Medicare fraud and protecting your parent's coverage

This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.

Medicare fraud isn't something that just happens to other people. It happens to people you know. It happened to my aunt's friend, a perfectly normal seventy-two-year-old living a quiet life. A clinic she'd visited once billed Medicare for treatments she never received. When her daughter started asking questions, things unraveled quickly. The fraud wasn't discovered by Medicare's oversight. It was discovered because someone cared enough to look closely at the bills.

Fraud costs the entire Medicare system hundreds of millions of dollars annually. That stolen money gets spread across higher costs for everyone. Fraud also harms your parent directly. When someone commits fraud using your parent's Medicare number, it confuses your parent's medical record. It exhausts benefits that should be available for real treatment. It can delay legitimate care if Medicare investigators think your parent's account has been compromised.

The good news is that fraud isn't impossible to spot. You don't need to be an insurance expert. You just need to know what to look for and be willing to ask questions about bills that seem odd.

What Medicare Fraud Actually Looks Like

Medicare fraud comes in several forms. The most common is billing for services that were never provided. A provider says they delivered treatment that didn't happen. They bill Medicare as if it did. Medicare pays. The provider keeps the money. Your parent might not even know treatment was supposedly delivered because it never was.

Another form of fraud is providing unnecessary services to inflate billing. A patient comes in with a minor complaint. Instead of treating the minor issue, the provider orders extensive testing, imaging, and treatments that aren't medically needed. They bill Medicare for all of it. The provider makes more money. The patient is confused about why they got tested for things not related to their complaint.

A third type of fraud is using your parent's Medicare number fraudulently. Someone commits identity theft, gets your parent's Medicare number, and uses it to buy medications or equipment in their own name but bill Medicare. Your parent's account gets charged for things your parent never received.

False billing of durable medical equipment is common. A supplier ships oxygen concentrators to addresses that don't exist. They bill Medicare as if they delivered them. Your parent's Medicare account gets charged with the copay even though your parent never received anything.

Some providers bill at higher rates than they charged the patient. A patient pays fifty dollars in cash at the clinic. The provider bills Medicare for two hundred dollars as the office visit fee. The difference is fraud.

Upcoding happens when a provider bills for a more complex or expensive service than was actually provided. A patient had a simple office visit. The provider codes it as if it was a complex evaluation and management visit that costs more. Medicare pays the higher amount.

These schemes exist because there's money involved. Medicare pays billions of dollars to healthcare providers. Some providers look at that system and see an opportunity to take more than they've earned.

How Your Parent Gets Harmed Directly

When fraud happens using your parent's Medicare coverage, your parent suffers real consequences. The most obvious consequence is confusion about their own care. Your parent sees a charge on their explanation of benefits for a treatment they don't remember having. Your parent questions whether they're losing their memory. That question is stressful and can trigger deeper worry.

A second consequence is that fraud exhausts Medicare benefits. Medicare has annual limits on certain services. If fraud charges your parent's account for expensive services that never happened, those charges count toward your parent's annual limits. Real treatments your parent needs later in the year might not be covered because the limit is already exhausted by fraudulent charges.

Fraud can also harm your parent's actual medical record. If fraudulent claims are added to your parent's record, the medical history gets confused. A provider looking at your parent's records might see treatments that never happened and become confused about what your parent actually needs. A doctor might avoid prescribing something thinking your parent already had a conflicting treatment, when in reality the conflicting treatment only exists in the fraudulent claims.

If your parent's Medicare number is used fraudulently, the confusion extends beyond just medical records. Your parent's benefits might be entangled. Your parent might be locked out of coverage temporarily while fraud is investigated.

The stress of dealing with fraud also harms your parent. If your parent discovers fraudulent claims, your parent has to contact Medicare, document the fraud, request corrections, and follow up to ensure the fraud is removed from their account. This is time-consuming and emotionally draining for someone already managing chronic conditions and complex healthcare.

Spotting Fraud at Doctor Visits

Part of protecting your parent is paying attention to what happens when your parent visits the doctor. Small red flags at the doctor's visit can warn you that something's off before fraud actually happens.

One red flag is charging for preventive services. Preventive services like annual wellness visits, screening mammograms, colorectal cancer screenings, and certain vaccinations are covered by Medicare with no patient cost. If your parent goes in for a preventive visit and the clinic tries to charge a copay, that's not right. Your parent shouldn't pay anything. If the clinic insists, something is probably wrong.

Another red flag is testing ordered without explanation. Your parent goes in for a sore knee. The doctor orders an extensive blood panel, imaging of your parent's chest, and neurological testing. Why would knee pain require all of that testing? If the doctor doesn't explain why these tests are necessary, that's a warning sign.

A third red flag is procedures recommended that seem unrelated to your parent's actual complaint. Your parent mentions occasional joint pain. The doctor recommends spinal surgery. That recommendation might be legitimate, but it should make sense based on your parent's complaints and examination. If it feels like the recommendation is coming out of nowhere, ask for a clearer explanation.

A fourth red flag is pressure to undergo treatment or testing immediately. Good healthcare providers explain options and give patients time to think. Providers who pressure your parent into immediate decision-making might be motivated by billing concerns rather than your parent's actual needs.

A fifth red flag is an unusually high number of treatments or tests recommended. Healthcare is individualized, and some complex patients do need extensive evaluation. But if your parent is relatively healthy and suddenly lots of treatments are being recommended, question whether they're all necessary.

None of these red flags automatically mean fraud is happening. Sometimes extensive testing is genuinely needed. Sometimes multiple treatments are appropriate. But the red flags should prompt you to ask more questions and better understand why your parent's care is taking the direction it's taking.

Reviewing Bills and Explanations of Benefits

Medicare sends your parent something called an Explanation of Benefits for every claim processed. This document shows what services were billed, what Medicare paid, what your parent owes, and the total claim amount. These documents are where fraud often becomes visible.

The first step in reviewing bills is confirming that the services listed actually happened. If your parent's EOB shows an office visit on a date when your parent was out of town or didn't go to the doctor, that service shouldn't be there. If the EOB shows testing your parent doesn't remember having, ask about it.

Look at the service dates. They should match the dates when your parent actually received care. If service dates don't match appointment dates, something's wrong.

Look at the service descriptions. If the description doesn't match what your parent thinks they received, ask for clarification. The medical terminology on bills can be confusing, so don't hesitate to call the doctor's office and ask what a particular code or description means.

Look for duplicate charges. If the same service appears twice in the same week from the same provider, that might be a billing error or fraud. Sometimes duplicate charges happen by mistake. Sometimes they're intentional.

Look at the provider information. Does your parent recognize the provider listed? If your parent receives a bill for care from a provider they've never been to, that's a red flag.

Look at the charge amounts. If one office visit is billed at one hundred dollars and another similar visit is billed at five hundred dollars, that's inconsistent. Healthcare costs vary, but large discrepancies without explanation are worth investigating.

One helpful strategy is keeping a simple log of your parent's medical visits: the date, the provider, and what was done. When EOBs arrive, checking them against this log makes it easy to spot services that shouldn't be there.

Protecting Your Parent's Medicare Information

Medicare fraud often starts with identity theft. Someone gets your parent's Medicare number and uses it fraudulently. Preventing identity theft prevents this type of fraud.

Your parent should not give out their Medicare number casually. The number should only be given to legitimate healthcare providers, Medicare, and insurance companies that legitimately need it. Not to people who call unsolicited. Not to people on the phone claiming to be from Medicare. Not to people offering free healthcare or discount medications.

Legitimate Medicare never calls to ask for personal information. If someone calls claiming to be from Medicare and asks for your parent's number or personal information, it's a scam. Your parent should hang up and call Medicare directly at 1-800-MEDICARE to report the call.

A common fraud scheme involves people calling seniors offering free healthcare, free equipment, or free services. They ask for the Medicare number so they can "process the free benefit." Once they have the number, they submit fraudulent claims. Your parent should be wary of any unsolicited call offering free services.

Your parent should keep their Medicare card in a safe place. A wallet might be convenient, but if the wallet is lost or stolen, the Medicare number can be used fraudulently. Leaving the card at home except when needed for healthcare is safer.

Sensitive information should not be shared in public. Your parent shouldn't read their Medicare number out loud in a waiting room where others can hear it. Your parent shouldn't leave opened bills with Medicare numbers visible on a table.

If your parent suspects their Medicare number has been compromised, they should contact Medicare immediately. Medicare can monitor the account for fraudulent activity and take steps to protect it.

Reporting Suspected Fraud

If you spot something that looks like fraud, you should report it. The reporting process is straightforward and confidential.

Call Medicare at 1-800-MEDICARE. Tell them you suspect fraud. Provide specific information: the date of the suspicious claim, the provider involved, the service that seems fraudulent, and why you think it's fraudulent.

Alternatively, you can report fraud online through the Medicare website or through the HHS Office of Inspector General website.

Fraud can also be reported to your state's insurance commissioner or your state's Medicaid fraud office if your parent has Medicaid.

When reporting, be specific. Saying "I think there's fraud" is less helpful than saying "My parent's EOB shows an office visit on a date my parent was out of town and we have plane tickets proving they weren't at the clinic."

Reporting suspected fraud helps protect your parent's coverage and helps protect the entire Medicare system. Fraud that goes unreported costs more money and encourages more fraudsters. Fraud that's reported gets investigated and stopped.

You won't get a financial reward for reporting fraud, but your parent gets protection. Their account gets reviewed, fraudulent charges get removed, and the provider gets scrutinized.

Creating a Paper Trail for Your Parent

One of the best protections against fraud is a good paper trail. When your parent keeps records of what healthcare services they received, when they received them, and who provided them, any fraudulent claims become obvious.

Your parent should keep a simple calendar or notebook. After each medical visit, your parent writes down the date, the provider's name, the location, and what was done that day. This takes two minutes and creates a record.

Your parent should save all medical bills, EOBs, and receipts. If a question comes up later about whether a service actually happened, these documents prove it did or prove it didn't.

Your parent should keep insurance cards, including the Medicare card, in a safe place where they can be found if needed but aren't sitting on a counter or in a wallet where they could be lost or stolen.

Your parent should know the names and contact information for their main healthcare providers. If a bill arrives from a provider your parent doesn't recognize, your parent can call one of their known providers and ask if they referred to this other provider.

A simple paper trail prevents confusion and makes fraud obvious if it occurs. This protection is free and takes minimal time.

When Fraud Gets Complicated

If fraud is discovered and reported, the investigation process takes time. Medicare investigates. The provider might be contacted. There might be back-and-forth about whether a service was actually provided.

During this investigation period, your parent might feel frustrated. Fraudulent charges might still appear on bills while the investigation is ongoing. Your parent might feel like the problem isn't being addressed quickly.

What matters is that you reported it and Medicare is investigating. The process takes weeks or months sometimes, but the end result is that fraudulent charges get removed and your parent's account is corrected.

If the investigation is taking a long time, your parent or you can call Medicare and ask for a status update. Providing more detailed information might speed the investigation.

In the meantime, your parent still receives healthcare. Fraudulent charges don't prevent legitimate care. Your parent's coverage continues. The fraud investigation happens in the background.

If fraud becomes a pattern or if your parent's entire account feels compromised, Medicare might issue your parent a new Medicare number. This is unusual but does happen in severe fraud cases.

The Larger Picture

Medicare fraud exists because the system is large and complex and there's money involved. Not every provider commits fraud. Most providers are ethical and bill appropriately. But the small percentage of providers who do commit fraud can cause significant problems.

Your parent can't prevent all fraud. But your parent can be informed, pay attention to medical bills, and report anything suspicious. Your parent can protect their Medicare number. Your parent can ask questions about unexpected care.

You help protect your parent by paying attention to bills when your parent shares them with you. You help by asking questions about recommendations that seem unnecessary. You help by listening if your parent mentions something odd about a visit or bill.

Medicare fraud happens in silence. It happens because nobody notices. When someone pays attention, fraud gets caught. Being that someone for your parent might be one of the most valuable protections you can offer.

How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you suspect Medicare fraud, contact 1-800-MEDICARE or visit the Medicare website to report it. You can also contact the HHS Office of Inspector General at 1-800-HHS-TIPS.