Medicare Fraud: Has Your Doctor Been Flagged?
Medicare is one of the federal government’s largest programs. After spending roughly $1.23 trillion in 2025, outlays are approaching $1.3 trillion this year to cover more than 70 million Americans. Each year, a portion of that sum leaks out as “improper payments.” According to the Centers for Medicare & Medicaid Services (CMS), about $57 billion in 2025 claims involved missing paperwork, wrong recipients, or incorrect amounts — largely sloppy billing rather than outright fraud.
Real fraud, however, is a massive problem. CMS defines it as knowingly deceiving, concealing, or misrepresenting facts to secure money or property from a federal healthcare program. In 2025 alone, a nationwide crackdown alleged $14.6 billion in ‘intended’ losses, followed by another $1.8 billion in overpayments uncovered during the first half of 2026. Focusing on physician billing, OpenMedicare analyzed a decade of official data — scrutinizing every line, provider, and dollar across a $940 billion stream — and flagged $400 million in abnormal claims across 500 providers.
Has your doctor been flagged? Here’s how to tell.
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How Medicare fraud hurts your wallet
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Signed into law in 1965, Medicare gave older Americans health coverage they often could not buy on their own. Hospital care (Part A) was the core benefit and came automatically at age 65. Doctor coverage (Part B) was optional and required a monthly premium. Medigap policies soon appeared to help pay deductibles, coinsurance, and copays. In 1997, Congress created Medicare Part C, now known as Medicare Advantage, which lets private insurers offer managed-care health plans to seniors instead of traditional Medicare Parts A and B. Then, in 2003, Medicare added a prescription drug benefit (Part D). Given Medicare’s importance, combating fraud, waste, and abuse is key to its sustainability.
Medicare fraud, waste, and abuse (pdf) costs taxpayers and diverts resources that could be spent on beneficiaries’ care or other societal priorities and needs. So when fraud drains Medicare, there is less money for the health care you may need. You might pay for things you never get or pay for tests, medicines, and care you don’t really need. Doctors, pharmacies, and medical suppliers can make mistakes and bad choices, but on occasion, they have been accused of stealing from Medicare.
For instance, in February 2025, a New York doctor was convicted of submitting fraudulent claims to Medicare for unnecessary medical lab tests and orthotic braces (Department of Justice [DOJ], 2025a). This resulted in more than $24 million in fraudulent Medicare claims. Besides that, the doctor received tens of thousands of dollars in illegal kickbacks and bribes.
Jason Gerstenberger, with Insured With Jason, adds that if you are on traditional Medicare without a supplement, a fraudulent claim on your Part B will result in a real 20% cost to you. “You end up paying coinsurance on a service that never happened.” He says that if a scammer already billed Medicare using a patient’s number for a back brace, for instance, the real one they need could be denied because Medicare’s record shows they already have it.
How Medicare Fraud hurts your health
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Receiving care from a fraudulent provider can mean poor-quality, medically unnecessary, or outright harmful treatment. You could also be denied legitimate care. For instance, if a service has coverage limits and Medicare mistakenly believes you already received it, your claim will be denied
Many people don’t even realize they are victims until months later when:
- They receive surprise bills for care or services they never requested
- Their coverage is unexpectedly denied
- They are notified about medical treatments they didn’t receive
- They receive medical equipment in the mail they didn’t request or want
Gerstenberger recounts an April 2026 House Ways and Means Committee hearing where a Medicare beneficiary testified that she was denied physical therapy for a shoulder issue in July 2024 because Medicare showed she was enrolled in a hospice she had never heard of. Her claims were denied for months while she kept paying her premiums. The doctor listed on the hospice paperwork was a surgeon whose identity had been stolen.
Stacy Kemp Ferrari, a personal injury attorney at Kemp Law Group, shared a similar story about a 61-year-old patient who was told he needed heart surgery for $100,000. The patient questioned the recommendation because he could still function normally and did not feel as severely ill as his doctor had described.
The patient contacted Kemp Law Group, which opened an investigation and obtained a second opinion from an independent cardiologist. “After reviewing the tests, that cardiologist concluded the blockage did not require surgery,” says Ferrari. “If the patient had proceeded anyway, he may have been exposed to complications such as a mild stroke or heart attack, which affect about 15% of patients over 60, plus three months of recovery, lost work, and likely extensive physical therapy.”
Receiving care from a fraudulent provider can mean poor-quality, medically unnecessary, or outright harmful treatment. You could also be denied legitimate care.
What are some common Medicare fraud risks?
Scammers exploit patients’ trust in Medicare through things like billing fraud (charges for unused or upgraded services, or duplicate claims), identity theft or insurance swapping, illegal kickbacks, impersonating licensed providers, and prescription fraud such as forgery, doctor shopping, and drug diversion (FBI, n.d.).
What to do if your doctor (or organization) is on the list
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Start by confirming which list you’re using. OpenMedicare is the most comprehensive option, covering about 1.7 million providers across all 50 states and more than 100 specialties. This list comes from CMS’s publicly available Medicare Physician & Other Practitioners dataset, released yearly, and includes billing amounts, service volumes, beneficiary counts, submitted charges, procedure codes, geographic data, and specialty classification.
If your doctor is on this list, it doesn’t necessarily mean they were or will be charged with fraud. Even so, your first step may be to ask for an itemized list of every service billed in your name and compare it with the visits you actually had, according to OpenMedicare. Then, if you see tests, procedures or equipment you never received or don’t recognize, call 1-800-MEDICARE or use the Medicare fraud hotline to report it. If Medicare already paid for fraudulent claims, you may also need to dispute bills from a collector. Watch your Medicare Summary Notices and credit reports for new claims you did not order.
Check if your doctor has been banned from Medicare: Perform an online search at https://oig.hhs.gov/exclusions/
Look up the doctor on Medicare’s site: Care Compare: https://www.medicare.gov/care-compare/
Report suspected fraud:
Get help reading bills and spotting bad claims: Senior Medicare Patrol (free local help): https://www.smpresource.org or 1-877-808-2468. Or, check out the Medicare fraud booklet (PDF): https://www.medicare.gov/publications/11610-4rs-for-fighting-medicare-fraud.pdf
See your claims: Log in to your Medicare account and check claims / Medicare Summary Notices. If you have Medicare Advantage or Part D, you can also call 1-877-772-3379.
Keep in mind most Medicare claims are legitimate
Most Medicare claims are legitimate and most doctors are honest professionals. Coding mistakes or missing paperwork are far more common than a doctor planning to steal from Medicare. Accusing a provider can hurt the doctor/patient relationship, but ignoring charges you don’t recognize can cost you and the program real money. If you suspect fraud, take the necessary steps to report it. The goal is to catch legitimate problems early, before your wallet and your health pay the price.
Disclaimer
These are statistical flags based on publicly available CMS data, not accusations of fraud. Billing anomalies can have legitimate explanations. Report suspected fraud to: 1-800-HHS-TIPS.
