(SPOILER: IT’S COMPLICATED) WHO’S WATCHING FOR MEDICARE FRAUD?
You may not think much about Medicare fraud, waste, and abuse. But behind the scenes, it’s a big deal and costs taxpayers billions annually. So, who’s keeping an eye on things? That depends on what kind of Medicare you have. Let’s take a look. MEDICARE ADVANTAGE PLANS: BUILT- IN FRAUD WATCHDOGS If you have a Medicare Advantage plan , you're getting your Medicare through a private insurance company like Aetna, UnitedHealthcare, or Humana. These companies must keep fraud under control — it’s in their contract with Medicare. Because they’re managing your care and paying the bills, they have a strong reason to make sure: • Doctors aren’t overbilling • Services aren’t being faked • Your card isn’t being used by someone else They use technology, analytics, and even real humans to catch suspicious behavior. If they see a doctor billing for 100 patients daily or someone traveling 100 miles for weekly foot massages, red flags go up fast. They also work with law enforcement if someone breaks the rules.
fishy happened months later. And by then, the money is gone.
Peraton has already helped save $13 billion for taxpayers over the past 10 years — including $1.2 billion last year. There’s even a new version called Rapid Fraud Intelligence (Rapid FI) , which works even faster and smarter. WHO’S RUNNING THE SHOW? This new effort is part of an initiative from the Department of Government Efficiency (DOGE) — yes, that’s a real name, not a meme! Their job is to: • Cut down waste in federal programs • Cancel shady contracts • Pause suspicious payments • Make sure taxpayer money goes where it’s supposed to DOGE and CMS are working closely together, sharing systems, data, and new fraud-fighting strategies. SO, WHAT DOES THIS MEAN FOR YOU? Whether you’re on Medicare Advantage or Original Medicare with a Medigap plan, know this: • If you have a Medicare Advantage plan, your insurance company is already monitoring you for fraud every day. • If you’re on Original Medicare, the government is finally getting the tools to catch up — and crack down. This means your Medicare benefits are being better protected. And it means your tax dollars are being used more wisely.
It’s not that nobody is watching— but compared to private Medicare Advantage companies, the fraud
detection tools in Original Medicare have been slower, older, and less connected.
GOOD NEWS: BIG CHANGES ARE COMING Thanks to pressure from Congress, the public, and the Trump administration, the federal government is now making huge improvements in fighting fraud in Original Medicare. One of the most powerful new tools is the Fraud Detection Operations Center (FDOC) , which is run by the Centers for Medicare & Medicaid Services (CMS) .
Here’s what it does:
• Uses artificial intelligence and machine learning (yep, robots!) to spot fraud faster • Flags suspicious billing behavior from doctors or clinics • Stops payments before the money is sent out • Removes providers who were convicted of crimes or who don’t meet standards
An example?
Bottom line? With Medicare Advantage, fraud detection is part of the deal.
The FDOC recently found Medicare was still sending payments to a doctor who died 20 years ago. Yep. 20. Years. Ago . THE TECH POWER BEHIND IT The government has partnered with Peraton, a technology company that built the Fraud Prevention System (FPS) .
2 • OmahaInsuranceSolutions.com ORIGINAL MEDICARE + MEDIGAP: NOT QUITE THE SAME Things work differently if you have Original Medicare (Parts A & B) plus a Medigap (supplement) plan. Here, Medicare is run directly by the federal government. And while Medigap plans help cover costs like deductibles and copays, they don’t manage your care or claims. Until recently, the government’s fraud system was mostly “pay and chase.” That means someone gets paid, and investigators might realize something
WHAT YOU CAN DO You can help, too! Keep an eye out for:
• Bills for services you didn’t receive • Duplicate charges • Providers who pressure you into services you don’t need If you see something that doesn’t look right, report it to your Medicare plan or to Medicare directly at 1-800-MEDICARE .
And what exactly does the FPS do? It:
• Scans billing records in real time • Flags doctors who look suspicious • Tracks patterns (like billing for services no one needs) • Compares one provider’s claims to others to spot outliers
Together, we can all fight fraud — one step at a time.
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