How to Report Medical Billing Fraud

Co-authored by Arvind Madan

Last Updated: December 19, 2024

The medical billing process in the United States is complex for both doctors and their patients. Medical procedures are never cheap, and the cost of a doctor or hospital visit may surprise many patients. However, unethical medical professionals may also try to get extra money out of patients. For example, doctors may bill patients for procedures or tests that the patient never received. If you believe that you have been fraudulently billed, first try to sort the bill out with the doctor or hospital. It may have been an honest mistake. If they refuse to correct the charges, contact your health insurance provider.

Part 1

Part 1 of 2:

Working with the Doctor or Hospital

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1
Contact the hospital's billing department. In case the doctor or hospital made an honest mistake, it's best to bring the billing error to their attention as soon as you notice the problem. Look on the office's or hospital's website to find information regarding billing disputes.
- If the billing department doesn't have contact information listed, call the office's main number and ask to talk to someone in charge of billing disputes.
2
Request the CFO's contact information. If the hospital billing department doesn't correct the billing error, request to contact the Chief Financial Officer. Explain your concern with the billing to the CFO, and ask them what they can do to rectify the situation.
- In some cases, the threat of contacting the CFO will be enough to make the billing department take your claim more seriously.
- If you're dealing with a small office or individual practice, there may not be a CFO. If this is the case, you can request the contact information of the head doctor.
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The advocate will be able to determine whether you have been fraudulently billed and, if you have, they'll follow up with the hospital or with the state medical board.^{[1]
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Research source} If you're not comfortable accusing the hospital of billing fraud, or if you simply don't have time to pursue the issue, a medical billing advocate may be your best option.

Part 2

Part 2 of 2:

Reporting Fraudulent Billing

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1
Contact your state's Department of Health. If you're confident that you have been fraudulently billed, and the hospital or doctor refuses to alter the bill, the next step is to contact the state DOH. Many states will have a medical board within the DOH that evaluates claims of unethical medical conduct or fraudulent billing. This board will investigate the billing fraud on your behalf.^{[2]
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- If you do not live in the United States, contact the government medical board that governs the region in which you live.
2
Report the fraudulent billing to your insurance company. In almost all circumstances, your insurance company will be paying for the majority of your medical bill, so they'll be very interested to hear about suspected fraud. Your insurance company will contact the doctor or hospital and inquire about the suspicions medical procedures or tests you've been billed for.
- The National Health Care Anti-Fraud Association (NHCAA) lists contact information for major insurance providers online.
3
Report insurance company fraud to the State Insurance Fraud Bureau. In extremely rare cases, your insurance company may be participating in the fraudulent billing with the unethical hospital or doctor's office. In this case, you need to report the fraud to your state's Insurance Fraud Bureau.
- These Bureaus are typically run through the state Department of Insurance or Attorney General's office.
4
Call to report fraudulent billing by a health-care provider under ACA. If you're registered for your health care under the Affordable Care Act, you can contact their billing department directly. Report the fraudulent billing you've experienced, including the name of the medical facility, the supplies, operations, or tests you were incorrectly charged for, and the amount of the charge.
- Contact ACA Billing at 1-800-318-2596.
5
Contact Medicare in the case of suspected billing fraud. If you receive insurance through Medicare, you can contact them directly in the case of billing fraud.
- Various Federal laws have been passed to protect Medicare clients from being falsely billed and to prevent doctors from sending falsified bills to insurance providers.^{[3]
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- Call Medicare to report billing fraud at 1-800-632-4327.

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Tips

If you suspect that a friend or family member—e.g., an aging parent—may have been fraudulently billed, talk with them about the bill. You can also enlist the services of a medical billing advocate on their behalf.

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