The short answer
You report Medicare fraud by calling Medicare or filing with the Office of Inspector General, and plan members can also call the drug integrity contractor. You can file anonymously, but doing so removes any reward. Expect no confirmation of receipt and no updates on what happens next.
You have a statement in front of you with a service on it that never happened. You are about to make the call. It is worth knowing first what that call will and will not set in motion, because most of what you are expecting is not coming.
How do I report Medicare fraud?
You report it to Medicare or to the Inspector General. Call Medicare's main line, or file online with the Office of Inspector General at the Department of Health and Human Services. Plan members can also call the drug integrity contractor. Expect no confirmation and no status updates.
That last sentence is not a warning about slow government. It is the published policy. The hotline states that it will not confirm receipt of your complaint and will not respond to any inquiries about action taken on it.
It goes further and says so plainly: the Inspector General does not provide the status of complaints. There is one route around that, and it is slow. You may request records through its Freedom of Information Act officer, phrased as a search for records rather than a status, and you should wait at least six months before filing that request.
Two other cold facts belong at the front rather than buried. Not every submission results in an investigation, and because of the volume of complaints it is not possible to contact every person who files one.
And there are no appeal rights against a decision by hotline operations. It is not a court or an administrative body, and the Inspector General has sole discretion over how complaints are handled.
There is a second destination the regulation names, which most pages skip. Information can go to the Inspector General, or to the Medicare contractor with jurisdiction over the provider or supplier you are reporting.
What counts as fraud?
Billing for something you never got, charging twice for one service, and using a stolen Medicare Number to submit claims. The Inspector General also investigates kickbacks for referrals, abuse or neglect in nursing homes, and a hospital failing to stabilize an emergency patient.
Medicare's own five published examples are narrower and more familiar. A provider bills Medicare for services or supplies they never gave you. A provider charges Medicare twice for one thing. Someone steals your Medicare Number or card and submits claims in your name.
The last two are the ones people do not think of as fraud. A company offers you a Medicare drug plan that Medicare has not approved. A person calls or comes to your house offering to sign you up for hospice care if you hand over your Medicare Number.
Medicare has a name for the harm behind several of those. Medical identity theft is someone using your personal information without your consent to commit Medicare fraud or other crimes.
What does not count is set out just as clearly, and by the Inspector General itself.
- Issues about Medicare policy, coverage, billing claims or appeals go to Medicare
- A lost or stolen Medicare card goes to Medicare
- Identity theft or consumer scams unrelated to health programs go to the Federal Trade Commission
- A failure to safeguard medical information goes to the HHS Office for Civil Rights
- Fraud relating to Social Security, including disability fraud, goes to the Social Security Administration's own Inspector General
That list is the boundary between this page and two others on this site. A refusal to cover something is an appeal. Poor treatment by your plan is a grievance. Neither is fraud.
Who do I call?
Medicare's main line for anything Medicare handles, and the Inspector General hotline for fraud. If you have a Medicare Advantage plan or a drug plan, the Investigations Medicare Drug Integrity Contractor takes those. Coverage, billing and appeal questions go to Medicare, not the hotline.
Medicare's number is 1-800-MEDICARE, which is 1-800-633-4227. Medicare also offers an online fraud report, and that report goes to the Inspector General rather than to Medicare.
The Inspector General's own line, for anyone who cannot file online, is 1-800-HHS-TIPS.
Plan members have the extra route. The Investigations Medicare Drug Integrity Contractor takes calls on 1-877-7SAFERX, which is 1-877-772-3379, and it covers Medicare Advantage plans and Medicare drug plans.
There is one more door the regulation opens and the consumer pages do not mention. You may submit information to the Medicare intermediary or carrier that has jurisdiction over the suspected provider or supplier, rather than going to the Inspector General at all.
Choosing between them is less important than not choosing the wrong category. Coverage, billing and appeal questions sit on the Inspector General's published refusal list, and its own instruction sends those to Medicare.
What information do I need?
Two lists, depending on who you call. Medicare wants your name and Medicare Number, the provider's name, the service you are questioning, the amount approved and paid, and the date on your notice. The Inspector General wants a narrative and evidence.
Medicare's list, in full, is what to have in front of you before you dial.
- Your name and Medicare Number
- The name of the provider you are reporting, with any identifying information you have
- The service or item you are questioning, and when you supposedly got it
- The amount that Medicare approved and paid
- The date on your Medicare Summary Notice, your plan's Explanation of Benefits, or the claim
The Inspector General asks for something different in shape.
- The name and contact information of the individual or business your complaint concerns
- A narrative explaining the nature, scope and time frame, and how you came to learn of it
- The name and contact information of anyone who can corroborate what you are reporting
- Supporting evidence in electronic format, such as emails, documents, billing records or photographs
The difference is worth reading twice. Medicare's list is about a claim. The Inspector General's list is about an allegation, and the corroborating witness is the item most people do not think to include.
What happens to it is modest and stated. An analyst reviews your complaint for relevance and completeness, and not all complaints result in an investigation.
If you identified yourself, a reviewing official may contact you for more information. The Inspector General adds one reassurance to that: not being contacted does not mean your complaint is not being investigated.
Can I report anonymously?
Yes, and it costs you two things. Filing anonymously stops the Inspector General treating your report as a whistleblower retaliation complaint, and may hinder its review. It also removes any chance of a reward, because a reward requires your name, address and telephone number.
You can be anonymous or you can be paid. This is our reading rather than a rule either document states, and two government facts produce it, from two different places.
The Inspector General's disclosure page says the anonymous option means providing no identifying information at all. The regulation on rewards separately says that a participant interested in receiving a reward must provide their name, address, telephone number and any other requested identifying information.
So the two cannot both be true of one report. Those facts are the government's. Reading them together is ours.
There are three levels, and each has a price.
| Your choice | Who learns who you are | What it costs you |
|---|---|---|
| No restrictions | OIG, HHS and others as needed | Your identity can be shared outside HHS-OIG |
| Confidential | HHS-OIG only | Hinders their review of your complaint |
| Anonymous | Nobody | No reward, and no whistleblower case |
The middle row is the one that surprises people, because confidentiality sounds free and the Inspector General says outright that it will hinder its own review.
Two qualifications sit under that table. A request for confidentiality can still be overridden if disclosure is necessary during the investigation or required by law. And even an anonymous report can be traced where public safety, crime prevention or another lawful purpose requires it.
If you choose the first row you can change your mind. You may revoke consent later if an agent is assigned and contacts you, though the Inspector General reserves the right to close an investigation if that leaves it unable to resolve the allegations.
On the reward side there is a separate confidentiality rule, and it is stronger. CMS does not reveal a participant's identity to any person, except as required by law.
Is there a reward?
Yes, and it is smaller and rarer than it sounds. CMS pays a reward for information leading to recovery of at least 100 dollars, capped at 10 percent of what is recovered or 1,000 dollars, whichever is less. The decision is at the discretion of CMS.
The figure in wide circulation is not the law. A CMS newsroom item once described a proposal to raise rewards toward 10 million dollars, and that proposal is not the rule. The rule is the regulation, and the regulation says 10 percent or 1,000 dollars, whichever is less.
There is a second exclusion, quieter and easy to miss. CMS does not give a reward for information about an individual or entity that is already the subject of a review or investigation by CMS, its contractors, the Inspector General, the Department of Justice, the FBI, or any other federal, state or local law enforcement agency.
Your information must also be specific. It has to relate to the activities of a named individual or entity, and it has to specify the time period of the alleged activities.
The arithmetic behind the cap is worth spelling out. Because the payment is the lesser of 10 percent or 1,000 dollars, the cap binds on anything recovered above 10,000 dollars, and a larger case does not produce a larger reward.
Payment is also last in the queue. Rewards are based only on recovered Medicare payments and not on penalties or fines, and CMS does not pay until it has collected all overpayments, fines and penalties in the case. Where several people are eligible, they share one capped amount.
Some people cannot be paid at all. That includes employees of HHS, the Social Security Administration, the Inspector General or law enforcement and their immediate families, other public employees who learned the information on duty, anyone who obtained it illegally, and anyone who took part in the offense.
What this means for you
Reporting is worth doing and it is not what most pages imply it is. The Inspector General will not confirm it received your report, will not tell you what happened, and there is no appeal against how it decides to handle it.
It also says, in its own words, that if your purpose is to obtain a refund from a Medicare participating provider you should pursue other remedies, because it rarely intervenes in personal or civil grievances. Reporting fraud is not the route to getting your own money back.
Before you file, decide the disclosure question, because it is the one choice that cannot be reversed after the fact. Anonymity costs you a whistleblower case and any reward, and confidentiality costs you some of the review itself.
The reward is real and narrow. At least 100 dollars recovered, capped at 10 percent or 1,000 dollars whichever is less, nothing at all if the target is already under investigation, and paid only after everything has been collected.
For the call that started this, read this publication's article on Medicare phone scams. If what you are worried about is your Medicare Number specifically, read the article on someone asking for your Medicare number.
FAQ
Will anyone tell me what happened to my report?
No, and the Inspector General says so directly. Its hotline will not confirm that it received your complaint and will not respond to any inquiry about action taken on it, and it states plainly that it does not provide the status of complaints.
Not every submission leads to an investigation, and because of the volume received it is not possible to contact everyone who files.
There is one indirect route: you may request records through the Inspector General's Freedom of Information Act officer, phrased as a search for records pertinent to your complaint rather than as a status request, and you should wait at least six months before filing it. There are also no appeal rights against how hotline operations handle a complaint.
Will reporting get my money back?
No, and this is the part worth reading before you spend an afternoon on paperwork. The Inspector General marks it important on its own page.
If your purpose in filing is to gain some type of relief, such as a refund from a Medicare participating provider or qualifying for benefits from a federally funded program, it strongly advises that you pursue other administrative or judicial remedies instead.
It rarely intervenes in personal or civil grievances. A fraud report is a tip to an investigator about a pattern. Getting a specific charge reversed is a different process with different rules, and starting the wrong one costs you time.
How much is the reward, really?
The regulation caps it at 10 percent of the overpayments recovered in the case or 1,000 dollars, whichever is less, and it applies only where the information leads to recovery of at least 100 dollars.
Because the payment is the lesser of the two, the cap binds on any case recovering more than 10,000 dollars, so a bigger case does not mean a bigger reward.
Payment comes only after CMS has collected all overpayments, fines and penalties, and it is calculated on recovered Medicare payments rather than on penalties or fines. If more than one person is eligible in the same case, they divide that single capped amount between them.
Why would a report not qualify for a reward?
One exclusion turns on timing rather than on merit. CMS does not give a reward where the individual or entity is already the subject of a review or investigation at the time you provide the information.
That covers a review by CMS, its contractors, the Inspector General, the Department of Justice, the FBI, or any other federal, state or local law enforcement agency. Your information must also relate to a specific individual or entity and specify the time period of the alleged activities.
Several groups are excluded outright, including federal and state employees who learned the information on duty, anyone who obtained it illegally, and anyone who took part in the offense being reported. And if the hotline declines to act on what you send, there are no appeal rights against that decision.
What is the difference between confidential and anonymous?
They are two of three named options and the costs differ. No restrictions means you give your details and the Inspector General may disclose your identity outside itself where people need to know, though you can revoke that consent later.
Confidential means you give your details but ask that they not be shared outside HHS-OIG, and the Inspector General says outright that this will hinder its ability to review or resolve your complaint.
Anonymous means giving no identifying information at all, which prevents it treating the matter as a whistleblower retaliation complaint and may hinder the review. Anonymity also removes any reward, because a reward requires your name, address and telephone number.
Which things should not go to the fraud hotline at all?
Several, and the Inspector General lists them so you do not waste a filing. Issues about Medicare policy, coverage, billing claims or appeals go to Medicare, as does a lost or stolen Medicare card.
Identity theft or consumer scams unrelated to health programs go to the Federal Trade Commission. A failure to safeguard medical information goes to the HHS Office for Civil Rights. Fraud relating to Social Security, including disability fraud, goes to the Social Security Administration's own Inspector General.
Appeals of administrative decisions, including Medicare payment decisions, follow the guidelines for that program rather than the hotline. Each of those refusals arrives with its own named destination, which is the useful part of the list.
