medicare fraud prevent report

 Fraud, Waste & Abuse
Medicare – Healthcare

Health Care Fraud is #defined as 

 “knowingly and willfully executing, or attempting to execute, a scheme or artifice

  • to defraud any health care benefit program; or
  • to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health benefit program.” 

Healthcare fraud can result in civil and criminal penalties that include fines, monetary damages, and even imprisonment.  Additionally, there is a penalty of up to 20 years in prison or life in prison if the violation resulted in a person’s death. 18 U.S.C. §1347

Fraud occurs when

someone knowingly lies to obtain some benefit or advantage to which they are not otherwise entitled or someone knowingly denies some benefit that is due and to which someone is entitled.


Waste includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.


Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.  The Medicare Learning Network®

Pamphlets, Brochures & Websites to help prevent Fraud




YouTube VIDEO's

you tube videos

#Risk Adjustment Fraud?

making patients look sicker than they are,”

False COVID Statistics?


With COVID going on, so many on Facebook are saying the COVID numbers are inflated so that hospitals & insurance companies can get more $$$.   Based on the rules of Risk Adjustment Fraud, I don’t think so.  Here’s the CDC rules for reporting deaths due to COVID.   See also the video at right or scroll down.


UHC and Anthem Blue Cross (and another article) were once accused of “gaming” the Medicare Advantage payment system by

making patients look sicker than they are,”  Risk Adjustment Fraud?

Damages are speculated to top $1 billion.

Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year.

“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,”

When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score. 

Resources, Links & Bibliography




#Latest Busts 

IRS Urges Public to Stay Alert for #Scam Phone Calls


The IRS continues to warn consumers to guard against scam phone calls from thieves intent on stealing their money or their identity. Criminals pose as the IRS to trick victims out of their money or personal information. Here are several tips to help you avoid being a victim of these scams:

  • Scammers make unsolicited calls.  Thieves call taxpayers claiming to be IRS officials. They demand that the victim pay a bogus tax bill. They con the victim into sending cash, usually through a prepaid debit card or wire transfer. They may also leave “urgent” callback requests through phone “robo-calls,” or via phishing email.
  • Callers try to scare their victims.  Many phone scams use threats to intimidate and bully a victim into paying. They may even threaten to arrest, deport or revoke the license of their victim if they don’t get the money.
  • Scams use caller ID spoofing.  Scammers often alter caller ID to make it look like the IRS or another agency is calling. The callers use IRS titles and fake badge numbers to appear legitimate. They may use the victim’s name, address and other personal information to make the call sound official.
  • Cons try new tricks all the time.  Some schemes provide an actual IRS address where they tell the victim to mail a receipt for the payment they make. Others use emails that contain a fake IRS document with a phone number or an email address for a reply. These scams often use official IRS letterhead in emails or regular mail that they send to their victims. They try these ploys to make the ruse look official.
  • Scams cost victims over $23 million.  The Treasury Inspector General for Tax Administration, or TIGTA, has received reports of about 736,000 scam contacts since October 2013. Nearly 4,550 victims have collectively paid over $23 million as a result of the scam.

The IRS will not:

  • Call you to demand immediate payment. The IRS will not call you if you owe taxes without first sending you a bill in the mail.
  • Demand that you pay taxes and not allow you to question or appeal the amount you owe.
  • Require that you pay your taxes a certain way. For instance, require that you pay with a prepaid debit card.
  • Ask for your credit or debit card numbers over the phone.
  • Threaten to bring in police or other agencies to arrest you for not paying.

If you don’t owe taxes, or have no reason to think that you do:

  • Do not give out any information. Hang up immediately.
  • Contact TIGTA to report the call. Use their “IRS Impersonation Scam Reporting” web page. You can also call 800-366-4484.
  • Report it to the Federal Trade Commission. Use the “FTC Complaint Assistant” on Please add “IRS Telephone Scam” in the notes.

If you know you owe, or think you may owe tax:

  • Call the IRS at 800-829-1040. IRS workers can help you.

Phone scams first tried to sting older people, new immigrants to the U.S. and those who speak English as a second language. Now the crooks try to swindle just about anyone. And they’ve ripped-off people in every state in the nation.

Stay alert to scams that use the IRS as a lure. Tax scams can happen any time of year, not just at tax time. For more, visit “Tax Scams and Consumer Alerts” on

Each and every taxpayer has a set of fundamental rights they should be aware of when dealing with the IRS. These are your Taxpayer Bill of Rights. Explore your rights and our obligations to protect them on


Scammers also know that whenever there’s a change or even discussion about possible changes in government programs or policy, the time is ripe to capitalize on consumers’ uncertainty by trying to get them to reveal personal information.


  • Government agencies already have your personal information on file. Unless you initiate contact, you will never be asked to provide or verify that data.
  • Don’t be fooled if your Caller ID screen indicates that a call is from an agency you recognize. Scammers have technology that lets them display any number or organization name on your screen.
  • Government agencies do not send unsolicited emails. Official correspondence is typically delivered by U.S. mail. If you get such a letter, you can authenticate it by looking up the agency’s phone number yourself in a directory and calling the agency.
  • Don’t expect government employees to make unannounced door-to-door visits about new or revised programs. You’ll typically receive advance notification of any official knock on your door, and your personal information will already be known to legitimate federal employees.


  • False and Fraudulent Claims  1871-1871.8
  • Bureau of Fraudulent Claims 1872-1872.96
  • Insurance Fraud Reporting  1873-1873.4
  • Motor Vehicle Theft and Motor Vehicle Insurance
  • Fraud Reporting  1874-1874.81
  • Insurer Inspections  1874.85-1874.87
  • Auto Insurance Fraud Crisis Areas  1874.90-1874.91
  • Arson Investigations .1875-1875.8
  • Insurance Claims Analysis Bureaus 1875.10-1875.18
  • Insurer Fraud Investigation  1875.20-1875.23
  • Deposit of Automobile Insurance Claims  Information .1876-1876.5
  • Workers’ Compensation Insurance Fraud Reporting   1877-1877.5
  • Insurance Fraud Prevention  §1879-1879.8
  • USC 1347 Federal Law on  Health Care Fraud
  • Medicare – Part D Fraud – Final Rules – Federal Register

Medi Cal – #MediCaid Fraud


  • Medi Cal, IRS, Failure to Report, ect
  • Question? There is a Medi-cal fraud issue here #right?
    • Dad is a police man with great health coverage. Baby is born. Employer pays $1,600 in coverage for family. Mother is a waitress on medi-cal.
      • Mom signs baby up for medi-cal and doesn’t mention dad being present, if involved at all. Mom does not mention dads health coverage.
        • It is believed mom notified DHSS dad is completely absent.
    • Dad never puts baby on his employer coverage due to having his head up his ass at birth of child yet starts paying 700 a month for support directly to mom.
    • 22 months go by, IRS sends mom a letter in the mail discussing penalties. Two weeks later mom makes a complaint to dads work for alleged harassment. This eventually leads to termination of dad.
    • Are there any employer mandates that could’ve been violated here? Anything related to 3751.5 of the family code?
    • If the mom got a penalty letter from the IRS, wouldn’t the employer also get one? There is a Medi-cal fraud issue here right?
    • What will happen in court if dad had employer coverage with mom said dad didn’t since the birth of child? Vs now dad doesn’t since moms complaint removed dads income and health coverage?
  • Answer

Web visitor Q & A

What year are you working through these Death Plans [Medicare Advantage]? I have been fighting with UHCA (which is a misnomer because is has no advantage ) since 2018 and and up to Level 4 with appeals and Maximus.

There is no control over Managed Health Plans.
There are no consequences for Managed Health Plans abusing seniors taking money from Medicare and tell bold face lies to cover their tracks.

We need a class action case but who will we take on? All Managed Health Plans do these things to some extent. Things will only get worse.


Managed Health Plans have tons of control.



#Links & Resources


Consumer Resources

How to Avoid Becoming a Victim of Insurance Fraud
An illustrated brochure describing the warning signs of insurance fraud and some concrete steps you can take to avoid becoming a victim. This brochure contains information helpful to all consumers. It details several types of insurance fraud, such as fake policies, premium fraud, unlicensed agents, unnecessary services, and insurance scams. It also describes how to get your money back and where to complain about insurance fraud.

National Health Care Anti-Fraud Association is the leading national organization focused exclusively on the fight against health care fraud. We are a private-public partnership — our members comprise more than 100 private health insurers and those public-sector law enforcement and regulatory agencies having jurisdiction over health care fraud committed against both private payers and public programs. Established in 2000,

The NHCAA Institute for Health Care Fraud Prevention is a separately incorporated, tax-exempt educational foundation that provides education and training to private- and public-sector health care anti-fraud personnel.

Preventing Credit Card Fraud: Learn How to Protect Yourself
A brochure, available in English and Spanish that describes how crooks steal and use credit cards and card numbers and explains how to protect your credit card and what to do if your card has been stolen.
By Consumer Action.

California Court Website on Fraud & Cyber Crime

Report   Worker’s Compensation Fraud

#Money Laundering

  • Patriot Act  
  • Placement is the initial stage in which money from criminal activities is placed in financial institutions.
    • One of the most common methods of placement is structuring—breaking up currency transactions into portions that fall below the reporting threshold for the specific purpose of avoiding reporting or recordkeeping requirements. Because most carriers do not accept cash payments, insurance producers should be on the lookout for cash equivalents. Gene’s opening of multiple accounts and making payments with bank checks of less than $10,000 are examples of placement and structuring.
  • Layering is the process of conducting a complex series of financial transactions, with the purpose of hiding the origin of money from criminal activity and hindering any attempt to trace the funds. In this scenario, Gene’s movement of money between accounts and his exercise of the 10-day free-look provision are examples of layering.
  • Integration is the final stage in which an apparently legitimate transaction is used to return the now-laundered funds back to the criminal. Gene’s request to take redemptions from his mutual funds is considered integration as he now has checks from financial institutions.

Insurance Agent – Broker Duty to #Report1 Fraud

Agents and brokers will be required to report fraud (See links below) to the California Department of Insurance (CDI).

More specifically, SB 1242 amends the California Insurance Code to require producers who suspect or know a fraudulent application or claim for insurance is being made to submit to the DOI Fraud Division via the electronic Consumer Fraud Reporting Portal (see below)  information regarding the factual circumstances of a dubious application and the alleged misrepresentations it contains.

This must be done within 60 days after the producer determines fraud has or may have occurred. Of note, the mandated notification cannot be made anonymously.

Where suspected or known fraud is discovered after an application has been placed with a carrier, the agent or brokers will be obligated from January 1 onward to report it to the impacted insurer (specifically, their special investigation unit), along with all documents and evidence that the unit may later request.

These reporting obligations are entirely new. Only carriers were previously burdened with fraud reporting requirements.

Consequently, agents and brokers should not turn a blind eye to obvious fraudulent conduct by any insurance applicant. Doing so could come with risk. SB 1242 creates regulatory exposure for failing to comply with the law.

The good news is that agents and brokers who fulfill their duties by reporting fraud or assisting with related investigations are insulated from civil liability, assuming they have acted in good faith.  Insurance Journal *


CA DOI Department of Insurance

File a Consumer Complaint Online
Independent Medical Review

Enforcement Branch Overview

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