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

Pharmacy and Prescription Drug Fraud

Pharmacy and prescription drug fraud is a consistent trend
in Medicare. Due to the lucrative nature of prescription drug diversion and
pharmacy scams, criminals continue to exploit Medicare Part D. Although there
are many types of prescription drug schemes, pharmacy fraud primarily occurs
when Medicare is billed for a medication that was not received or a beneficiary
is intentionally given a different prescription drug than was prescribed.

Report potential pharmacy or prescription drug fraud, errors, or abuse if:

  • You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) charges for:
    • Prescription drugs (including refills) that were never picked up, delivered, or even prescribed
    • Prescription drugs (occasionally controlled substances such as opioids) that were prescribed by a health care provider you have never seen
    • Amounts beyond the quantity you were prescribed
    • A different prescription drug (often a more expensive drug) than the one you were originally prescribed or a drug that is not approved by the U.S. Food and Drug Administration (FDA)
  • A pharmacy intentionally provided you less medication than you were prescribed
  • A pharmacy issued you expired drugs
  • A pharmacy provided and billed for an expensive compounded medication, including topical pain creams, when a traditional or less expensive prescription was ordered by your provider
  • A company offers you “free” or “discount” prescription drugs without a treating physician’s order and then bills Medicare
  • A pharmacy offers you gift cards or other compensation, so you switch your prescriptions over to that pharmacy
  • A pharmacy automatically refills a prescription you no longer need. You do not pick up the prescription, but the pharmacy still bills Medicare
  • An individual offers to pay you for the use of your Medicare number to bill for prescription drugs or offers you cash or other compensation to pick up prescriptions on your behalf

To learn more about tips related to pharmacy and prescription drug 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.

Report Suspected Medicare Fraud

SMP Resources

Remote Patient Monitoring (RPM) Fraud

Remote patient monitoring (RPM) is the ability for health care providers to monitor certain parts of a person’s health from their home. Providers collect and analyze different physiologic data (like heart rate, blood glucose, breathing rate, etc.) and then use it to make and oversee a person’s treatment plan. RPM can be good for people with short- and long-term conditions because it can cut down on travel costs and reduce the risk of getting an infection or illness.

Report potential remote patient monitoring (RPM) fraud, errors, or abuse if:

  • You see charges on your Medicare statements for remote physiologic monitoring or remote therapeutic monitoring services:
    • You didn’t need
    • You didn’t get
    • You didn’t agree to
    • That were from a provider you do not know
  • You are offered a “free” device that tracks your daily steps, like a smartwatch, in exchange for your Medicare number or other personal information.
  • You are told RPM services are free to Medicare beneficiaries and then RPM services are billed to Medicare.
  • Your doctor’s office calls to ask how you are doing. Later, you notice they billed the phone call to Medicare as an RPM service.

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.

SMP Resources

Telehealth Fraud

Medicare covers telehealth services (also known as teledoc services or telemedicine). This could include medical appointments, therapy, consultations, and other medical or health services. These services are provided through an interactive, live, two-way communication system with audio and video. Criminals are using telehealth services to steal from beneficiaries and the Medicare program.

Report potential telehealth fraud, errors, or abuse if:

  • You receive a call and are asked if you have pain or if you have a family history of cancer. They could be trying to approve you for a back brace, knee brace, or genetic testing that you do not need or want.
  • You are transferred by phone to someone who can “get you approved.” They may be trying to get you to agree to something you do not need or may not qualify for.
  • You are asked or pressured to agree to a test or procedure that would require an in-person visit.

Caregivers and family members, be on the lookout for:

  • Your loved one receives a call from someone they don’t know who pressures them to reveal personal information
  • Your loved one has a telehealth visit with a doctor they don’t know
  • Charges on your loved one’s insurance statements for appointments that never happened or from providers they don’t know

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

Report Suspected Fraud

To report suspected fraud, click here.

SMP Resources

OIG Resources

Other Resources

 

 

Tip Sheets for Printing

This handout includes common Medicare fraud schemes in one document for ease of printing.

The schemes included are:

  • Ambulance
  • Cardiac Genetic Testing
  • COVID-19
  • Durable Medical Equipment (DME)
  • Genetic Testing
  • Home Health Care
  • Hospice
  • Medical Identity Theft
  • Medicare Card Scams
  • Misleading Marketing and Marketing Violations
  • Nursing Home Care
  • Outpatient Mental Health Care
  • Pharmacy and Prescription Drug
  • Remote Patient Monitoring (RPM)

Additional topics included are:

  • Medicare Fraud by the Numbers
  • Medicare Statements Tip Sheet

Report Suspected Fraud

To report suspected fraud, click here.

SMP Resources

Tip Sheets for Printing

Feds File Nationwide Lawsuit Against Walgreens

In a civil complaint, the Justice Department alleges that Walgreens knowingly filled millions of prescriptions for controlled substances that lacked a legitimate medical purpose, were not valid, and/or were not issued in the usual course of professional practice. Among the unlawful prescriptions were those for dangerous and excessive quantities of opioids, for early refills of opioids, and for the especially dangerous and abused combination of drugs known as the “trinity,” which is made up of an opioid, a benzodiazepine, and a muscle relaxant. The complaint alleges that Walgreens’ actions helped to fuel the prescription opioid crisis and that some patients died after overdosing on opioids shortly after filling unlawful prescriptions at Walgreens. Read a story from The Associated Press and a Department of Justice press release.

SMP Resource Center products often contain links to copyrighted material. The SMP Resource Center is providing these links as a convenience and for informational purposes in our efforts to report and educate on Medicare fraud; they do not constitute a guarantee, endorsement, or approval by SMP of any of the information available on the external site. SMP bears no responsibility for the accuracy, legality, or content of the external site or for that of subsequent links. If you have any questions or concerns about the links provided, please contact the SMP Center at nliebau@smpresource.org.