Medicare fraud is when someone deliberately lies to Medicare or bills Medicare for services that were never provided or weren't medically necessary

Medicare fraud costs the program billions of dollars each year, and those costs get passed along through higher premiums and reduced benefits for everyone. Unlike a straightforward billing error — which happens by accident — fraud is intentional deception. It can involve doctors, hospitals, suppliers, or patients, and it ranges from billing for tests that weren't done to prescribing unnecessary treatments to upcoding (billing for a more expensive service than what was actually provided).

Understanding what fraud looks like helps you protect yourself. You are the best defense against it because you receive itemized statements from Medicare and can spot charges you don't recognize. Reporting suspected fraud is straightforward, and you don't need proof — just a description of what you saw.

Key Takeaways

  • Medicare fraud is intentional billing deception by providers, suppliers, or patients — not accidental billing errors.
  • Common schemes include billing for services never provided, upcoding to a more expensive service, and prescribing unnecessary treatments.
  • You can spot fraud by reviewing your Medicare statements and looking for charges you don't recognize or services you never received.
  • Report suspected fraud to the Medicare fraud hotline at 1-800-MEDICARE or online through the official Medicare website.
  • Reporting fraud protects your benefits and helps keep Medicare costs down for everyone.

Common types of Medicare fraud

Billing for services never provided is the most straightforward fraud. A supplier bills Medicare for a wheelchair, walker, or diabetic supplies you never received. A lab bills for blood tests that were never drawn. A clinic bills for an office visit that never happened. You receive a statement showing the charge, but you have no memory of the service and no paperwork to match it.

Upcoding means billing for a more expensive service than what was actually delivered. A doctor performs a routine office visit but bills it as a complex evaluation that requires more time and informed. A physical therapist bills for an hour-long session when the patient was there for 20 minutes. The service happened, but the bill doesn't match what was done.

Unbundling is breaking apart a bundled service into separate charges so each one can be billed at a higher rate. Instead of billing one comprehensive code for a procedure, the provider splits it into multiple codes and charges for each piece separately — even though Medicare's rules say those pieces should be billed together.

Unnecessary services and treatments occur when a provider orders tests, imaging, or procedures that have no medical reason. A patient with no symptoms gets a full-body scan. Someone gets physical therapy sessions that their condition doesn't warrant. The service is real and the patient receives it, but it wasn't medically necessary, and Medicare shouldn't have paid for it.

Kickbacks and self-referrals happen when a provider refers a patient to another provider (often one they own or have a financial stake in) in exchange for payment or profit. A doctor owns a lab and refers all his patients there, even when another lab would be more appropriate. A supplier pays a clinic to send patients their way. These arrangements create incentives to order more services than necessary.

How to spot fraud on your Medicare statements

Medicare sends you an Explanation of Benefits (EOB) for each claim. This document shows what was billed, what Medicare paid, and what you owe. Review it carefully, even if you think the bill is correct. Look for services you don't remember receiving, dates that don't match when you actually went to the doctor, or charges for items you never got.

Check the provider's name and location. If you see a bill from a clinic or supplier you've never heard of, that's a red flag. Scammers sometimes use names similar to real hospitals or clinics to confuse patients. If you're unsure whether a charge is legitimate, call the provider's main number (not the number on the statement) and ask whether they billed Medicare for you on that date.

Watch for duplicate charges. If you see the same service billed twice on the same date, or very similar charges close together, ask questions. One duplicate might be a billing error, but multiple duplicates suggest intentional fraud. Also look for services billed under your name but at a location you've never visited — that's a strong sign someone is using your Medicare number without your knowledge.

Keep your own records. Write down the dates you visit the doctor, what services you receive, and what you're charged. When your EOB arrives, match it against your notes. This straightforward step catches most fraud quickly, before it becomes a pattern.

How Medicare fraud affects you

When fraud happens, Medicare's trust fund loses money. That money comes from payroll taxes and premiums paid by current and future beneficiaries. As fraud increases, Medicare has less to spend on legitimate care, which can mean higher premiums, higher deductibles, or reduced coverage for services you actually need.

Fraud also affects your medical record. If a provider bills for services you never received, those charges can end up in your health history. If someone uses your Medicare number fraudulently, it can take time to correct the record and prove the services weren't yours. This can cause problems if you need to dispute a bill or if inaccurate information influences a doctor's treatment decisions.

Your out-of-pocket costs can rise too. If you're billed for unnecessary services, you may owe a copay or coinsurance even though the service shouldn't have been provided. If a provider upcodes, you pay a higher share of the inflated bill.

How to report suspected Medicare fraud

Call the Medicare fraud hotline at 1-800-MEDICARE (1-800-633-4227). This is the official number to report fraud, waste, or abuse. Have your Medicare number, the provider's name and location, the date of service, and a description of what happened. You don't need to have proof — a description is enough to start an investigation.

You can also report online through the official Medicare website. Go to Medicare.gov and look for the "Report Fraud, Waste, or Abuse" section. Fill out the form with the same information you would give over the phone. Online reporting creates a record you can reference later if you want to follow up.

If you suspect fraud by a specific type of provider — a durable medical equipment supplier, a home health agency, a lab — you can also contact your state's Medicaid Fraud Control Unit. These units investigate both Medicare and Medicaid fraud and have authority to pursue criminal charges if warranted.

Report fraud even if you're not sure. Medicare investigators are trained to sort out what's intentional deception and what's a billing error. If you saw something that didn't look right, report it. You're protected from retaliation, and your report helps protect other beneficiaries.

Protecting yourself from Medicare fraud

Guard your Medicare number like you guard your Social Security number. Don't give it to anyone except your doctor, hospital, or pharmacy. Scammers call seniors claiming to be from Medicare and ask for the number — Medicare will never call you asking for it. If someone calls asking for your Medicare number, hang up and call Medicare directly at 1-800-MEDICARE to report the call.

Be cautious about unsolicited offers. If a supplier calls offering free medical equipment, free testing, or free services, ask questions. Legitimate providers don't cold-call beneficiaries offering free things. If you didn't request the service and don't remember agreeing to it, don't accept it.

Ask your doctor before any test or procedure. If a provider orders something you don't understand, ask why it's necessary and what it will show. If the answer doesn't make sense or seems unrelated to your condition, get a second opinion. You have the right to know why a service is being provided.

Review your statements every month. This is your strongest defense. Most fraud is caught because a patient noticed a charge they didn't recognize. Set aside 15 minutes each month to look at your EOB. If something looks wrong, call the provider or Medicare.

The difference between fraud, waste, and abuse

Fraud is intentional deception — someone knowingly lies to get paid. Waste is spending Medicare money in a way that's not efficient or cost-effective, but without intent to deceive. A provider might order more tests than necessary because they're being cautious, not because they're trying to bill fraudulently. Abuse is billing practices that don't follow Medicare rules but may not be intentional fraud — like billing at the wrong rate or using the wrong code.

All three cost Medicare money, and all three should be reported. You don't need to figure out which category something falls into — just describe what you saw, and Medicare investigators will determine whether it's fraud, waste, or abuse.

Frequently Asked Questions

Can I get in trouble for reporting fraud if I'm wrong?

No. You are protected from retaliation when you report suspected fraud in good faith. If you describe what you saw and it turns out to be a billing error rather than fraud, you won't face any consequences. Medicare investigators are trained to distinguish between honest mistakes and intentional deception.

What happens after I report fraud?

Medicare's Office of Inspector General investigates your report. You typically won't hear back about the outcome — investigations are confidential. But if fraud is confirmed, the provider may be required to repay Medicare, face fines, or lose the right to bill Medicare. Serious cases can result in criminal charges.

What if I think my doctor is committing fraud but I'm not certain?

Report it anyway. Describe exactly what you observed — the service you received, what you were charged, and why it seemed wrong. Let the investigators determine whether it meets the definition of fraud. It's better to report something that turns out to be legitimate than to stay silent about something that isn't.

Can someone use my Medicare number to commit fraud?

Yes, and it happens. If you see charges for services you never received or at locations you've never visited, report it when ready. Contact Medicare and ask them to investigate whether your number was used fraudulently. You may need to request a new Medicare number if the fraud is extensive.

Is billing for an unnecessary service always fraud?

Not always. Sometimes a provider orders a test that turns out not to be necessary, but they had a reasonable medical reason to order it at the time. That's waste or poor judgment, not fraud. Fraud requires intent — the provider knew the service wasn't necessary and billed for it anyway to make money.