Reporting fraud and abuse under Medicare, not as easy as it should be, but who cares?

6 Oct

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I like to think of myself as a good citizen and since we all want to help keep health care costs down, helping Medicare spot fraud and abuse is a good idea…until you try it.

A few weeks ago I visited a major pharmacy chain and received my annual flu shot (or as they call it in England a flu jab) for free. Don’t you love when you get something for free even when it isn’t?

Yesterday I received my Medicare Explanation of Benefits (EOB) for this service. However, the EOB says I received Pneumococcal vaccine for $13.25 and Administration of influenza vaccine for $16.74. Since this service is “free” Medicare paid the total fee in full for each listed service.

Nobody said anything to me about receiving a vaccine for pneumonia so I went back to the pharmacy and asked what they were giving out. Only vaccine for the seasonal flu and H1N1 in a combined shot I was told. I mentioned the Medicare EOB and was told it must be a mistake. Indeed it may be a mistake both in billing and letting me think I received two different vaccines.

Now back to this good citizen stuff. I wanted to report this error or fraud to Medicare so I went to to see how to go about it. Here is what I found.

How to Spot & Report Fraud

Spotting Fraud

When you get health care services, record the dates on a calendar and save the receipts and statements you get from providers to check for mistakes. Compare this information with the claims Medicare processed to make sure you or Medicare weren’t billed for services or items you didn’t get.

3 Ways to Review Your Original Medicare Claims

1. Look at your Medicare Summary Notice (MSN).
2. Visit
3. Call (). TTY users should call .

Reporting Fraud

If you think a charge is incorrect and you know the provider, you may want to call their office to ask about it. The person you speak to may help you better understand the services or supplies you got. Or, your provider may realize a billing error was made.  If you’ve contacted the provider and you suspect that Medicare is being charged for a service or supply you didn’t get, or you don’t know the provider on the claim, call (). TTY users should call

You will notice that the number to call to report fraud is the same number you use to question a claim. What you get is a voice response system that takes you through endless and irrelevant menus and of course you must enter your personal information. Finally, when you discover that none of the menus available mention reporting fraud, you are eventually given the instruction to say “agent” and you are connected with someone to talk to…ah, not so much. What I got was the proverbial “all of our agents are busy assisting other customers” Then I was told the wait time was about ten minutes. By this time I had already spent five minutes or more in frustration finding my way around the interactive system and I was in no mood to sit and wait for another ten minutes so I hung up.  Hey, it’s only money.  In this case if such a mistake applied to all who received a flu jab, it only adds up to about $530,000,000.

Let’s hope this isn’t fraud, because they are not going to hear more about it from me. You would think that if the bureaucracy was truly interested in learning about fraud or even ongoing mistakes that cost money, there would be a dedicated telephone line where you immediately got to talk to a person and that you could also begin the process on-line to save everybody time and money.

There I go again thinking like a corporate executive in the private sector where what you spend needlessly actually does matter. You see, actually saving money in the Medicare bureaucracy matters little unless the money supposedly saved is double counted for some new spending program or is part of the daily political rhetoric come election time.

Am I being too cynical?

2 Responses to “Reporting fraud and abuse under Medicare, not as easy as it should be, but who cares?”

  1. Doug October 6, 2011 at 11:34 AM #

    Hey, this has been going on for years. On several occassions I have notified my carrier (Cigna prior to Medicare) about charges for things we never received. I was told that there was no way that we could prove we did not receive it so they just pay it. On example was a “Lambs Skin” pad to help prevent sores. No pad was ever used but the hospital said we did so its their word against yours. Maybe we should require the patient to sign for things while in the hospital before the insurance will cover.
    I handled bills for my in laws and when they were in the hospital ER my wife and I were present from the time they arrived by ambulance on serveral occasions. We knew which doctors were used. When the statements came and subsequent bills there were doctors names charging for services that never were there. The insurance wouldn’t pursue it but the residual bills I refused to pay with a letter to the doctor explaining that we knew they never provided services. Never heard another word from them but they got paid by the carrier. Very sad process.

  2. Bill October 6, 2011 at 9:24 AM #

    Welcome to the real world. This is why “nobody cares”. Bureaucratic “push or say one now” tends you mitigate the problem real fast. I like the one where the Customer Rep is named “Peggy” and transfer you to his genius boss….

    If you were trying to have a valid claim processed, this same speedy system is at your service.


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