Detect

What signs of a health care scam should I be aware of, or what if it’s just a mistake? DE SMP’s tools and resources help you to escape risky situations and to gain confidence in those scenarios.

Is There Something Wrong Here?

After following the steps to Protect yourself better, is there a health care bill or an offer you still don’t understand? Medicare is complicated, and fraud/errors are not always detected in the billing process. What may seem like an error to you may simply be the result of a misunderstanding about benefits. It may also be abuse, which involves billing Medicare for services that are not covered or are not correctly coded. So, is it fraud, or not?

Identifying Medicare fraud, errors, or abuse can be difficult, but you should be diligent in reviewing your bills and information when you receive it. You can detect potential problems by keeping a record of health care visits and services received and comparing that list to your Medicare Summary Notices (MSNs) and Explanations of Benefits (EOBs). DE SMP has Resources to keep track of information. Detection of errors should prompt you to call to your provider or DE SMP to come up with a plan for your questions.

Common Types of Health Care Fraud

Unfortunately, health care fraudsters will use things like COVID-19 and the popularity of Genetic Testing to take advantage of you. Some common examples of suspected Medicare fraud or abuse are:

  • Billing for services or supplies that were not provided
  • Providing unsolicited supplies to beneficiaries
  • Misrepresenting a diagnosis, a beneficiary’s identity, the service provided, or other facts to justify payment
  • Prescribing or providing excessive or unnecessary tests and services
  • Violating the participating provider agreement with Medicare by refusing to bill Medicare for covered services or items and billing the beneficiary instead
  • Offering or receiving a kickback (bribe) in exchange for a beneficiary’s Medicare number
  • Requesting Medicare numbers at an educational presentation or in an unsolicited phone call
  • Routinely waiving co-insurance or deductibles
  • Waivers are only allowed on a case-by-case basis where there is financial hardship, not as an incentive to attract business

Common Fraud Schemes

Fraud Scheme: COVID-19
Scammers use public health emergencies as opportunities for new fraud schemes, and because older adults are at greater risk for serious illness from COVID-19, scammers may target older populations. This may include delivering fake test kits, offering “free” supplies in exchange for your Medicare number, or a number of other angles. Learn more on the National SMP Resource: COVID-19 Fraud Alert and COVID-19 Fraud Resources

Fraud Scheme: Genetic Testing
Across the nation, genetic testing company representatives are offering “free” genetic tests to Medicare beneficiaries. During this popular scam, these criminals can steal people’s medical identity and falsely bill Medicare, draining the system of needed funds. Learn more on the National SMP Resource: Genetic Testing Fraud Alert and Genetic Testing Fraud Resources

Fraud Scheme: Hospice Care
The term “hospice fraud” covers a variety of different types of fraud that are each detrimental in their own way. Fraudsters are targeting assisted living facility and nursing home residents whose life expectancy exceeds six months and are using high-pressure and unsolicited marketing tactics to get them to agree to hospice services. Learn more on the National SMP Resource: Hospice Care Fraud Alert and Hospice Fraud Resources

Learn more about other fraud schemes that criminals exploit:

The Process of Investigating

How do I know if something is legitimate? Here are steps we recommend you take to investigate any concerns:

Step 1: Contact that Provider or Supplier 

Call your health care provider or supplier first to question the charge.

If the issue is determined to be a mistake, ask them to correct it.

Step 2: Contact The Payer/Insurance

If the provider or supplier can’t answer the question, contact the company that paid the bill. Their contact information can be found on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB).

Step 3: Contact DE SMP

If the issue still isn’t resolved, Contact Us, DE SMP, and we can assist. If fraud or abuse is suspected, we will guide you in resolving it and we will refer cases to the proper authorities on your behalf.

Fighting Fraud in the Moment

1. Don't answer

We know that you’re getting a lot of calls, and many of them are sales or suspicious in nature. The best practice is to not answer calls if you don’t recognize the number. If the call is coming from someone who really needs to reach you, the caller will leave a message.

2. Hang up

If you find that you have answered a call that you now suspect is fraudulent, simply hang up. It’s more important to protect yourself and your personal health information than it is to be polite to a stranger on the phone. 

If the call is from a charity, tell them to send you information in writing. Be sure to add that you do not give money to strangers over the telephone. 

If they are selling something and you are interested, ask for information in writing. If this is a one-time opportunity, tell them you do not make decisions over the phone. 

Ask the caller for his or her name, company name, and callback number. You can call back later to verify the legitimacy of the source and the offer. 

Most importantly, LISTEN for these red flags:  

  • Are they asking for credit card information? 
  • Are they asking for banking information? 
  • Are they asking for personal information like your Medicare or Social Security number? 
  • Do they say the offer is only good today? A real company will give you time to think and verify instead of putting pressure on you. 
  • Do they know something about you but ask to verify that the information is correct? 

If any of these flags are present, HANG UP! Keeping yourself and your information safe should be your priority. 

3. Walk away

Bad actors don’t just make phone calls; sometimes they even make house calls! It’s important to protect your personal health information no matter where you are. Fraudsters can be at community events, health fairs, expos, and in some cases even come to your home. They may offer a gift in exchange for signing up for a test or a free lunch to try their product in exchange for your Medicare number. Always remember: if it sounds too good to be true, it usually is! If you find yourself being approached by someone who isn’t taking no for an answer, just walk away. 

4. Contact a trusted friend or family member

People who are in the business of committing fraud are good at their jobs.  They can sound honest, helpful and tell you compelling stories to try and gain your trust. It can be easy to fall victim to their schemes. Talking with a close friend or family member can help you determine if the situation is potentially fraudulent, and keep your Medicare benefits safe.

5. Contact DE SMP

The Delaware Senior Medicare Patrol is always here to help. Our team can provide tips to protect yourself, notify you of fraud schemes that are targeting you, and guide you in identifying potential Medicare errors, abuse and fraud. In addition, the DE SMP can support you if you believe that you have been a victim. We will go over your experience in detail with you, help you determine if it is suspected fraud or abuse and, if needed, submit your claim to the Office of Inspector General (OIG) for investigation. Start now on our Find Help page.