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AARP Webinar Q-and-A: Protecting Yourself From Health Care Fraud

The following questions were asked during AARP’s webinar series about the new health care law.

Q: What actions should people take if they encounter or suspect a health care scam?

A: If the pitch comes by phone or in person, you should try to get contact information, such as a name, phone number, business card and any specifics about whatever it is that’s making you think the pitch is a scam. Get just the basic information, even though it’s likely the phone number may be blocked and the names given to you may be fake. You want some information, but you also want to get off the phone as quickly as possible.

If the pitch comes by mail or e-mail, you should save it and forward that information to local law enforcement, your state attorney general, state insurance department or the Senior Medicare Patrol (SMP). If you think someone is trying to scam you over the phone, stay on the line long enough to get any contact information, then hang up. Do not share your personal information. If you receive something suspicious by e-mail, do not link to any website provided in the pitch or open any attachments.
Q: How can I check to see if false information is being provided about services provided to me or others?

A: The best thing you can do is to examine your Medicare Summary Notice or insurance Explanation of Benefits and ask yourself the following questions:

  • "Are there any charges for something (services, equipment, medications) that I didn’t receive?"
  • "Are there charges for services that are not medically necessary?"
  • "Was I billed for the same thing more than once?"


If you see something on your statement that you don’t understand or that confuses you, call the provider.
Q: When a person reports fraud, is it anonymous?

A: Yes, you can report your concerns anonymously. Report Medicare fraud to the Inspector General of the U.S. Department of Health and Human Services:

  • Phone: 800-HHS-TIPS (800-447-8477)
  • Fax: 800-223-2164 (no more than 45 pages)
  • TTY: 1-800-377-4950
  • Mail: US Dept. of Health & Human Services, Office of the Inspector General, OIG Hotline Operations, P.O. Box 23489, Washington, DC 20026

Q: One type of fraud is upcoding. Should you report upcoding to the provider or report it to authorities as potential fraud?  

A: If you think there’s a coding error, it’s best to check with the provider first. What may appear to be upcoding could be a simple mistake. If you’re not satisfied with the provider’s response, report your concerns to Medicare or your insurance company.   

Q: Are there plans to simplify medical coding? I always read every bill and it is extremely confusing.

A: There is nothing in the new health care law that addresses the issue of simplifying medical coding. The codes, called CPT or Current Procedural Terminology, are developed by the American Medical Association’s CPT Editorial Panel.

Q: Is there any regulation for amounts charged for the same service at two different facilities?

A: Medicare, as well as most insurance companies, has a set fee schedule for each type of service. The Medicare-approved amount would be the same for the same service provided in the same geographical area. Different insurance companies have their own schedule of what payment is "usual and customary" for a particular service. They do not publish those schedules.

Q: How can I find out if a medical service was needed?

A:  Talk to your doctor if you have a question whether a service, such as a consultation with another professional or a lab test, was needed.

Q: If I don’t report fraud, either because I don't understand what is happening or I am a victim of fraud, am I personally liable for damages?

A: If you did not intentionally help in allowing the fraud to happen, you would not be held responsible. There is no legal liability for not reporting a fraud if you did not know a fraud was occurring or you were an innocent victim. You may have liability if you knowingly participate in a fraud, however.
Q: Is a provider required by law to provide information showing that changes have been made for charges to Medicare when an error is found?

A: After you talk with your provider about an error, the correction should appear on a subsequent Medicare Summary Notice. If you have any questions about whether the correction was actually made, you can call Medicare at 800-MEDICARE (800-633-4227). You can also go to to check your personal Medicare statement.
Q: For medical providers, how much of a factor is greed? Is it that providers aren’t afraid of getting caught?

A: The criminals who abuse the health care system certainly are motivated by greed. Many of the biggest abusers are hardened criminals engaged in elaborate schemes. When providers are prosecuted they face jail time, restitution costs and the loss of their licenses.  
Q: With all the organizations fielding fraud investigations, is there a centralized database to create efficiencies in time and resources?

A: One important provision of the new health care law is to make it easier for all the federal agencies involved in health care claims to share data. This includes Social Security Disability Insurance, Veterans Affairs, the Defense Department, Indian Health Services, Medicare and Medicaid. Additionally, there will be a significant effort to build better and faster ways of analyzing claims data.
Q: Does the federal government have plans to expand HEAT (Health Care Fraud Prevention and Enforcement Action Team) to other cities?

A: HEAT groups are placed in cities where there’s a high incidence of health care fraud. The strike forces began in south Florida and Los Angeles. Detroit and Houston were later added as target cities. Brooklyn; Baton Rouge, La.; and Tampa, Fla., are the newest locations with task forces. With expanding resources from the new health care law, HEAT can strategically concentrate resources and personnel to bring prosecutions where unexplainable billing patterns most frequently appear.
Q: I've been hearing ads in local supermarkets for prepaid insurance. Are these legitimate offers?

A: You’re smart to want to make sure that the information you see in advertisements is legitimate. Before purchasing any type of insurance you need to do your homework. Make sure you get all the details in writing about what’s covered and, just as importantly, what’s not covered, and what you have to do to be reimbursed for a claim. With any kind of prepaid plan or discount card, be sure you know the limitations on where the plan can be used, what services would be covered and how long the plan is in effect.
Q: I currently have Medicare but no Part B coverage. I also have Tricare for Life as my supplemental insurance coverage, which takes care of prescription medicines as well as other services. I have been told that I should consider getting an additional policy and doing away with my Tricare coverage. Was this a case of a high-pressure sales tactic?

A: Always verify any information you get and do careful comparisons before changing any coverage. To do their job, salespeople need to be convincing. But to do your job as a consumer, you need to ask probing questions and do your own review of the pros and cons of your current coverage versus any new coverage. One way to do this is to use the plan comparison tool at
Q: Do the electric wheelchair sellers on TV charge a fair amount to Medicare, or is shopping through a local dealer a better option?

A: Before making a choice, ask each durable medical equipment supplier what Medicare reimbursements they expect to receive for providing you with equipment. Be suspicious of any supplier who says it will bill Medicare for a power wheelchair or scooter when you don’t meet Medicare’s qualifications.  
Q: What actions are taken to force advertisers to stop false TV ads?

A:  Ads are not "pre-approved" by any federal regulator. If you see an advertisement you think is making false or deceptive claims about some product, notify the television channel, the Federal Trade Commission and/or the Federal Communications Commission

Q: There are a lot of "health care consultants" out there offering to help people understand their medical bills. How can someone know if they are legit?

A:  Select a health care consultant the way you would select any service provider. Check with friends for recommendations, consult with the Better Business Bureau or a consumer protection agency. Get a written contract and be sure you understand what services or assistance you’ll receive and how you will be billed for those services. You may also want to check with your local Senior Medicare Patrol for help from trained volunteers.
Q: I thought that SHIPs — as in State Health Insurance Counseling and Assistance Programs — stood for Senior, not State, and that it only helped Medicare recipients.  

A: The "S" in SHIP stands for "State." Some states may call their SHIP program by another name, for example SHINE or HIICAP or something else. While most SHIP programs specialize in Medicare, in many states the counselors are well trained in other types of insurance and can counsel on Medicaid, long-term care insurance, other state insurance supports, COBRA and health insurance issues in general.  
Q: Is the Centers for Medicare & Medicaid Services out of Iowa City, Iowa, a legitimate operation? They sent a questionnaire saying I should log onto and sign in with my Medicare number. It supplied me with a temporary password.

A: The Centers for Medicare & Medicaid Services is the government agency that is responsible for Medicare and Medicaid. The website is a legitimate website where you can find information about your personal Medicare account. It is safe to go directly to that website and enter personal information. What you need to be cautious about is when you get an e-mail that asks you to click on a link. The link may be to a fictitious look-alike site.
Q: Why is the Medicare member number almost identical to our Social Security number? It makes it easier for fraud.
A: Your Medicare number is the same as your Social Security number. This is because you have to be eligible for Social Security to be eligible for Medicare. Your Medicare number is valuable to criminals. If they can steal your Medicare card, talk you into revealing your number or even pay you for your card, they have the key piece of information necessary to file a false claim or to steal your identity.

Carry your Medicare card only when you know you will need it to get the health services you require. In fact, it would be smart to make a copy of your card and scratch out all but the last four digits of your number and carry that copy instead of the real card. If you are in an accident and need emergency medical care, no hospital will deny you treatment because you don’t have your card with you.
Q: We were told not to carry our Medicare card because it shows our Social Security number. But my card does not have my individual number. Instead, it has my deceased husband's number with the letter D after it. Will scammers be able to use his number and get anything with it?

A: Scammers can try anything and they sometimes try to use the Social Security numbers of deceased persons. That’s why it is smart to notify Social Security and the three consumer credit reporting agencies (Experian, Equifax and TransUnion) of the death of a spouse so the number can be appropriately flagged.  

Q: Some Medicare and health maintenance organization (HMO) providers have asked patients to sign forms stating that the providers have no contracts with Medicare or the HMO, that the patient is the one who has the contract, that the patient is responsible for paying the provider and that the provider will bill Medicare or the HMO directly if the patient will sign a form allowing this. The form states that the patient, not the HMO or Medicare, is responsible for payment. The provider will then bill the patient for the difference between what they received from the HMO or Medicare.

I asked my HMO about this. They claim that the contract is between the provider and the HMO, that the patient cannot see the contract because they are not a party to it and that the contract states that the provider must accept the HMO payment as full payment. When I asked my HMO what to do for the providers who did not agree to this, they told me to find a different provider.

A:  Providers enter into contracts with Medicare and health plans that establish how much the provider is going to be paid for specific services. Most contracts also establish how much the provider can receive from the patient.

The difference between what the provider has contracted to receive and the amount he or she would like to be paid is the “balance” of the bill, or balance billing. Under most contracts, balance billing is prohibited or capped. Under Medicare rules, a provider treating a Medicare patient, but not accepting the Medicare approved amount as payment, can charge up to 15 percent more than Medicare’s approved amount. The patient must pay 20 percent of the Medicare approved amount plus all of the additional charges, up to an additional 15 percent of the Medicare approved amount. If a provider is not part of an HMO plan network or not participating with Medicare, the provider can charge the patient any amount. Co-payments are much lower when you use a provider who accepts the Medicare-approved payment or a provider who is part the private plan network.
Q: I just received a postcard in the mail today to fill out survey. It says if I fill out the survey it will give them information that will help us become eligible for Medicare. They will then forward us a Planning for Medicare booklet.

A:  It is very easy to find out if you are eligible for Medicare. Just go to or get a copy of the free Medicare and You. You can download it from, read a copy at your public library or get a copy from your local Social Security office.

The postcard you received is most likely from an insurance company that wants to find out if you are interested in a Medicare Advantage plan or Part D Prescription Drug plan. If you aren’t interested in getting marketing material, don’t fill out the survey.
Q: Somebody came to my door wanting to sell me a Medicare supplemental policy that he said was required by the new law. When he asked for my Medicare number I told him to get lost. Did I do the right thing?

A: Yes, you sure did. Medicare never sends representatives to go door-to-door. Nor will it try to sell you a supplemental policy. If you think someone is trying to scam you or steal your Medicare number, call Medicare at 800-633-4227.

Q: I assume there are sometimes legitimate phone calls to consumers from health insurance agents and appointment setters.

A: Yes, most heath care providers and insurance agents, as well as all other professionals, are honest. But before you purchase any insurance product or share personal information, be sure to verify any information you receive and carefully compare the details with other similar offerings.
Q: How can you check on a state license?

A: To see if an insurance agent is licensed to sell insurance in your state, contact your state insurance department. You can find contact information in the blue (government) pages of your phone book. You can also go to to find the phone numbers and website for your state insurance department.

Q: Can I ask for an agent’s license number over the phone to verify before setting the appointment?

A: You certainly can ask for the agent’s license number before making an appointment to meet with that individual. At most state insurance department websites, you just need a name and you don’t need to have the license number to verify whether or not an individual is authorized to sell insurance in your state.
Q: Are there any legitimate insurance companies that offer health insurance without any medical questions being asked?

A: Because there are so many different types of health insurance, the answer may depend on the type of insurance you are considering. But with any type of insurance plan, be sure you understand when the coverage starts, what you have to do to file a claim, and what conditions, treatments or services are or are not covered. You don't want to be surprised by something in the fine print.  
It's always a good idea to check with your state insurance department if you have any questions about an insurance company or policy. You can find contact information in the blue (government) pages of your phone book. You can also go to to find the phone numbers and website for your state insurance department.
Some private insurance companies offer coverage for people with pre-existing conditions. If you enroll in Medicare Part B, as soon as you become eligible for this coverage, you cannot be denied coverage or charged higher premiums because of your medical history. You have the right to enroll in a Medicare supplement plan (Medigap plan) of your choice during the six months following your initial enrollment in Medicare Part B. After that six-month window, an insurance company can refuse you Medigap coverage because of a pre-existing health condition. Because of the new health care law, after 2014 no insurance company will be able to deny you coverage because of your prior medical history.  

Q: Where can I volunteer to aid in detecting fraud?

A: You may want to volunteer with your local Senior Medicare Patrol (SMP). SMP volunteers are trained to go out into their communities to help others spot and stop Medicare fraud. To find the closest SMP go to or

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