Last year, Jean Bound received a package with COVID tests that she hadn’t ordered. She called the company whose name was on the packing list to say she hadn’t ordered them. In response, she was told not to worry, because Medicare had been billed and would be taking care of the cost.
She immediately contacted Medicare to report that she hadn’t ordered the tests. A couple of months later, she again received COVID tests that she hadn’t asked for. She called Medicare to report the fraud a second time but never received any confirmation that the situation had been resolved.
Later, when she received an explanation of benefits, she saw the charges on her Medicare statement.
“Medicare scammers send emails, make calls and create fake websites to trick you into giving them your personal Medicare and Social Security information,” says Ari Parker, co-founder and head of Medicare Advisory at Chapter, an independent company that offers free Medicare advice from licensed independent Medicare advisors.
And now is the time to be on alert, as Medicare fraud is more common during the annual open enrollment period (October 15 to December 7), a window in which you can change your Medicare Advantage plan or drug coverage.
[READ: How to Appeal a Denied Medicare Claim: A Step-by-Step Guide]
Understanding Medicare Scams and Medical Identity Theft
Medicare fraud costs Americans an estimated $60 billion a year, according to Senior Medicare Patrol (SMP). SMP is a group of volunteer-based organizations funded by the U.S. Department of Health and Human Services to educate Medicare beneficiaries on how to prevent, detect and report Medicare errors and abuse.
A Medicare scam occurs when a provider, a supplier or an individual poses as you to receive medical care, services, supplies or prescription medications and uses your personal information — your name, Social Security number, Medicare number — without your consent to submit false Medicare claims.
Beware of criminals pretending to be from Medicare or other known organizations trying to trick you into giving them your information. It’s one of the most rampant kinds of fraud in the country and is a serious crime.
[READ: Medicare Mistakes to Avoid.]
Official Medicare Outreach vs. Fraudulent Scammer Tactics
| Outreach Category | Legitimate Official Communication | Scammer Red Flags and Fraud Tactics |
| Contact initiation | Official communications arrive through the mail or through electronic Medicare Summary Notices delivered to your secure online account. Representatives only call you by request through 1-800-MEDICARE. | Scammers will try unsolicited phone calls, text messages, emails or unannounced door-to-door visits demanding immediate action. |
| Information requests | Representatives never contact you unprompted to ask for your Medicare Beneficiary Identifier, Social Security number or financial information. | A scammer might claim that your Medicare card has expired, requires a new plastic chip or needs a payment to maintain coverage. |
| Offers and sales | Representatives will never contact you to sell you insurance products, offer cash rebates or solicit enrollment over the phone. | Fraudsters may promise free medical equipment or cash refunds or use high-pressure demands to get you to switch your plan. |
[Read: What to Do if Your Doctor Stops Accepting Medicare]
Common Medicare Scams During Open Enrollment
Medicare scams come in many different and ever-evolving forms. A good rule of thumb to combat all of them is to never give your personal information to anyone unless you are completely certain of who they are. Guard your Medicare and Social Security information the same way you would guard your credit cards.
Here are some of the current common Medicare scams:
Identity theft and account exploitation
— Enrollment center and card impersonation: Scammers call, claiming they’re from your Medicare Enrollment Center and requesting your Medicare Beneficiary Identifier (the series of 11 letters and numbers listed on your Medicare card). They might say that they’re doing a survey that requires your information, that you need a new card with a chip or that you need a laminated card. Medicare cards come in paper form only.
— Phony organization calls: Callers pose as representatives from your doctor’s office or a state or local agency and request information.
— Unwanted plan switching: Scammers try to convince you that your coverage is ending and offer to switch you to a lower-cost plan, for which they’ll need your personal information, including your MBI.
Unsolicited supplies, tests and care billing
— Unrequested medical equipment: Scammers ship unneeded equipment, such as back braces, wheelchairs or electric scooters, and bill it to Medicare or ask your doctors for supplies and equipment you don’t need. They may also say they’re from companies offering free medical supplies or testing trial offers and need your MBI before you can receive these services.
— Genetic screening and health fair schemes: A company will offer you “free” or “at no cost to you” genetic tests, such as cancer screening tests or dementia screening tests, without a physician’s order and will bill Medicare for the cost. Fraudsters will request your MBI at senior centers, church-sponsored events or health fairs, where they’ll offer raffles and free gifts that require your MBI.
— Unauthorized service claims: Scammers will try to bill Medicare for fake telehealth services, unrequested home healthcare services or unnecessary hospice care.
Financial traps and coercion
— Threats to cancel coverage: You get a call from someone saying there’s been fraudulent activity or a problem with your Medicare account. They may tell you that your benefits will be canceled unless you immediately verify your personal information.
— Fake rebate and refund promises: Scammers offer rebates, refunds, cheaper plans or better deals in exchange for your MBI.
— Pressure tactics: Scammers pose as licensed insurance agents who pressure you to buy high-priced medical services and diagnostic tests or threaten to withhold services if you don’t provide your information.
How Healthcare Providers Defraud the Medicare System
Most healthcare providers are doing their best and practicing medicine honestly and in good faith. However, there are some who also are scamming the Medicare system. They may use the following tactics:
— Double billing: Submitting multiple claims for the same service
— Phantom billing: Submitting bills for a visit that never took place
— Upcoding: Billing for a more expensive service than a patient received
— Performing medically unnecessary services: Attempting to generate more Medicare reimbursement payments
— Misrepresenting noncovered treatments: Submitting treatments that aren’t medically necessary, such as cosmetic surgeries, to Medicare for payment
— Falsifying patient medical records: Trying to justify additional tests, surgeries and procedures that aren’t medically necessary
— Unbundling: Billing for each step of a procedure as if they were all separate procedures to be paid higher fees
— Billing Medicare more than the required copayment: Billing for services that were paid in full by a patient’s benefit plan
— Kickbacks: Offering money for patient referrals
Consequences of Medical Identity Theft for Beneficiaries
Medically unnecessary products and services that end up on your records could later result in improper medical treatment from legitimate providers, according to Nicole Liebau, a center director advisor at SMP.
“Because of inaccurate or fraudulent claims to Medicare, you may be denied needed medical benefits,” Liebau explains. “Some services have limits, and if Medicare thinks such services have already been provided, they will deny payment.”
Inaccurate medical records could contain misinformation such as false diagnoses, treatments that never occurred, nonexistent allergies or incorrect lab results.
What’s more, Medicare fraud, errors and abuse can result in higher out-of-pocket costs for beneficiaries.
Medicare Education to Prevent Fraud
Because Medicare is complicated, it’s important to learn what your coverage includes, how Medicare uses your personal information, what your rights are and which services providers can and can’t bill to Medicare.
“Educating yourself on how to spot red flags of potential fraud is the best way to prevent and detect Medicare fraud,” Liebau confirms.
Here are some of the ways you can educate yourself to prevent Medicare fraud:
— Learn how to read your Medicare statements. Your Medicare Summary Notice shows the services, supplies or equipment you received, what you were charged and how much Medicare paid. SMP provides information to help you do that.
— Use tools to help you detect Medicare fraud. You can and should track your medical appointments and services. SMP can help with a tool called My Health Care Tracker.
How to Protect Your Medicare Number and Lower Your Risk
Medicare fraud is sometimes hard to detect. Criminals can be very sophisticated in their schemes and fraudulent activities. Here are some strategies to avoid becoming a victim:
— Don’t give out your personal information. As soon as someone asks for your personal information by mail, social media or text or someone shows up at your door, it’s a scam.
— Watch out for phishing. Don’t click on email links, open attachments or call any number on messages. Scammers are likely phishing for personal information.
— Medicare phone calls. Don’t be tricked if someone says they’re calling from Medicare, even if the number looks official.
— Check statements from healthcare providers. Look at the statements you get from your healthcare providers for mistakes. Call them if you think something isn’t correct. Save receipts and statements from your providers to compare with statements sent to you after claims have been processed.
— Protect your medical records. Don’t give anyone access to your medical records except the providers you know and trust.
— Hang up if you accidentally answer an official-looking call. Scammers have many ways of devising phone numbers to make them look official, but if you do answer a call and it isn’t who you thought it would be, hang up immediately.
— Check your prescriptions. Before leaving a pharmacy, make sure you’ve gotten the right medicine and the right amount.
How and Where to Report Suspected Medicare Fraud
Depending on your situation, there are actions you can take for potential Medicare scams:
— If you want to ask questions about potential fraud or error concerns, call the following Medicare fraud phone numbers: 1-800-MEDICARE (1-800-633-4227) or, for TTY users, 1-877-486-2048.
— Report fraud to the Office of the Inspector General at the Department of Health and Human Services. They have a fraud hotline that can be reached at 1-800-HHS-TIPS (1-800-447-8477). TTY users, call 1-800-377-4950.
— If you have a Medicare Advantage plan or Medicare drug plan, you can call the Investigations Medicare Drug Integrity Contractor at 1-877-SAFERX (1-877-772-3379).
— The SMP Resource Center can help direct you to your local SMP if you call 1-877-808-2468. You can also report potential Medicare fraud, errors or abuse to the SMP online. Your local SMP can assist with appropriate referrals to state or federal agencies.
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How to Avoid Medicare Fraud originally appeared on usnews.com
Update 08/25/26: This story was previously published at an earlier date and has been updated with new information.
