Medicare contractors are responsible for administering Medicare benefits to millions of beneficiaries throughout the nation. This responsibility is taken very seriously.

Each contractor strives to do everything possible to control unnecessary or inappropriate Medicare costs so that beneficiaries receive the maximum benefit from the program. Every effort is taken to ensure that payments made are for covered services rendered to Eligible Individuals and performed by Qualified Physicians, other Health Care Providers and Suppliers.

Medicare Program Safeguard areas use a variety of methods to control violations of Medicare guidelines. Great strides have been made in preventing incorrect and inappropriate Medicare payments by educating Medicare beneficiaries to report what they consider to be billing irregularities.

Medicare contractors also depend on the physician and health care provider communities to report observed instances of fraud and abuse of the Medicare program. Contractors are concerned about individuals who perform services not because they are needed or appropriate, but simply because Medicare dollars are available to pay for them. There is also concern about individuals who bill for services that were never provided or not performed to the extent reported.

Although only a very small percentage of healthcare professionals engage in fraudulent or abusive practices. Those few are taking needed benefit dollars and damaging the integrity and preservation of the Medicare program. We need your help in identifying those persons.

The Center for Medicare and Medicaid Services defines health care fraud as follows:

• A surgeon bills for more complicated extensive surgery than was actually performed. For example, the size or number of growths removed is inflated, resulting in a higher Medicare reimbursement level than is actually due.
• An independent diagnostic testing facility enters into arrangements with physicians and agrees to pay them for every patient referred for vascular studies. This practice is considered a "kickback" and is specifically prohibited by federal law.
• A physician with many hospital and nursing home patients always bills for intermediate or extended care even when only limited or brief levels of care are given. This billing practice is commonly known as "upcoding".
• A hospital, clinic or independent laboratory "unbundles" a panel laboratory test in an effort to obtain a higher reimbursement.
• A hospital or outpatient clinic bills Medicare for a noncovered service with a covered revenue code.

How You Can Help

If you become aware of a situation or practice that you consider to be potential fraud or abuse, please contact the appropriate Medicare contractor for your state. Being able to contact you during the course of an investigation is very helpful and important, however, you may remain anonymous if you wish.

Medicare contractors view controlling Medicare costs as a partnership – a partnership with physicians, other health care providers, suppliers, the public, and Medicare patients in helping to detect fraud and abuse; and a partnership with government in determining how documented problems should be resolved.