Medicare scams: how they work and how to shut them down

Medicare fraud is not a fringe problem. It is an organized industry that costs the program tens of billions of dollars a year, and the raw material it runs on is Medicare numbers taken from people over the phone. Older adults are targeted deliberately, relentlessly, and with a level of professionalism that catches sharp, capable people all the time.

So this guide contains no advice about being more careful. Careful is not the variable. Knowing the specific scripts is.

A caveat that trips people up: a plan your parent already belongs to may legitimately call them, and so may their doctor's office. The distinction is who initiated contact and what is being requested. If your parent did not initiate it and the caller wants the number, the answer is no. They can always hang up and call the organization back on a number they look up themselves.

• Free genetic or cancer screening. A caller offers a free cheek-swab DNA test to check for hereditary cancer risk, sometimes at a health fair or a church event. The swab is real, the test is billed to Medicare at an enormous figure, and the results are usually never returned or are clinically meaningless.
• Free braces and equipment. Back braces, knee braces, wrist braces — offered unsolicited, shipped without an examination, billed to Medicare. Often the patient never even opens the box.
• Catheters and other supplies. Large-scale schemes have billed Medicare for urinary catheters and similar supplies for patients who never ordered them and never received them. Frequently the first sign is a line on a statement.
• The new card. A caller says Medicare is issuing new plastic or metal cards and needs the current number to process it. Medicare is not issuing new cards, and never charges for a replacement.
• The plan switch. During the autumn enrollment season, cold callers pose as Medicare or as an official helpline to move people onto a different plan. Some are outright fraud; others are aggressive brokers who will happily move your parent off a plan their oncologist accepts.
• COVID or flu test kits. Boxes of tests shipped unsolicited, billed to Medicare, sometimes repeatedly.
• Hospice enrollment. The cruelest one. Someone signs a person up for hospice care they do not need and do not understand, in exchange for a gift card or free housekeeping. It can quietly interfere with their regular Medicare coverage.
• The refund. A caller says Medicare owes your parent money and needs their bank details to send it.

A stolen credit card gets cancelled in a phone call and the loss is capped. A Medicare number is different. It can be billed against by multiple fake providers for years, it is difficult and slow to change, and the damage is not only financial — fraudulent claims can end up in your parent's medical record, where a diagnosis they never had or equipment they never received can affect future coverage decisions.

Treat the number the way you would treat a passport. It goes to the doctor, the pharmacy, the hospital and the insurer. It does not go to anyone who rings up.

Every quarter, Original Medicare sends a Medicare Summary Notice listing what was billed. Advantage and Part D plans send an Explanation of Benefits. Most people file these unread, and they are the single best fraud detector available.

1. 1.Check the dates against reality. Was your parent actually at a medical appointment that day?
2. 2.Check the provider names. An unfamiliar name, especially a laboratory or equipment supplier in another state, is worth a question.
3. 3.Check for equipment and supplies. Braces, catheters, test kits and monitors that never arrived are the classic pattern.
4. 4.Check for duplicates — the same service billed twice on the same day.
5. 5.Compare against the appointment calendar if your parent keeps one. Families who track appointments spot this in minutes.

Your parent can also see claims as they are processed, rather than waiting for a paper notice, by logging into their account on Medicare's website. For a family member doing the checking, that is far more practical than intercepting post.

This is the part most guides skip, and it is the part that decides whether any of the above happens. People who have been scammed very often do not tell their families, because they are ashamed and because they are frightened that this will be used as evidence that they can no longer manage on their own.

That fear is not irrational, and it is worth defusing directly. A few things help:

• Lead with the professionalism of the criminals rather than the mistake. These operations run scripts refined on thousands of calls; being taken in is not a character flaw or a sign of decline.
• Make it mutual. Talk about the scam call you got last month. It changes the conversation from an assessment into a shared annoyance.
• Give them a script instead of a rule. "I don't give that out over the phone, I'll call you back" is easier to use than a general instruction to be careful.
• Set up call screening on the phone rather than relying on judgement in the moment.
• Offer to be the second pair of eyes on statements, framed as a chore you are taking off their hands rather than supervision.
• Never say "I told you." The cost of that sentence is that the next one goes unreported.

Navigators review statements as a matter of routine, which means fraudulent charges tend to surface early rather than after a year of billing. When something looks wrong we call the provider, and we can tell the difference between an ordinary coding error and a pattern worth reporting. If a number has been compromised we work the process with Medicare, and we make sure any bogus diagnoses that landed in the record get challenged, because those cause problems long after the money is sorted out.