Medicare fraud and protecting your parent's coverage

Reviewed by the How To Help Your Elders Team | Updated March 2026

Medicare fraud costs the federal program tens of billions of dollars annually and directly harms individual beneficiaries through exhausted benefits, confused medical records, and unexpected charges. Spotting fraud starts with reviewing Explanations of Benefits, and reporting it is straightforward through 1-800-MEDICARE or the HHS Office of Inspector General.

Fraud Isn't Rare, and Your Parent Is a Potential Target

Medicare fraud isn't something that just happens to other people. It happens to people you know. A clinic bills Medicare for treatments that never happened. A supplier ships equipment to addresses that don't exist. Someone gets hold of a Medicare number and uses it to buy medications in another person's name. When a daughter or son starts asking questions about a confusing bill, things unravel quickly. The fraud often isn't discovered by Medicare's oversight systems. It's discovered because someone cared enough to look closely at the bills.

According to CMS and the HHS Office of Inspector General, Medicare fraud and improper payments account for an estimated $60 billion or more per year. The Government Accountability Office has kept Medicare on its "High Risk" list since 1990 specifically because of its vulnerability to fraud and improper payments. 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 the medical record. It exhausts benefits that should be available for real treatment. It can delay legitimate care if Medicare investigators think the 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 off.

What Medicare Fraud Actually Looks Like

The most common form is billing for services that were never provided. A provider says they delivered treatment that didn't happen, bills Medicare as if it did, and keeps the money. Your parent might not even know treatment was supposedly delivered because it never was.

Another form 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.

A third type involves someone stealing your parent's Medicare number and using it fraudulently to buy medications or equipment. Your parent's account gets charged for things they never received.

False billing of durable medical equipment is common. A supplier ships equipment to addresses that don't exist and bills Medicare as if delivery happened. Or equipment is billed at full price when it was never ordered by a doctor.

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

These schemes exist because there's money involved. Medicare pays hundreds of 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 coverage, the consequences are real and personal. The most obvious is confusion about their own care. Your parent sees a charge on their Explanation of Benefits for a treatment they don't remember having. They question whether they're losing their memory. That question is stressful and can trigger deeper worry about cognitive decline.

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

Fraud can harm the actual medical record. If fraudulent claims are added to your parent's record, a doctor looking at that record 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 the conflicting treatment only exists in the fraudulent claims.

The stress of dealing with fraud is its own harm. If your parent discovers fraudulent claims, they have to contact Medicare, document the fraud, request corrections, and follow up. 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 during medical visits. Small red flags can warn you that something's off before fraud actually occurs.

Charging for preventive services is a red flag. According to Medicare.gov, preventive services like annual wellness visits, screening mammograms, colorectal cancer screenings, and certain vaccinations are covered with no patient cost. If a clinic tries to charge a copay for a preventive visit, something is wrong.

Testing ordered without explanation is another warning sign. Your parent goes in for a sore knee, and the doctor orders an extensive blood panel, chest imaging, and neurological testing. If the doctor doesn't explain why these tests are necessary for the actual complaint, that's worth questioning.

Procedures recommended that seem unrelated to the actual complaint should prompt a closer look. Your parent mentions occasional joint pain and the doctor recommends spinal surgery. The recommendation might be legitimate, but it should make sense based on the complaints and examination.

Pressure to undergo treatment or testing immediately is a concern. Good healthcare providers explain options and give patients time to think. Providers who pressure your parent into immediate decisions might be motivated by billing concerns rather than medical necessity.

An unusually high number of treatments or tests recommended can also be a signal. Some complex patients genuinely need extensive evaluation. But if your parent is relatively healthy and suddenly lots of treatments are being recommended, ask whether they're all necessary.

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

Reviewing Bills and Explanations of Benefits

Medicare sends 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.

Start by confirming that the services listed actually happened. If your parent's EOB shows an office visit on a date when they were out of town or didn't go to the doctor, that service shouldn't be there. If it shows testing your parent doesn't remember, ask about it.

Check the service dates against the dates your parent actually received care. If they don't match, something's wrong.

Look at the service descriptions. If the description doesn't match what your parent thinks they received, call the doctor's office and ask what a particular code or description means.

Check 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.

Check the provider information. If your parent receives a charge from a provider they've never visited, that's a red flag.

Look at charge amounts. If one office visit is billed at a hundred dollars and another similar visit is billed at five hundred, 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 only give out their Medicare number to legitimate healthcare providers, Medicare itself, and insurance companies that legitimately need it. Not to people who call unsolicited. Not to people claiming to be from Medicare on the phone. Not to people offering free healthcare or discount medications.

According to CMS, legitimate Medicare representatives will never call beneficiaries to ask for personal information or Medicare numbers. If someone calls claiming to be from Medicare and asks for personal information, it's a scam. Your parent should hang up and call 1-800-MEDICARE directly.

A common fraud scheme involves people calling seniors offering free healthcare, equipment, or 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 rather than carrying it in a wallet where it could be lost or stolen. Sensitive information shouldn't be shared in public, like reading a Medicare number out loud in a waiting room.

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. In severe cases, CMS can issue a new Medicare number.

Reporting Suspected Fraud

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

Call Medicare at 1-800-MEDICARE and 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.

You can also report fraud online through the Medicare website or through the HHS Office of Inspector General at 1-800-HHS-TIPS or oig.hhs.gov. Fraud can also be reported to your state's insurance commissioner or Medicaid fraud office.

When reporting, be specific. "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" is far more helpful than "I think there's fraud."

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

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, write down the date, the provider's name, the location, and what was done. This takes two minutes and creates a record that makes fraud obvious if it occurs.

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.

Know the names and contact information for main healthcare providers. If a bill arrives from a provider your parent doesn't recognize, call one of the known providers and ask if they made a referral.

This protection is free and takes minimal time. When fraud does happen, it's caught quickly because the evidence is already organized.

When Fraud Gets Complicated

If fraud is discovered and reported, the investigation takes time. Medicare investigates. The provider might be contacted. Fraudulent charges might still appear on bills while the investigation is ongoing.

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, call Medicare and ask for a status update. Providing more detailed information might speed things along.

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

Medicare fraud exists because the system is large and complex and there's money involved. Most providers are ethical and bill appropriately. But the small percentage who do commit fraud cause real harm. Your parent can't prevent all fraud. But they can be informed, pay attention to bills, and report anything suspicious. Being the person who pays attention for your parent might be one of the most valuable protections you can offer.

Frequently Asked Questions

How do I report suspected Medicare fraud?
Call 1-800-MEDICARE or contact the HHS Office of Inspector General at 1-800-HHS-TIPS or oig.hhs.gov. You can also report to your state's insurance commissioner. Provide specific information: the date, provider, service in question, and why you believe it's fraudulent. Reports are confidential.

Will Medicare call my parent to ask for their Medicare number?
No. According to CMS, legitimate Medicare representatives will never call beneficiaries to ask for their Medicare number or personal information. Any such call is a scam. Your parent should hang up and call 1-800-MEDICARE directly.

What happens after I report fraud?
Medicare investigates the claim. The investigation can take weeks or months. During this time, your parent's coverage continues normally. Fraudulent charges are removed from the account once the investigation confirms fraud. You can call 1-800-MEDICARE for status updates.

Can Medicare issue a new Medicare number if my parent's was stolen?
Yes. In severe cases of identity theft or fraud, CMS can issue a new Medicare Beneficiary Identifier. Contact 1-800-MEDICARE to request this if your parent's number has been compromised and fraudulent activity is ongoing.

Does my parent get a reward for reporting fraud?
Not through the standard reporting process. However, if fraud involves a very large amount and leads to a successful government recovery, some cases may qualify under federal whistleblower statutes. For most families, the benefit of reporting is protecting your parent's coverage and getting fraudulent charges removed.

How can I tell the difference between a billing error and actual fraud?
A billing error is usually a one-time mistake, like a duplicate charge or incorrect date. Fraud involves a pattern of intentional false billing, such as repeated charges for services never provided or billing for expensive procedures when only simple visits occurred. Both should be reported and investigated. Start by calling the provider's billing department; their response will often make the distinction clear.