How to Prevent Medicare Fraud - Springhill Group

Over the years, Medicare has been proactive in its efforts to bring awareness to Medicare fraud, a national problem that costs the program millions of dollars each year. The Medicare program relies heavily on a number of sources to assist them in the detection and prevention of Medicare fraud including professionals of the healthcare industry.

Overview of Medicare Fraud

Medicare fraud generally refers to willfully and knowingly billing medical claims in an attempt to defraud the Medicare program for money. Anyone found guilty of Medicare fraud is subject to exclusion from participation in the Medicare program in addition to fines and possibly imprisonment. Most Medicare fraud occurs in these areas:

• Billing for DME

• Billing for physicians services

• Billing for institutional services such as nursing homes, hospitals, hospice, etc.

Be Aware of Common Schemes


There are four popular Medicare fraud schemes.

1. Medical Equipment Never Provided The most common area of Medicare fraud is billing for Durable Medical Equipment (DME). DME refers to any medical equipment necessary for a patient’s medical or physical condition. It includes wheelchairs, hospital beds, and other equipment of that nature. The provider will bill Medicare for equipment that the patient never received. Mobility scooters have been particularly popular for Medicare fraud schemes.

2. Services Never Performed In this instance, the provider bills for tests, treatment or procedures never performed. This can be added to the list of tests a patient has actually received and never be noticed. A provider may also falsify diagnosis codes in order to add on unnecessary tests or services.


3. Upcoding Charges Misrepresenting a level of service or procedure performed in order to charge more or receive a higher reimbursement rate is considered upcoding. Upcoding also occurs when a service performed is not covered by Medicare but the provider bills a covered service in its place.

4. Unbundling Charges Some services are considered all inclusive. Unbundling is billing for procedures separately that are normally billed as a single charge. For example, a provider bills for two unilateral screening mammograms, instead of billing for 1 bilateral screening mammogram.


Medicare Fraud Indicators

There are certain indicators that are common in the detection of Medicare fraud. Is your practice:

• Routinely waiving copayments and deductibles for Medicare patients without checking for their ability to pay?


• Charging higher rates to Medicare patients compared to other persons for similar services?

• Missing treatment documentation such as physician or nurses notes?


What to Do If I Suspect Fraud?

It is your responsibility as a representative of the healthcare industry to be aware of and report any fraudulent activity suspected. If you would like to report suspected Medicare fraud, contact the Department of Health and Human Services or the Office of Inspector General for further assistance.