why you are reporting the provider

What Happens When Reporting Medicare Fraud
Medicare fraud can be investigated by a variety of government agencies, the most likely to be the US Attorney Office, the Department of Justice (DOJ), and the Office of Inspector General (OIG) - which is part of the Department of Health and Human Services (HHS). The DOJ agency would be the Federal Bureau of Investigation (FBI). Investigations conducted by the DOJ or US Attorney’s Office are usually in cooperation with the OIG since healthcare fraud abuse and prevention is the responsibility of the HHS/OIG and because of their expertise in healthcare.

The HHS OIG has the ability and expertise to conduct audits and investigations into healthcare fraud and can impose penalties of their own as well as prevent healthcare providers from participating in federal programs such as Medicare or Medicaid.

The Centers for Medicaid and Medicare Services (CMS) which administers Medicare also has a program called Programme Safeguard Contractors (PSC). This program contracts with several companies to monitor and review claims to insure compliance with CMS standards. If suspicious activity is detected, the PSC contractor can recommend payment suspensions and refer the case to the appropriate law enforcement agency.

In addition to federal agencies, many states have Medicare and Medicaid fraud and abuse monitoring programs.  All states administering Medicaid benefits will have Medicaid fraud programs responsible for investigating and prosecuting fraud and abuse.

Enforcement Agencies
There are several government agencies and partnerships set up to fight fraud with the Centers for Medicare and Medicaid Services (CMS) being the lead organization. Here’s the primary resources CMS has to report and combat Medicare fraud.

Office of Inspector General (OIG)
The OIG is tasked by the Department of Health and Human Services, of which CMS is a part of, to protect Medicare from fraud and abuse. They accomplish this by conducting audits, inspections, and investigations. When the OIG has determined violations have occurred, they have the authority to exclude the offenders from participating in Medicare or Medicaid programs and imposing monetary penalties - or fines - on the offending parties.

Health Care Fraud Prevention and Enforcement Action Team (HEAT)
HEAT is a joint team between the Department of Justice (DOJ) and Health & Human Services to strengthen federal programs and establish new processes and technology to combat Medicare fraud. An example of their efforts is the Stop Medicare Fraud website (http://www.stopmedicarefraud.gov) which provides guidance on identifying and reporting fraud.

General Services Administration (GSA)
The U. S. General Services Administration keeps a list of those who cannot participate in federal government programs. This means they cannot receive federal contracts, aid, or non-monetary benefits.

Rewards
Under certain conditions, those reporting Medicare fraud can be eligible for a max $1,000 reward. To qualify, the following conditions must be met:

The alleged medicare fraud is confirmed by the responsible federal agency or contractor and referred to the Office of Inspector General.

  • The person reporting didn’t participate in the alleged fraud.
  • The provider or organization you reported is not already under investigation.
  • The issue you report leads to at least $100 being recovered.
  • You don’t qualify for another award.
  • The award amount cannot exceed 10% of the recovered amount or $1,000 - whichever amount is smaller.

Summary
It's important to recognize and combat Medicare fraud and abuse. Not only is it unethical and costs taxpayers billions of dollars, but your practice or organization could be vulnerable. It's important to recognize abuse of the Medicare/Medicaid system. Reporting Medicare fraud promptly protects your organization from civil or criminal penalties - or both.




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