Preventing and Identifying Fraud, Waste and Abuse

MediGold is committed to fighting health care fraud, waste and abuse. One way we're doing this is by sharing helpful information with you.

What is Medicare Fraud?

It's typically characterized by:

  • Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist;
  • Knowingly soliciting, paying and/or accepting payment to induce or reward referrals for items or services reimbursed by federal health care programs; or
  • Making prohibited referrals for certain designated health services.

How Can I Help to Fight Fraud?

If you suspect someone of committing fraud against you or MediGold, please report any suspicious activity by calling Member Services.

Below are several examples of health care fraud:

  • A health care provider bills for services, supplies or items that were not provided.
  • A health care provider bills for more expensive procedures or services than what was provided.
  • A pharmacy bills for prescriptions that were not dispensed.
  • Someone contacts a beneficiary and obtains his/her personal information in order to submit fraudulent claims to receive payment from the insurance company.

Here are some tips to help you avoid becoming a victim of fraud:

  • Never give out your Social Security, Medicare or MediGold ID numbers or your banking information to someone you don't know.
  • Review your Explanation of Benefits promptly and make sure you received the services or items billed.
  • Refuse any medical supplies you did not order.
  • Return unordered medical supplies that are shipped to your home.
  • Report companies that send you items you never ordered.

Updated 01/2020