What is Medicare Fraud?

Medicare fraud occurs when a hospital, nursing home, doctor's office, hospice care facility, ambulance service, pharmacy, rehabilitation center, or any other type of healthcare provider overbills Medicare.


Who can report Medicare fraud?

Medicare fraud whistleblowers are almost always healthcare professionals. They are commonly employed as hospital administrators, nurses, hospice or nursing home workers, ambulance drivers, pharmacists, or as any other type of healthcare professionals.

Receive a financial reward for your information.

Healthcare professionals may be entitled to a significant financial reward for becoming Medicare whistleblowers. Learn about receiving a financial reward for your information here.


Deputy Inspector General discusses nursing home Medicare Fraud in the US - Page 3
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Another item in wide use in nursing homes is incontinence supplies. His group fund that up to half of allowances for these supplies involved questionable billing practices in 1993.

Another widely abused service in nursing homes is mental health services. Grob said a review his organization conducted indicated that over 30 percent of the records they reviewed revealed Medicare paid for unnecessary services. The figure? $17 million or 24 percent of all 1993 Medicare payments.

One particularly costly and recurring issue Grob pointed out was the excessive cost of Medicare Part A ancillary services. Since these services are not subject to the per diem limit, they are ripe for abuse.

He cited examples in the use of portable x-rays, enteral nutrition and I-V poles as examples. In some cases, these charges would be more appropriately billed under Medicare Part B with much tighter guidelines.

Hospice services marked another category that is open to rampant Medicare payment abuse. His group’s studies have shown up to 1 in 5 nursing home patients enrolled in these programs didn’t really belong in them.

Another problem is that nursing home patients in hospice programs often receive lesser benefits than hospice patients in their own homes. Equally, many of the treatments these nursing home patients received would have been provided by the nursing home anyway.

Another danger he pointed out is that patients enrolled in the hospice program automatically disqualify themselves from curative care. As a result, inappropriately enrolled patients could have their very lives endangered from this inappropriate enrolment.

Solutions to combat Nursing home Medicare fraud


Although he painted a glum picture of the widespread abuse of the system, Grob also offered hope to bring the ship right.

The previously mentioned Operation Restore Trust, in conjunction with the Office of the Inspector General and Health Care Financing Administration have initiated a number of programs. These include state teams, Medicaid fraud control groups with the assistance of Department of Justice and State attorneys and local law enforcement officials.

Grob pushes for legislative changes to rectify structural issues within the Medicare and Medicaid programs. For instance, he believes a move to a prospective payment system would go a long way to curb many of the abuses.

He also pushes for a more simplified categorization of payments. He said the complexities built into today’s system encourage unbundling of services and creative ways of sidestepping payment limits.

Every suggestion he made would create an environment where nursing home facilities would strive to achieve economy in the provision of goods and services, in opposition to the way many homes operate today, while still staying within the current laws and guidelines.

At the same time, Mr. Grob pointed out the necessity to keep patient care utmost in the discussion of any changes. He believes greater vigilance, cost-cutting and fraud reduction can co-exist very easily with the continued emphasis on patient care.

Report Nursing Home Fraud/Medicare fraud here.

Do you work for a nursing home that is committing Medicare fraud? Help stop government waste and abuse, and get rewarded for your efforts. Our attorneys have significant experience representing healthcare industry whisteblowers. Complete the secure form on this page or call 1-800-581-1790 for a free no obligation consultation with a lawyer.