Fraud Examples - California Health Advocates

Medicare fraud happens in many ways. It most commonly occurs in:

Billing for institutional facilities such as nursing homes, residential facilities, hospitals, home health, and hospice.
Billing for physician visits and services not rendered or not medically necessary.
Billing for durable medical equipment such as wheelchairs, body jackets, incontinence supplies, or diabetic supplies without a doctor’s prescription.
Billing for genetic testing kits not ordered by one’s physician.
Improper marketing of health insurance plans through phone calls, door-to-door sales, and misleading flyers.

Providers commit fraud when they…

Submit bills for services not provided or unnecessary services. One common fraud is a “gang visit,” when a provider visits a nursing home and invoices for services as if they had treated most residents. Alternatively, a provider may perform a service regardless of whether each resident needs it.
Upcode a service. This is when a provider charges Medicare for a more expensive service than was provided. For example, a provider may bill for surgery when only a bandage was placed over a cut.
Unbundle services. This occurs when a provider submits separate bills for lab services that combine three or four tests intended to be billed as one service. As a result, Medicare pays the provider more for each service than if the services were billed as a group.
Bill non-covered services as covered services. This occurs when a provider bills a service such as routine toenail clipping (non-covered service) as foot surgery (covered service).

Bill for different equipment than what the beneficiary received.
Bill for home medical equipment after it is returned.
Solicit, offer or receive a bribe or kickback. Recruiters may stop Medicare beneficiaries on the street or make an at-home visit, offering money and promotional gifts as incentives to take “free” medical exams, after which they give the beneficiary medical equipment they do not need.

Bribe, mislead, or coerce a beneficiary to enroll into or switch plans to make a commission even though the plan may not be the best choice for the beneficiary.
Enroll a beneficiary into a Medicare Advantage plan without the beneficiary’s consent.
Make unsolicited phone calls, emails, or home visits.

Enroll beneficiaries into hospice when they are not terminally ill.
Offer a Medicare drug plan that hasn’t been approved by Medicare.
Use false information to mislead beneficiaries into joining Medicare plans.
Do not follow Medicare marketing rules. For example, a company may not send out an advertisement mailing with the Medicare or Centers for Medicare and Medicaid Services (CMS) logo on it. They also cannot offer financial incentives to their insurance agents and brokers that would encourage them to maximize commissions by inappropriately moving, or churning, beneficiaries from one plan to another each year.
Offer bribes or kickbacks to doctors as incentives to prescribe certain expensive drugs.
Mark beneficiaries as sicker than they are for a higher Medicare payment.

Provide their Medicare number in exchange for money or a free gift. In some cases, beneficiaries may unknowingly commit fraud in this way.
Let someone use their Medicare card to get medical care, supplies or equipment.
Sell their Medicare number to someone who bills Medicare for services not received.