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Understanding Healthcare Fraud and Abuse Complaints

By Staff Reporters

According to Patricia Trites PhD, complaints are the most common way that a Medicare audit can be triggered. Anyone can register a complaint. Physicians can report their colleagues, whether competitors in the same town or partners / associates. The literature mailed by Medicare encourages seniors and their family members to report their healthcare providers, if there is any suggestion of inappropriate billing activities.

Beneficiary Literature

Literature has been sent out in beneficiary information and in their Explanation of Medical Benefits [EOB]. The following is an example of information that patients have access to through the Internet.

Fraud and Abuse

NHIC Medicare is responsible for overseeing how your health care dollars are spent. This involves watching how physicians and suppliers submit bills. NHIC works with the Health Care Financing Administration (HCFA-CMS), Office of Inspector General (OIG), Federal Bureau of Investigation (FBI) and the United States Attorney’s Office, to develop suspected fraud and abuse cases. This team approach has resulted in numerous criminal convictions and civil monetary recoveries.

Patients: We Need Your Help!

While the vast majority of providers are honest, there are some who defraud and abuse the system — misusing money that supports your health care. Fraud adversely affects everyone in the form of higher health care costs. With your help, we can identify abusers and halt this costly waste of your health care dollars.

Fraud can take many forms — some obvious and some not so obvious. Fraudulent acts include, but are not limited to, practices like:

· Billing for services or supplies that are not provided or requested.

· Billing for non-covered services as if they were covered services.

· Misrepresenting a patient’s diagnosis.

· Submitting false claims.

· Paying for referral of patients.

· Altering claim forms and records. 

These are just a few examples of the most obvious forms of fraud. Other activities are not so obvious but are fraudulent acts nonetheless. These include changing the date of service so that it falls within a patient’s coverage period, or billing for services over a period of days when all treatment was given during one visit.

How Patients Can Help Detect Fraud

Patients are in a good position to detect and report Medicare fraud and abuse. Patients should read the Explanation of Medicare Benefits (EOMB) forms carefully. Make sure that the information on their EOMBs matches the services received. For example, patient should:

· Look at the type and number of services provided.

· Look at the dates services were provided.

· Look at the services billed to determine if received. Look at the Medicare payment to the doctor or supplier to determine if he or she was paid for more services than received or was paid for services not needed.

· Do not lend your Medicare card to anyone. If your card is lost or stolen, report it to your nearest Social Security office immediately.

What to Do If You Suspect Fraud (Patients)

If you know or suspect that a physician, supplier or hospital may be committing fraud or abuse, or if you would like someone from Medicare to talk to your group about Medicare fraud and what you can do to help stop it, please write or call your local Medicare carrier.

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