Medicare Fraud: CMS engages patients in fighting fraud

Do you have an elderly parent or friend? Have you ever taken a look at the Medicare Summary Notice (MSN) they receive each quarter from Medicare?

I don’t know when the last time was that my 92 year old mother looked at hers. I usually check it to make sure there is not some gross overbilling going on, but Mom ignores the statement. It is not the easiest document to review.

According to Karen M. Cheung at, Medicare is taking several steps to make it easier for elderly patients to review their monthly charges. The form and the website has been re-designed to make reviewing the explanation of benefits easier for the elderly Medicare subscribers who use the site. Sample


Drilling down by clicking on  

allows the user to see the details of the Medicare Summary Notice for each claim.

CMS is also making it more obvious that subscribers can earn a reward of up to $1000 for a tip that leads to uncovering fraud. That’s right . . . CMS will pay a Medicare recipient up to $1000 if their tip leads to finding actual fraud. Last year, consumer input resulted in $4 billion of savings, thanks to those who reported suspicious billing. On the MSN, just under the explanation of “How to Check This Notice”, the subscriber sees the following announcement:



Encouraging subscribers to report suspected fraud is one of the major ways CMS plans to save money. If by accident or on purpose, a provider bills for services not provided, for products not delivered, for medically unnecessary services or for misrepresented services, they become subject to a whole host of consequences based on the amount of money involved.

According to Wikipedia, The Office of the Inspector General for the U.S. Department of Health and Human Services is responsible to protect the integrity of HHS programs. The Office of Investigations for HHS works with the FBI to combat Medicare Fraud. The site has its own pages on Fraud & Abuse. The U.S. Department of Health & Human Services and the U.S. Department of Justice have created a site aimed directly at stopping Medicare fraud.

Clearly, this initiative is extremely important to CMS. We were recently surprised by a telephone call from someone claiming to be an FBI agent investigating one of our customers. Whether this was an unhappy patient, a disgruntled former employee, or an actual agent, we do not know. If we were to receive a supoena or request through proper channels, we might know more, but we would never provide information in response to a telephone call.

None of this is unique to the behavioral healthcare community, nor are mental health and addiction providers exempt from concerns about Medicare fraud. Abuses happen in all areas of healthcare.

What is your personal or professional experience with Medicare fraud or abuse? Does your organization have processes in place to prevent mistaken Medicare billing? We would love to hear about how you deal with these issues . . . short of not serving Medicare patients!

Please post your comments below.

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