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Washington State Office of the Insurance Commissioner

How to identify and report Medicare fraud and abuse


Washington State Statewide Health Insurance Benefits Advisors LogoWe all pay a price for Medicare fraud, abuse and waste! It affects all consumers not just Medicare clients. And contributes significantly to rising health care costs.

Most health providers are honest, but some intentionally misrepresent or bill Medicare for services they never provided. When fraud occurs, someone is using you for their criminal scheme to steal health care dollars. Trust your instincts and learn how to detect fraud.

 

How to report Medicare fraud | Washington State Office of the Insurance Commissioner

Call 1-800-562-6900 or send an email to SHIBAHelpLine@oic.wa.gov.

 

Examples of possible fraud

You are:

  • Billed for services and equipment you did not receive
  • Offered free testing or screening in exchange for your Medicare number
  • Charged for filling out claim forms

A provider:

  • Performs services that exceed what is medically necessary
  • Offers or accepts referral fees from another provider for the referral
  • Misrepresents services that are billed to Medicare
  • Waives the 20% coinsurance or deductible

Tips to protect yourself from MedicarePart D and Medicare Advantage fraud and abuse

  • Make sure the person you are buying insurance from is licensed. Ask to see their credentials or look them up to see if they’re licensed.
  • Agents and brokers cannot make unsolicited door-to-door visits, telephone calls or any other type of sales contact without your express invitation. They also cannot send unsolicited emails.

  • Never give out personal information such as your Social Security, bank account or credit card numbers over the phone unless you are the one who has initiated the contact.

  • Be careful of any sales person who says he or she is from Medicare. Medicare does not send sales people to solicit your business.
  • Agents and brokers cannot market Medicare products or share any plan specific details in places where health care is delivered, such as a doctor's office, clinic, or pharmacy counter, or at an educational event.
  • Insurance sales people cannot offer free meals to potential clients listening to a Medicare sales presentation or for signing up for a particular plan.
  • Agents and brokers cannot sell additional insurance products during any sales or marketing presentation for a Medicare Advantage or Medicare Part D plan.
  • Make sure the plan you choose matches your needs and that you can still see your current health care providers if you wish. It may be very difficult or even impossible to "undo" your selection later.
  • You have rights! If you have any questions about an insurance offer, scheme or agent, call us at 1-800-562-6900.  

The U.S. Administration on Aging has Senior Medicare Patrol (SMP) programs in many communities that train volunteers to detect and report fraud related to Medicare prescription drug coverage. SMP volunteers are equipped to address a variety of beneficiary inquiries and complaints, either by resolving matters directly or by referring issues to state and national fraud control/consumer protection entities. The SHIBA HelpLine is the Washington state SMP.



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