Haris Ashley
Pharmacy and prescription drug fraud is a lucrative and consistent trend in Medicare. Criminals exploit Medicare Part D by billing for medication that was not received or intentionally giving beneficiaries different prescriptions than those that were initially recommended. This type of fraud can also occur when patients acquire prescriptions under false pretenses, providers write illegitimate prescriptions, or pharmacies process phantom claims. To combat this, health plans and pharmacy benefit managers (PBMs) can choose to only contract with legitimate pharmacy providers. Additionally, the FBI's Internet Crime Complaint Center (IC3) at ic3.gov provides a platform for reporting healthcare fraud, while Medicare offers a hotline, 1-800-MEDICARE (1-800-633-4227), and an online reporting system for suspected fraud.
| Characteristics | Values |
|---|---|
| Types of insurance fraud | Double billing, Phantom billing, Unbundling, Upcoding, Bogus marketing, Identity theft/identity swapping, Creating or using forged prescriptions |
| Reporting | Contact your health insurance provider, Call 1-800-MEDICARE (1-800-633-4227), Report Medicare Fraud online, Visit ic3.gov (FBI's Internet Crime Complaint Center), Call Investigations Medicare Drug Integrity Contractor (I-MEDIC) at 1-877-7SAFERX (1-877-772-3379) |
| Preventative measures | Treat health insurance information like a credit card, Beware of "free" services, Check your explanation of benefits (EOB) regularly, Compare the dates and services on your calendar with Medicare statements, Protect your personal information, Be aware of what a Medicare health or drug plan can and can't do |
| Organizations involved in prevention and investigation | Centers for Medicare and Medicaid Services (CMS), National Health Care Anti-Fraud Association, National Insurance Crime Bureau, Insurance investigative units, FBI, Office of Inspector General, U.S. Department of Health and Human Services |
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What You'll Learn
Reporting to the FBI's IC3
The FBI's Internet Crime Complaint Center (IC3) is the main intake form for a variety of complaints, including cyber-enabled frauds and scams, and cybercrime. IC3 is an important tool that helps the FBI to investigate reported crimes, track trends and threats, and, in some cases, even freeze stolen funds. IC3 also shares reports of crime throughout its network of FBI field offices and law enforcement partners, strengthening the collective response to crime both locally and nationally.
You can file a report with IC3 to share information with the FBI, even if you are unsure whether your complaint qualifies. IC3 cannot respond directly to every submission, but the organisation takes each report seriously.
IC3 accepts reports of health care fraud, including insurance fraud. Health care fraud is not a victimless crime, and it affects everyone, causing tens of billions of dollars in losses each year. The FBI is the primary agency for investigating health care fraud, for both federal and private insurance programs.
Examples of health care fraud include double billing, phantom billing, unbundling, upcoding, bogus marketing, and identity theft/identity swapping. Double billing involves submitting multiple claims for the same service. Phantom billing is billing for a service visit or supplies the patient never received. Unbundling is submitting multiple bills for the same service. Upcoding is billing for a more expensive service than the patient received. Bogus marketing is convincing people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identities, or enrol them in a fake benefit plan. Identity theft/identity swapping involves using another person's health insurance or allowing another person to use your insurance.
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Medicare fraud phone line
If you suspect Medicare fraud, there are several phone lines you can call to report it. Medicare fraud and abuse can happen anywhere, so it's important to be vigilant and protect your personal information. Here are some dedicated phone lines for reporting Medicare fraud:
1-800-MEDICARE (1-800-633-4227)
This is the general Medicare fraud reporting line. You can call this number to report any suspected instances of Medicare fraud or abuse. They will be able to guide you through the process of reporting and investigating your concerns.
1-877-7SAFERX (1-877-772-3379)
This number is specifically for providers who suspect that their identity has been stolen. The line is operated by the Office of Inspector General (OIG) Hotline Operations, which accepts complaints about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services' programs, including Medicare.
Investigations Medicare Drug Integrity Contractor (I-MEDIC)
If you have a Medicare Advantage Plan or Medicare drug plan, you can also report fraud by calling the I-MEDIC line at 1-877-7SAFERX. This line is dedicated to investigating fraud related to Medicare drug plans.
Local Senior Medicare Patrol (SMP)
The SMP is a local organization that can provide assistance in reporting suspected Medicare fraud. You can call or locate your local SMP online to get help with the reporting process. They are there to support you if you suspect any fraudulent activity.
Remember, it is important to regularly check your Medicare claims and compare them with your records to identify any discrepancies that may indicate fraud. If you ever suspect fraud, don't hesitate to reach out to these resources for help.
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Online reporting of Medicare fraud
Medicare fraud can take many forms, including criminals stealing directly from Medicare or doctors, pharmacies, or medical suppliers providing unnecessary care or equipment. It is important to protect your Medicare card and personal information, and to regularly check your Medicare claims to spot and prevent fraud.
If you suspect Medicare fraud, there are several ways to report it. You can call the Medicare Fraud hotline at 1-800-MEDICARE (1-800-633-4227) or report it online. If you have a Medicare Advantage Plan or Medicare drug plan, you can also contact the Investigations Medicare Drug Integrity Contractor (I-MEDIC) at 1-877-7SAFERX (1-877-772-3379). Additionally, you can reach out to your local State Health Insurance Assistance Program (SHIP) for assistance.
The Office of Inspector General's (OIG) Hotline also accepts complaints about potential fraud, waste, abuse, and mismanagement in Medicare and other U.S. Department of Health and Human Services programs. You can submit an online complaint through their website.
In Washington State, the Office of the Insurance Commissioner provides resources for reporting Medicare fraud. You can call the Statewide Health Insurance Benefits Advisors (SHIBA) at 800-562-6900 or submit a fraud report online. They also offer volunteer assistance to help you understand Medicare and assess your needs.
It is important to keep records of your receipts, bills, and Medicare statements to help identify and prevent fraud. Additionally, be cautious about sharing your Medicare card and personal information. By staying vigilant and utilizing the available resources, we can all play a part in combating Medicare fraud.
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Health plan and PBMs
Health insurance fraud is a costly crime that affects everyone. It causes billions of dollars in losses annually, leading to increased health insurance premiums, unnecessary medical procedures, and higher taxes. To combat this, health plans and pharmacy benefit managers (PBMs) can play a crucial role in reducing fraudulent payments. By only contracting with legitimate pharmacy providers, health plans and PBMs can proactively prevent fraud instead of relying on recovering payments from third parties after the fraud has occurred.
AMCP, an organization working to combat fraud, waste, and abuse in prescription drug benefits, advocates for exemptions that would allow health plans and PBMs to suspend payments when there is credible evidence of fraud. This approach would enable them to proactively address suspected fraud before any payments are made. Additionally, AMCP opposes "any willing provider" requirements, which mandate that MCOs contract with any pharmacy that agrees to the terms and conditions of an organization's contract. Such requirements hinder the ability of health plans and PBMs to thoroughly investigate suspected fraudulent activity.
To further strengthen the fight against fraud, AMCP emphasizes the need for adequate funding for the CMS Center for Program Integrity, which is responsible for identifying and prosecuting suspected fraud within Medicare and Medicaid programs. With sufficient resources, this division could save taxpayers millions of dollars annually.
If you suspect health insurance fraud, there are several avenues for reporting it. The FBI, as the primary agency for investigating healthcare fraud, provides the website ic3.gov for reporting such crimes. Additionally, the Federal Bureau of Investigation's Internet Crime Complaint Center (IC3) is a valuable resource for reporting healthcare fraud. Protecting your health insurance information is essential; treat it with the same care as your credit card information. Regularly review your Explanation of Benefits (EOB) to ensure that billed dates, locations, and services match what you received. If you notice any discrepancies, contact your health insurance provider to address these concerns.
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Prescription drug fraud
The FBI's Internet Crime Complaint Center (IC3) can be used to report health care fraud. The National Health Care Anti-Fraud Association, the National Insurance Crime Bureau, and insurance investigative units can also be contacted. The Office of Inspector General (OIG) also accepts tips and complaints about potential fraud in the U.S. Department of Health and Human Services' programs, including Medicare and Medicaid.
The Centers for Medicare and Medicaid Services (CMS) estimates that fraud costs taxpayers billions of dollars annually. AMCP supports efforts to enhance law enforcement's ability to combat prescription fraud, such as the adoption of electronic prescribing systems, which reduce fraud at the pharmacy point-of-sale. AMCP also supports exemptions from laws that require payment within a short timeframe, allowing health plans to suspend payment when there is credible evidence of fraud.
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Frequently asked questions
Pharmacy insurance fraud is when Medicare is billed for a medication that was not received or a beneficiary is intentionally given a different prescription drug than was prescribed. This can also include patients acquiring prescriptions under false pretenses, providers writing illegitimate prescriptions, and pharmacies processing phantom claims.
You can compare the dates and services on your calendar with the Medicare statements you get to make sure you got each service listed and that all the details are correct. You can also check your Explanation of Benefits (EOB) regularly to ensure the dates, locations, and services billed match what you received.
You can report suspected pharmacy insurance fraud to the FBI's Internet Crime Complaint Center (IC3) at ic3.gov. If you have Medicare, you can also call 1-800-MEDICARE (1-800-633-4227) or the Investigations Medicare Drug Integrity Contractor (I-MEDIC) at 1-877-7SAFERX (1-877-772-3379).
