[Last updated October 2, 2025]
Medicare, the federal health insurance program for adults 65 and over, is supposed to give peace of mind, not stress. Yet every year, criminals exploit the system with scams that cost billions of dollars. In doing so, they also put seniors at risk of losing money, personal information, and possibly even access to care. Knowing how Medicare fraud works and how to spot it can make it easier to protect both your health and your benefits. Here, we’ll go over what Medicare fraud is, the consequences of this type of fraud, how to spot it, and what to do if you think you’re a victim.
What is Medicare fraud?
Medicare fraud is any intentional deception that results in unauthorized Medicare payments. It affects taxpayers who fund Medicare with their tax dollars, and it affects seniors who may have to spend time straightening out mistaken billing for products and services they never requested or received.
Fraud statistics are hard to pinpoint. In governmental reporting, these statistics are typically rolled in with billing errors and administrative mistakes, labeled as “improper payments,” and estimated to be around $60 billion a year.
Medicare plays a crucial role in seniors’ health care, which makes them more vulnerable to anything that puts that care at risk. Fraudsters know older adults are prime targets. Understanding the most common scams is the first step toward avoiding them.
Common types of Medicare fraud
Here are the schemes seniors are most likely to come across:
| Type of fraud | How it works | Red flags |
| Identity theft | Scammers pose as Medicare reps to steal your Medicare number and file false claims. | Threats to suspend your benefits unless you share personal info. |
| Bogus marketing | Fake offers for free or discounted equipment or unauthorized Medicare Advantage sales. | Unsolicited calls about plans or equipment. |
| Forgery | Criminals use stolen prescription pads to order drugs or durable medical equipment. | Calls asking you to verify your coverage, but you didn’t request care or schedule an appointment. |
| Prescription drug diversion | Fraudsters steal prescriptions to resell or use themselves. | Your prescriptions stop arriving or are altered. |
| Impersonating providers | Unlicensed individuals pose as doctors and bill Medicare. | Care from providers who seem unverified or evasive. |
| Phantom billing | Providers bill for services, meds, or equipment you never received. | Strange charges in your explanation of benefits (EOB). |
| Double billing | The same service is billed more than once. | Duplicate charges for one date of service. |
| Upcoding | Providers bill for a more complex (and costly) service than they provided. | Routine visits are coded as surgeries or specialized consultations. |
Consequences of Medicare fraud
Fraudsters who get caught may face prison and heavy fines, but the fallout for seniors can be personal and lasting. Here are some examples:
- Financial loss: Paying copays or coinsurance on items or services you never received.
- Coverage problems: Hitting coverage limits early or being denied needed services because your record shows they’ve already been provided.
- Compromised health: Delays in getting legitimate prescriptions, tests, or treatments.
How to spot Medicare fraud
The best way to avoid getting caught up in Medicare fraud is to be alert for:
- Unsolicited calls, emails, or texts asking for your Medicare or Social Security number.
- Threatening language (“Your benefits will be cut off if you don’t respond”).
- Offers that seem too good to be true.
- Errors, duplicate charges, or unfamiliar providers listed on your Medicare summary notice (MSN) or EOB.
What to do if you suspect fraud
The Centers for Medicare and Medicaid Services (CMS) has a Reporting Medicare Fraud and Abuse webpage with helpful fraud prevention tips and examples of the most common types of Medicare fraud and abuse.
In addition to being familiar with the traps that fraudsters could be setting for you, you can also take these actions:
- Protect your information. Treat your Medicare number like a credit card, and never share it with strangers.
- Hang up on suspicious calls. Medicare rarely calls you directly unless you’ve requested it.
- Check your paperwork. Review your Medicare summary notice or explanation of benefits regularly for errors.
- If you believe you’ve been approached by fraudsters, whether they succeeded in scamming you or not, report it immediately:
- Call Medicare at 1-800-MEDICARE (1-800-633-4227).
- Report to the Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477).
- If your identity has been stolen, contact the Federal Trade Commission (FTC) immediately.
Your role in preventing Medicare fraud
The government has teams of agents and investigators working cases to stop the loss of Medicare resources. However, all Medicare beneficiaries play a vital role. Instead of letting those thick envelopes reporting all incurred charges pile up in a drawer, open them and scan through to see if you recognize all the doctors, procedures, and equipment. Don’t assume that because you’re careful with your Medicare card, you couldn’t be caught up in fraud.
Medicare fraud schemes are becoming more sophisticated, especially with the growing use of AI. However, by staying informed, vigilant, and proactive, you have your best defense. By recognizing red flags and acting promptly, you can safeguard your health, benefits, and peace of mind.
