What Is Medicare Fraud?

Medicare Fraud is intentionally submitting false information to a government contractor to receive money or a benefit by knowingly and willfully executing a scheme to defraud this health care benefit program.

Examples of fraudulent behavior:

• Deliberately altering claim forms to obtain a higher reimbursement amount (including billing Medicare for appointments that the patient failed to keep)
• Knowingly billing Medicare for services or supplies that were not provided (including billing for appointments beneficiaries neglected to keep)
• Knowingly billing both the beneficiary and Medicare for the same service/item
• Knowingly billing preadmission testing prior to a hospital admission that should be included in that DRG (i.e., global fee)
• Deliberately applying for duplicate reimbursement in order to get paid twice
• Completing CMN for patients not personally and professionally known by the provider
• Deliberately unbundling or “exploding” charges
• Knowingly soliciting, offering, or receiving a kickback, bribe or rebate
• False representation with respect to the nature of the services rendered or charges for such services, identity of the person receiving or rendering the services, dates of the services, etc.
• Knowingly filing claims for services that are noncovered but billed as if they were covered services

Revised 12/20/2024