How to Report Medicare Advantage Fraud and Where to Get Help

Suspected fraud involving a Medicare Advantage or drug plan can be reported to the plan, 1-800-MEDICARE at 1-800-633-4227, or the Investigations Medicare Drug Integrity Contractor at 1-877-772-3379. According to the Centers for Medicare & Medicaid Services, people in the United States can report suspected Medicare fraud to 1-800-MEDICARE. Reporting Medicare Advantage fraud can begin with a suspicious charge, an enrollment you didn’t authorize, or a diagnosis that appears unsupported.

It’s reasonable to want clarity before raising a concern. A billing error isn’t automatically fraud. Compare the statement with the care you received and ask the plan or provider to explain unfamiliar charges. If the explanation doesn’t resolve your concern, report the facts through an appropriate channel.

This article explains common signs of Medicare fraud, how to document what you noticed, and where to report concerns about Medicare Advantage or Part D plans. You’ll also learn when a local Senior Medicare Patrol can help you organize information and understand your next steps.

What are some examples of Medicare fraud?

Fraud involves suspected deliberate deception; waste or abuse can describe improper billing or use that merits review. An unfamiliar claim alone doesn’t prove fraud. Record what you observe, distinguish what you know from what you suspect, and let the facts guide your report.

1. Compare each claim with care received. Review your Medicare Summary Notice or plan’s Explanation of Benefits. Match dates, services, and supplies against your calendar and provider receipts. Original Medicare Summary Notices are mailed every three months when Medicare receives bills for that period. Medicare claims information is available in an online account within 24 hours after processing. If a service or item appears that you didn’t receive, contact the provider or plan and ask for an explanation.
2. Watch for medical identity theft. It occurs when someone uses your personal information without consent to commit Medicare fraud or another crime. A caller offering “free” medical equipment in exchange for your Medicare number may be trying to submit false claims. Don’t give your Medicare number, card, Social Security number, or Social Security card to unsolicited callers or emailers. Share them only with your doctor or others who should have the information.
3. Preserve details about suspicious diagnosis codes. In Medicare Advantage, plans report diagnoses to CMS for risk adjustment. If a plan discovers a submitted diagnosis code is unsupported, it must delete it; failing to do so violates the False Claims Act. The HHS Office of Inspector General identifies knowing submission of false information and failure to correct inaccurate information as conduct addressed in Medicare Advantage cases. Note the records and communications that explain why you suspect a code is incorrect.
4. Understand the whistleblower route. A False Claims Act qui tam lawsuit allows a whistleblower to bring suspected fraud forward. If the government recovers funds because of the lawsuit, the whistleblower may receive a reward. A case can pay the whistleblower 15% to 30% of the government’s recovery. That potential recovery depends on government funds recovered, not simply on submitting a concern.

Referrals to government agencies and law enforcement

1. Send a report to the agency suited to the concern. The HHS Office of Inspector General accepts tips about potential fraud, waste, and abuse in HHS programs. Call 1-800-HHS-TIPS (1-800-447-8477), or use its reporting options by fax or mail. The fax limit is 10 pages. Mail reports to P.O. Box 23489, Washington, DC 20026. You may report without identifying yourself, although investigators may seek follow-up information.
2. Ask a Senior Medicare Patrol about referrals. A local SMP may refer a complaint to HHS OIG, the Centers for Medicare & Medicaid Services, a state attorney general, local law enforcement, a state insurance department, or a State Medicaid Fraud Control Unit. The appropriate destination can depend on the suspected conduct and who may have submitted or paid the claim. Preserve records that explain your concern and identify the entities involved.
3. Understand what enforcement outcomes show. Settlements illustrate how allegations can be resolved, but they don’t establish liability in every case. In September 2023, Cigna paid the federal government $172 million to resolve False Claims Act allegations involving inaccurate patient diagnosis data, without a determination of liability. Sutter Health paid the Justice Department $30 million to settle allegations of unsupported diagnosis codes submitted to CMS.
4. Use public actions as context, not proof of your case. Freedom Health, Optimum Healthcare, and affiliates paid the federal government and Florida $32.5 million to settle a Medicare Advantage fraud case. Kaiser Foundation Health Plan paid $6.37 million to settle a case alleging false risk-adjustment data. These outcomes show that government enforcement can address different alleged conduct, including diagnosis coding and plan data. They don’t prove that a separate billing concern is fraud. Describe the facts you have observed, and let investigators assess them.

Getting help from a local Senior Medicare Patrol

1. Contact your state’s Senior Medicare Patrol. SMP programs serve every U.S. state, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. A local patrol can help identify suspected Medicare fraud and deceptive health care practices. Examples include misleading enrollment efforts, illegal marketing, and billing for medical equipment or services you never received. Tell the SMP where the concern occurred and whether it involves Original Medicare or a Medicare Advantage plan.
2. Describe the concern and share relevant records. SMP staff and volunteers can help gather evidence and consider next steps. Explain what you noticed, when it happened, and which plan, provider, or other entity was involved. You can provide statements, notices, receipts, or correspondence that help clarify the issue. Include your state and how you would like someone to contact you when reporting suspected fraud, errors, or abuse.
3. Protect sensitive information in your report. Don’t include your Medicare number, Social Security number, or other confidential information in a report to an SMP. You can describe the suspicious claim without exposing those identifiers. If an unsolicited caller offered medical equipment in exchange for your Medicare details, tell the SMP what was offered and how the contact occurred. Those details may help distinguish misleading marketing from a billing concern.
4. Ask what referral may fit the facts. An SMP may refer potential fraud or abuse to the HHS Office of Inspector General, the Centers for Medicare & Medicaid Services, a state attorney general, local law enforcement, a state insurance department, or a State Medicaid Fraud Control Unit. The right destination depends on the concern. If evidence suggests a broader federal fraud scheme beyond an individual billing dispute, review options for bringing that concern forward.

Reporting fraud involving Medicare Advantage or drug plans

1. Choose a reporting channel. According to the Centers for Medicare & Medicaid Services, people in the United States can report suspected Medicare fraud by calling 1-800-MEDICARE at 1-800-633-4227. For a Medicare Advantage plan or Part D concern, you can also call the Investigations Medicare Drug Integrity Contractor at 1-877-772-3379. The plan’s general or fraud-reporting contact is another option; methods vary by plan.
2. Ask about anonymity before sharing details. You can report suspected fraud to the HHS Office of Inspector General without identifying yourself. Investigators may seek follow-up information, so provide a safe way to reach you if you want to support questions later. An anonymous report to the OIG is an option; the available facts don’t establish that every plan or contractor accepts anonymous reports.
3. Use a federal reporting route for suspected billing fraud. For Medicare Advantage or drug-plan billing concerns, call the Medicare Drug Integrity Contractor at 1-877-772-3379, or report the matter to the HHS Office of Inspector General. The OIG hotline accepts tips about potential fraud, waste, and abuse in federal health programs. Include the plan, provider, claim details, and why the charge appears incorrect.
4. Raise state-level concerns through the relevant department. If the issue involves a Medicare Advantage plan’s conduct or enrollment practices, contact your state insurance department or ask a local Senior Medicare Patrol to refer the complaint. A state department can assess concerns within its jurisdiction. For concerns involving misleading marketing or enrollment, explain what was said, who contacted you, and which plan was involved.
5. Keep the report focused and protect your information. Describe the dates, services, durable medical equipment, or enrollment activity that prompted concern. Don’t include your Medicare number, Social Security number, or other confidential information in an SMP report. Reporting Medicare Advantage fraud means sharing observed facts, not treating a suspicious claim as proof; agencies and contractors can assess the information and determine appropriate next steps.

Decide whether your concern may support a broader action

An agency report can address suspected improper billing, while evidence of a broader scheme may raise separate legal questions. If you have strong information and evidence that knowingly false claims were submitted to the government, Piacentile & Associates LLP can assess whether a False Claims Act action may be relevant. The facts, records, and your connection to the information can shape that assessment. Whistleblower cases are very complex and take a long time to resolve.

Piacentile & Associates LLP handles False Claims Act / Qui Tam Lawsuits, as well as SEC and IRS Whistleblower Program Filings. Those programs address distinct types of alleged misconduct; SEC or IRS filings are not substitutes for reporting Medicare Advantage concerns to the appropriate health agency. A careful review can help clarify which route fits the information you hold.

If you believe your evidence points beyond an isolated billing issue, contact Piacentile & Associates LLP to discuss a potential whistleblower matter regarding reporting Medicare Advantage fraud. Taking a deliberate next step can help you protect the integrity of your information and make an informed decision about what to do next.

Piacentile & Associates LLP and Reporting Medicare Advantage Fraud

Piacentile & Associates LLP handles False Claims Act / Qui Tam Lawsuits. If you are considering reporting suspected Medicare Advantage fraud and want to understand whether a False Claims Act or qui tam lawsuit may fit, the firm’s practice is a relevant next step.

The firm also handles SEC, IRS, FinCEN, and CFTC whistleblower program filings, as well as import export customs fraud legal action.

Frequently Asked Questions

What are the most common types of Medicare scams?

Common schemes include offers of “free” durable medical equipment that seek your Medicare details, charges for equipment or services you never received, and unauthorized plan enrollment. A suspicious offer may involve pressure or a request for personal information before the service is explained. Keep the caller’s details and any written offer, then compare related charges with your plan records before deciding what to report.

What information should I have ready when I call?

Before calling, note the plan name, the date of the contact or charge, the provider or supplier involved, and what seems incorrect. Keep the relevant Explanation of Benefits, receipt, or enrollment notice available. Describe what happened in your own words. Don’t include your Medicare or Social Security number in a report to a Senior Medicare Patrol.

How do I report suspected Medicare Advantage fraud?

You can report the concern to your Medicare Advantage plan, Medicare, the Investigations Medicare Drug Integrity Contractor, or the HHS Office of Inspector General. Choose a channel that fits the issue, such as an unexplained claim or enrollment you didn’t authorize. Reporting Medicare Advantage fraud alerts the appropriate entity; give clear facts and don’t treat suspicion alone as proof.

Where can I report Medicare Advantage fraud to Medicare or the OIG?

Call 1-800-MEDICARE at 1-800-633-4227 to report suspected Medicare fraud. You can also contact the HHS Office of Inspector General at 1-800-HHS-TIPS, or 1-800-447-8477. The OIG accepts reports by fax and mail as well. If you use those methods, keep a copy of what you sent and note the date for your records.

What information should I include when reporting suspected Medicare Advantage fraud?

Explain which plan or provider is involved, what transaction or contact raised concern, when it happened, and why the information appears inaccurate. Identify any relevant claim, service, or enrollment notice, and describe the response you received from the plan or provider. Share records only through the reporting channel’s process, and omit Medicare and Social Security numbers from reports to an SMP.

What protections apply to Medicare fraud whistleblowers?

Available protections depend on the reporting route and the facts, so don’t assume every report is anonymous or carries the same safeguards. The HHS Office of Inspector General accepts reports without requiring your identity, though investigators may seek follow-up information. A False Claims Act qui tam case may provide a whistleblower a recovery share if the government recovers funds. Consider legal guidance before disclosing sensitive information.