Ambulance Fraud

Medicare will cover an ambulance ride to the hospital to diagnose or treat symptoms of an illness in an emergency. However, Medicare will not cover the cost of an ambulance if the reason for using the ambulance is not medically necessary, meaning the ride is not to treat or identify an illness. It will also not be covered by Medicare if other forms of transportation can move you safely or if it is for a ride to your doctor’s office, a community mental health center, or other health care appointments. Ambulance fraud, errors, or abuse can occur when ambulances are used for medically unneeded reasons.

Report potential telehealth fraud, errors, or abuse if:

  • You were billed for more mileage than the actual distance traveled in the ambulance trip
  • You think the cost of an ambulance ride is an unreasonable amount

Caregivers and family members, be on the lookout for:

  • Calling for an ambulance for a loved one when it is not an emergency and they should be using other ways to travel
  • Charges on your loved ones’ Medicare statements for ambulance trips that seem unreasonably high in cost, or the distance seems to be too far

Watch this video to learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB).

Report Suspected Fraud

To report suspected fraud, click here.

COVID-19 Fraud

As the COVID-19 Public Health Emergency comes to an end, fraudsters are still attempting to bill Medicare for sham tests or treatments and are targeting individuals to illegally obtain money or Medicare numbers.

Report potential COVID-19 fraud, errors, or abuse if:

  • You provided your Medicare number to someone other than your doctor, health care provider, or other trusted representative who contacted you through an unsolicited call, text, or email
  • Someone comes to your door offering “free” coronavirus testing, treatment, or supplies
  • You were told there was a COVID-19 Medicare card coming and you needed to confirm your Medicare number
  • You took a survey and gave out your Medicare number in exchange for money or gifts
  • You purchased a COVID-19 vaccination card

To learn more about tips related to COVID-19 fraud, click here.

To learn how to read your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB), click here.

Report Suspected Fraud

To report suspected fraud, click here.

COVID-19 Fraud Resources

Ending of the Public Health Emergency:

SMP Consumer Fraud Alert Resources:

Coverage:

Testing Scams:

  • Flyers
  • Infographics – Optional: When posting about COVID-19 use #SMPwatchCOVID19

Vaccine/Treatment Scams:

  • Infographics – Optional: When posting about COVID-19 use #SMPwatchCOVID19
    • COVID-19 Vaccine Scams Infographic – Light background (English) (Spanish)
    • COVID-19 Vaccine Scams Infographic – Dark background (English) (Spanish)
    • COVID-19 Vaccine “No Payment” Infographic (English)
    • COVID-19 Antiviral Drug SMP Scam Watch Infographic (English)

Other COVID-19 Resources

 Centers for Disease Control and Prevention (CDC):

 CMS COVID-19 Resources for Vulnerable Populations:

  • COVID-19 Vaccination Information and Vaccine Access Fact Sheets (English) (Spanish)

Federal Trade Commission (FTC)

OIG Fraud Alert Resources

Social Security Fraud Alert Resources

Durable Medical Equipment Fraud

Durable medical equipment (DME) and orthotics companies offer a valuable service by providing wheelchairs, surgical supplies, catheters, and respiratory nebulizers as well as nutrition and tube feeding supplies and other health care equipment. DME and/or orthotics are considered medical equipment prescribed by your doctor that can withstand repeated use, serve a medical purpose, and can be used in the home. However, many fraudulent companies across the country are charging Medicare beneficiaries for this equipment without showing the medical necessity and sometimes without even sending the equipment to the beneficiaries.

Report potential DME fraud, errors, or abuse if:

  • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for equipment you do not need or did not receive
  • You accepted an offer for “free” equipment or supplies but see Medicare was billed instead
  • You receive medical equipment or supplies that you never requested or that you do not need
  • You see on your loved one’s MSN or EOB suppliers billing Medicare for items after they passed away
  • A supplier requests your Medicare number at a presentation, during a sales pitch, or in an unsolicited phone call
  • A beneficiary knowingly accepts money, gifts, or unnecessary equipment and supplies from a supplier in exchange for their Medicare number
  • A supplier delivers an off-the-shelf product to you but billed Medicare for a more costly product
To learn more about tips related to DME fraud, click here.

To learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB), click here.

Report Suspected Fraud

To report suspected fraud, click here.

SMP Resources

OIG Fraud Alert Resources

Genetic Testing Fraud

Scammers are offering Medicare beneficiaries cheek swabs for genetic testing to obtain their Medicare information for fraudulent billing purposes or possibly medical identity theft. Genetic testing fraud occurs when Medicare is billed for a test or screening that was not medically necessary and/or was not ordered by a beneficiary’s treating physician.

Here are several ways genetic testing is advertised:

  • Cancer screening/test
  • DNA screening/test
  • Hereditary cancer screening/test
  • Dementia screening/test
  • Pharmacogenetics (medication metabolization)
  • Parkinson’s screening/test

Report potential genetic testing fraud, errors, or abuse if:

  • A company offers you “free” or “at no cost to you” testing without a treating physician’s order and then bills Medicare
  • A company uses “telemedicine” to offer testing to you over the phone and arranges for an unrelated physician or “teledoc” to order the test
  • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB):
    • Charges (usually thousands of dollars) for a broad range of genetic tests that you did not request or possibly even receive
    • Charges for pharmacogenomic tests (to determine how you metabolize drugs) for drugs that do not apply to you
  • A company requests your Medicare number (or possibly driver’s license) at health fairs, senior centers, assisted living facilities, malls, farmers markets, parking lots outside retail stores, home shows, or church-sponsored wellness events

Learn more about genetic testing fraud from this printable tip sheet.
Be on the lookout for genetic testing scams by reviewing your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB).

Cardiovascular Genetic Testing Fraud

Cardiovascular genetic testing fraud occurs when Medicare is billed for a cardio type of test or screening that was not medically necessary and/or was not ordered by a beneficiary’s treating physician.

Here are several ways cardiovascular genetic testing is advertised:

  • Cardio/cardiac genetic screening/test
  • Cardiovascular genetic screening/test
  • Comprehensive cardiovascular panel
  • Comprehensive cardiomyopathy NSG
  • Cardiovascular disease genetic kit
  • Hereditary cardiovascular profile

Report potential cardiovascular genetic testing fraud, errors, or abuse if:

  • A company offers you “free” or “at no cost to you” testing without a treating physician’s order and then bills Medicare
  • A company uses “telemedicine” to offer testing to you over the phone and arranges for an unrelated physician or “teledoc” to order the tests
  • Medicare is billed (usually thousands of dollars) for a broad range of cardiac genetic tests that you did not request or possibly even receive
  • A company calls you stating your doctor or cardiologist requested that you have the testing done, and they will send you a testing kit

Learn more about cardiovascular genetic testing fraud from this printable tip sheet.

Report Suspected Fraud

 

SMP Consumer Fraud Alert Resources

SMP Resources

OIG Fraud Alert Resources

Home Health Care Fraud

Medicare Parts A and B cover intermittent or short-term home health services. These services must be provided by a Medicare-approved home health agency that works with your doctor to manage your care. To be eligible for Medicare coverage:

  • Your doctor must determine it’s medically necessary for you to receive skilled care services at home. Skilled care services at home could include part-time or “intermittent” nurse and nurse aide visits (personal, hands-on care) and rehabilitation services, which include speech-language pathology, physical and occupational therapy, and medical social services.
  • Your condition must be expected to improve in a reasonable amount of time or your condition requires skilled therapy to maintain your current condition or prevent or slow, further deterioration.
  • You must be considered “homebound.” This means you are unable to leave your home without assistance, it requires considerable and major effort, or it is considered dangerous due to your current health condition. You may leave home for medical care and some short or infrequent outings (for example, worship services) as long as you meet these conditions.
    • Note: Even if you do not qualify for home health services, you may still be eligible to receive outpatient therapy services in a doctor’s office, outpatient hospital setting, rehabilitation agency, Comprehensive Outpatient Rehabilitation Facility (CORF), public health agency, or your home. Outpatient therapy services are covered by Medicare Part B and subject to the 20% copayment.

 

Report potential home health care fraud, errors, or abuse if:

  • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for:
    • Home health services when you did not meet Medicare’s “homebound” criteria
    • Services that were not deemed medically necessary by your doctor
    • Home health services like skilled nursing care and/or therapy services that were not provided
  • You were:
    • Enrolled in home health services by a doctor you do not know
    • Offered things such as “free” groceries or a “free” ride from a home health agency in exchange for your Medicare number or to switch to a different home health agency
    • Charged a copayment for home health services
    • Asked to sign forms verifying that home health services were provided even though you did not receive any services
  • Someone came to your home and provided housekeeping or medication services, but you see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) that Medicare was billed for a covered service like skilled nursing or other therapy instead.
  • You accept cash or gifts in exchange for going along with a home health scam.

To learn more about tips related to home health care fraud, click here.
To learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB), click here.

Report Suspected Fraud

To report suspected fraud, click here.

SMP Resources

 

Hospice Fraud

Hospice is an important benefit for the Medicare population. Hospice fraud threatens this benefit for all beneficiaries. Scammers are getting beneficiaries to agree to hospice care even though they do not qualify for the benefit. Hospice fraud occurs when Medicare Part A is falsely billed for any level of hospice care or service.

Report potential hospice fraud, errors, or abuse if:

  • You or someone you know was falsely certified as being terminally ill – that is, with a life expectancy of six months or less if the disease runs its normal course
  • You were enrolled in hospice without you or your family’s permission
  • You find out someone is falsely certifying or failing to obtain physician certification on plans of care
  • You were offered gifts or incentives to receive hospice services or to refer your friends and family for hospice services.
  • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) that you were billed for a higher level of care than was needed or provided or for services not received
  • You hear about assisted living facility and/or nursing home residents being targeted for hospice services even though their life expectancy exceeds six months
  • You come across marketers using high-pressure and unsolicited marketing tactics of hospice services
  • You receive inadequate or incomplete services, including, for example, no skilled visits in the last week of life
  • You are provided/offered gifts or incentives, including noncovered benefits such as homemaker, housekeeping, or delivery services, to encourage you to elect hospice despite not being terminally ill
  • You hear about hospice beneficiaries being abused or neglected by a hospice worker
  • You hear about a hospice worker stealing a beneficiary’s medication
  • You are kept on hospice care for long periods of time without medical justification
  • You were provided less care on the weekends and the beneficiary’s care plan was disregarded

To learn more about tips related to hospice fraud, click here.

To learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB), click here.

Report Suspected Fraud

To report suspected fraud, click here.

SMP Consumer Fraud Alert Resources

Other Resources

Medical Identity Theft

  • Medical identity (ID) theft occurs when someone steals personal information – such as a beneficiary’s name and Medicare number – and uses the information to get medical treatment, medical equipment, prescription drugs, surgery, or other services and then bills insurance (such as Medicare) for it. When Medicare beneficiaries fall prey to consumer scams aimed at obtaining Medicare and/or health ID numbers, their Medicare and/or health ID number is considered to be “compromised” as a result of medical identity theft.

    Medical identity theft can also affect beneficiaries’ medical and health insurance records. Every time a scammer uses a beneficiary’s identity to receive or bill for care/supplies, a record is created with incorrect medical information about them.

    Report potential medical identity theft from fraud, errors, or abuse if:

    • You gave out your Medicare and/or health ID number:
      • Over the phone or internet to someone offering durable medical equipment, genetic testing, COVID-19 testing/supplies, back braces, etc.
      • At a fair or other gathering as a check-in or to receive free services
      • In response to a television or radio commercial, Facebook ad, postcard, or print ad requesting a Medicare number
    • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for medical services or equipment that you did not receive
    • You are contacted by a debt collection company for a provider bill you do not owe
    • You received boxes of braces, testing kits, or other medical supplies in the mail that you did not request
    • A Medicare and/or a Medicare Advantage plan denies or limits your coverage or benefits because of a medical condition you do not have
    To learn more about tips related to medical identity theft, click here.

    To learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB), click here.

    Report Suspected Fraud

    To report suspected fraud, click here.

    SMP Resources

    Other Resources

Medicare Marketing Violations and Misleading Marketing

Health insurance companies try to reach people in various ways, like television commercials, radio ads, events, mailings, phone calls, and texts. The Centers for Medicare & Medicaid Services (CMS) has rules for marketing Medicare Advantage plans and Part D plans, though. These rules protect Medicare beneficiaries from aggressive or misleading marketing.

Report potential Medicare marketing violations and/or misleading marketing if someone:

  • Says they are from or sent by Medicare, Social Security, or Medicaid
  • Offers you gifts if you agree to sign up for their plan
  • Sends you text message or calls you without your permission
  • Pressures you to enroll in their plan
  • Approaches you in public and tries to sell you a plan

Caregivers and family members, be on the lookout for:

  • People who show up at your loved one’s home and try to sell them a Medicare plan
  • People who offer your loved one gifts or money to sign up for a plan
  • Medicare plan flyers left at your loved one’s door or on their car

Watch this video to learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB).

Report Suspected Fraud

To report suspected fraud, click here.

Report Suspected Medicare Fraud

SMP Resources

  • Misleading Marketing & Marketing Violations Tip Sheet
    (English) (Spanish)

SMP Consumer Fraud Alert Resources

Medicaid Renewal Partner Resources

Nursing Home Care Fraud

Medicare doesn’t generally pay for long-term nursing home care. However, Medicare Part A covers medically necessary, short-term care in a skilled nursing facility (SNF) within a nursing home under certain conditions. SNFs play a crucial role in providing therapy and rehabilitation after you or a loved one has suffered a debilitating illness or stroke. After a qualifying stay in the hospital, Medicare beneficiaries frequently need some time in a SNF to regain their strength.

However, some unscrupulous facilities (even some associated with national chains) have taken to fraudulent billing.

Report potential nursing home care fraud, errors, or abuse if:

  • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for:
    • Services that were not deemed medically necessary by your doctor
    • Therapy services or visits that were billed to Medicare but were not provided
    • More expensive services than what you were provided
    • More therapy than what you were provided
    • Skilled nursing services for dates after you were released from the SNF
  • You are forced to remain in a SNF until your Part A benefits have expired even though your condition has improved and you wish to change to home health care services

To learn more about tips related to nursing home care fraud, click here.
To learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB), click here.

Report Suspected Fraud

To report suspected fraud, click here.

SMP Resources

Other Resources

Outpatient Mental Health Care Fraud

Outpatient mental health care can be an important benefit to a beneficiary. Medicare covers outpatient mental health services in settings such as a doctor’s office or other health care provider’s office, a hospital outpatient department, or a community mental health center. Medicare only covers visits when they are provided by a health care provider who accepts assignment, which means that they agree to accept the Medicare-approved amount as full payment for any covered service provided.

Report potential outpatient mental health care fraud, errors, or abuse if:

  • You are picked up by a bus or van along with other beneficiaries and taken out for a meal and Medicare was billed for a psychiatric evaluation
  • You spend all day watching TV or playing games at a facility and Medicare was billed for group psychotherapy
  • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for:
    • Mental health services or time spent in excess of what was received
    • Mental health services that were not received
    • Mental health services that were not provided by a psychiatrist or other doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, or physician assistant

To learn how to read your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB), click here.

Report Suspected Fraud

To report suspected fraud, click here.

SMP Resources