Georgia Medicare Fraud Protection Guide 2026

Medicare fraud protection in Georgia is not an abstract concern for the more than two million Georgians on Medicare. It is the unsolicited call asking for "your Medicare number," the brace that arrives without a doctor's order, the "free" genetic screening pitched at a community center. If you suspect fraud, you can report it for free through GeorgiaCares Senior Medicare Patrol at 1-866-552-4464 or the HHS Office of Inspector General hotline at 1-800-HHS-TIPS (1-800-447-8477). This guide explains how to spot it, how to report it, and the federal framework built to stop it.1,2,3

Medicare Fraud Protection in Georgia: Why It Matters

Medicare covered 2,024,284 people in Georgia as of March 2026, according to CMS.3 With that scale comes real money at risk. CMS estimated $28.83 billion in improper Medicare fee-for-service payments in fiscal year 2025, though CMS stresses that improper payments are not a measure of fraud: most were payments lacking enough documentation to show they were proper.4 Fraud is one slice of that problem, and the slice that lands on beneficiaries.

For Georgia Medicare beneficiaries, fraud takes concrete forms. It is the unsolicited call asking for "your Medicare number to confirm benefits." It is the orthotic brace that arrives at the door without a doctor's order. It is the "free cancer screening" pitched at a community center booth. It is the telemedicine practitioner who issues a five-minute consult and then orders thousands of dollars of unnecessary equipment. HHS OIG's consumer alerts warn about exactly these pitches: "free" genetic tests, "free" braces, and requests for your Medicare number.2

The federal anti-fraud framework rests on a network of statutes enacted over more than 160 years. The False Claims Act (FCA, 31 U.S.C. §§ 3729-3733), originally enacted in 1863 during the Civil War as "Lincoln's Law" to combat Union Army contractor fraud, was substantially strengthened by the False Claims Amendments Act of 1986 (Public Law 99-562, October 27, 1986), the Fraud Enforcement and Recovery Act of 2009 (FERA, Public Law 111-21, May 20, 2009), and the Patient Protection and Affordable Care Act of 2010 (Public Law 111-148, March 23, 2010). Section 1128 of the Social Security Act gives HHS OIG mandatory and permissive authority to exclude individuals and entities from Medicare and Medicaid. Section 1128A authorizes civil monetary penalties (CMPs). Section 1128B contains the Anti-Kickback Statute (AKS), a criminal felony prohibiting payment for referrals of items or services payable by federal health care programs. Section 1877, the Stark Law, prohibits physician self-referral for designated health services to entities with which the physician has a financial relationship absent a regulatory exception. HIPAA 1996 Title II Section 1128C (Public Law 104-191, August 21, 1996) created the Health Care Fraud and Abuse Control (HCFAC) Program that coordinates federal anti-fraud efforts.

Enforcement is executed by an interlocking network of federal and state agencies. HHS OIG performs civil enforcement, exclusions, CMP impositions, audits, and program integrity evaluations. The U.S. Department of Justice (DOJ) Health Care Fraud Unit handles criminal prosecutions and civil FCA litigation. The Medicare Fraud Strike Force, a DOJ/HHS OIG joint task force model first deployed in Miami in 2007, uses data analytics to identify and prosecute organized fraud schemes. CMS's Center for Program Integrity (CPI) coordinates federal program integrity operations. Unified Program Integrity Contractors (UPICs) perform fraud investigation work for CMS. Medicare Administrative Contractors (MACs), namely Palmetto GBA (Part A/B) and CGS Administrators (DME) for Georgia, process claims and do claim-level review.5 The Senior Medicare Patrol (SMP), operating in Georgia through GeorgiaCares SHIP (1-866-552-4464), provides beneficiary-facing education and a reporting channel.1,2

This guide walks through what every Georgia Medicare beneficiary and provider should understand about the federal Medicare anti-fraud framework: the statutory authorities, the enforcement structure, the common schemes affecting Georgia beneficiaries, the reporting mechanisms, the beneficiary protections, and the provider compliance obligations.

Key Takeaways

The Federal Anti-Fraud Framework

The Medicare anti-fraud framework is the product of more than 160 years of statutory evolution. Each statute has a distinct role.

Section 1128 of the Social Security Act: Exclusion Authority

Section 1128 (42 U.S.C. § 1320a-7) gives HHS OIG authority to exclude individuals and entities from participation in Medicare, Medicaid, and all federal health care programs. Exclusion means the excluded person cannot bill federal programs and federal programs cannot pay for items or services furnished, ordered, or prescribed by the excluded person.

Mandatory exclusions under Section 1128(a) include conviction of:

• A program-related crime (1128(a)(1))
• Patient abuse or neglect (1128(a)(2))
• A felony health care fraud offense (1128(a)(3))
• A felony controlled substance offense (1128(a)(4))

Permissive exclusions under Section 1128(b) include conviction of misdemeanor health care fraud, license revocation or suspension, suspension from a federal or state health care program, claims for excessive charges or unnecessary services, fraud against beneficiaries, kickbacks, and other categories.

Exclusion durations range from 5 years (mandatory minimum) to permanent. HHS OIG maintains the List of Excluded Individuals/Entities (LEIE) at oig.hhs.gov, which providers must check at hire and monthly thereafter for all employees and contractors who furnish or arrange items or services payable by federal programs.

Exclusion has cascading consequences: an excluded provider cannot bill, an entity that knowingly employs an excluded person can incur CMP liability, and beneficiaries who receive services from excluded providers may have those services denied by Medicare.

Section 1128A: Civil Monetary Penalties (CMPs)

Section 1128A (42 U.S.C. § 1320a-7a) authorizes HHS OIG to impose civil monetary penalties and assessments for a wide variety of misconduct, including:

• Presenting false or fraudulent claims
• Violations of the Anti-Kickback Statute
• Beneficiary inducements (offering remuneration to beneficiaries to influence selection of providers)
• Stark Law violations
• Employment of excluded individuals
• Failure to grant OIG access to records
• Numerous other categories specified in statute and 42 CFR Part 1003

Penalty amounts are set by statute and regulation (42 CFR Part 1003). HHS OIG's physician-education roadmap states that CMP penalties range from $10,000 to $50,000 per violation, with the amount varying by the type of violation, and that kickbacks draw penalties of up to $50,000 per kickback plus three times the amount of the remuneration.6 Those are the figures OIG prints for physician education, not a schedule for any one case, so confirm what applies to a specific situation with OIG or a lawyer.

CMP impositions are administrative actions, so the burden of proof is preponderance of the evidence, not the higher beyond-a-reasonable-doubt criminal standard. CMP decisions are reviewable by an HHS administrative law judge, then the Departmental Appeals Board, then federal court.

Section 1128B: Criminal Provisions Including the Anti-Kickback Statute

Section 1128B (42 U.S.C. § 1320a-7b) holds criminal provisions of the federal health care program fraud laws, and its best known is the Anti-Kickback Statute (AKS) at 1128B(b).6

The AKS is a criminal law prohibiting any person from knowingly and willfully offering, paying, soliciting, or receiving any remuneration (in cash or in kind, directly or indirectly, overtly or covertly) to induce or reward referrals of items or services payable in whole or in part by federal health care programs.

Penalties and sanctions include:6

• Jail terms
• Criminal fines
• Exclusion from participation in Medicare, Medicaid, and the other federal health care programs
• Civil False Claims Act liability, because every claim resulting from an AKS violation is automatically a false claim per Section 6402(f) of the ACA (codified at 42 U.S.C. § 1320a-7b(g))

The AKS has safe harbors, which are regulatory exceptions at 42 CFR Part 1001.952 that immunize specific arrangements (e.g., investments in large entities, space rental, equipment rental, personal services arrangements, employment, etc.) if the arrangement fits squarely within one and meets all of its requirements.6 Safe harbor compliance is voluntary; falling outside a safe harbor is not itself a violation but means the arrangement is judged on the totality of facts.

Section 1877: Stark Law (Physician Self-Referral)

Section 1877 of the Social Security Act (42 U.S.C. § 1395nn), commonly called the Stark Law after Congressman Fortney "Pete" Stark, prohibits a physician from making a referral to an entity for the furnishing of designated health services (DHS) payable by Medicare if the physician (or an immediate family member) has a financial relationship with the entity, absent an exception.

Designated health services include clinical laboratory services, physical therapy, occupational therapy, outpatient speech-language pathology, radiology and imaging, radiation therapy, durable medical equipment and supplies (DME), parenteral and enteral nutrients, prosthetics and orthotics, home health services, outpatient prescription drugs, and inpatient and outpatient hospital services.

Stark Law is a strict liability statute, so there is no intent requirement (unlike AKS, which requires knowing and willful conduct). Its penalties include fines as well as exclusion from participation in federal health care programs.6

Stark Law has dozens of regulatory exceptions at 42 CFR Part 411 Subpart J, including bona fide employment, in-office ancillary services, fair market value compensation, and many others. Exception compliance is mandatory for self-referral arrangements to be legal.

The Stark Law and AKS often overlap, and many arrangements implicate both. Compliance with a Stark exception does not automatically satisfy AKS, and AKS safe harbor compliance does not automatically satisfy Stark.

The Federal False Claims Act (31 U.S.C. §§ 3729-3733)

The federal False Claims Act (FCA), originally enacted in 1863 as Lincoln's response to Civil War contractor fraud, prohibits any person from:

• Knowingly presenting a false or fraudulent claim for payment to the federal government
• Knowingly making a false record or statement material to a false or fraudulent claim
• Knowingly retaining an overpayment (the "reverse false claims" provision, added by FERA 2009)
• Other categories

"Knowingly" includes actual knowledge, deliberate ignorance, and reckless disregard. Specific intent to defraud is not required.6

Penalties (per claim):

• Fines of up to three times the program's loss (treble damages)
• A per-claim civil penalty on top of that, and every item or service billed to Medicare or Medicaid counts as its own claim, so the total mounts quickly. The per-claim dollar amount is not fixed in this guide; confirm the amount in force with the Department of Justice before relying on any figure.6

A separate criminal false claims statute (18 U.S.C. § 287) carries imprisonment and criminal fines.6

Qui tam provisions (31 U.S.C. § 3730(b)) allow private individuals ("relators" or "whistleblowers") to file FCA suits on behalf of the United States. The relator files under seal in federal court, serves the United States, and the government investigates and decides whether to intervene. Under 31 U.S.C. § 3730(d), a successful relator is entitled to a percentage of any recovery. OIG notes that whistleblowers can be current or former business partners, hospital or office staff, patients, or competitors.6

The False Claims Amendments Act of 1986 (Public Law 99-562, October 27, 1986) substantially strengthened the FCA: it increased penalties, lowered the scienter standard from "specific intent" to "knowing," expanded qui tam provisions, and added anti-retaliation protections.

The Fraud Enforcement and Recovery Act of 2009 (FERA, Public Law 111-21, May 20, 2009) further expanded FCA: it clarified that liability attaches to false claims submitted to recipients of federal funds (not just direct submissions to the federal government), added the "reverse false claim" provision for knowing retention of overpayments, and expanded other liability theories.

The Patient Protection and Affordable Care Act of 2010 (Public Law 111-148, March 23, 2010) further strengthened FCA application in health care, including the AKS-FCA linkage at Section 6402(f), the 60-day overpayment refund requirement at Section 6402(a) (codified at 42 U.S.C. § 1320a-7k(d)), and the expansion of public disclosure bar in qui tam cases.

The FCA is a central tool for civil health care fraud enforcement. The Department of Justice obtained more than $2.9 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending September 30, 2024.6

HIPAA 1996 Title II Section 1128C: Health Care Fraud and Abuse Control Program

The Health Insurance Portability and Accountability Act of 1996 (HIPAA, Public Law 104-191, August 21, 1996) Title II included substantial anti-fraud provisions, including:

• Section 1128C of the Social Security Act, which created the Health Care Fraud and Abuse Control (HCFAC) Program jointly administered by HHS and DOJ
• Criminal health care fraud statute (18 U.S.C. § 1347)
• Theft or embezzlement in connection with health care (18 U.S.C. § 669)
• False statements relating to health care matters (18 U.S.C. § 1035)
• Obstruction of criminal investigations of health care offenses (18 U.S.C. § 1518)
• Health care benefit program definitions (18 U.S.C. § 24)

The HCFAC Program provides dedicated funding for Medicare and Medicaid fraud enforcement, coordinates federal-state enforcement efforts, and produces annual reports to Congress documenting recoveries, exclusions, and convictions.

Affordable Care Act 2010 Section 6401: Provider Screening and Compliance

The Affordable Care Act of 2010 included numerous anti-fraud provisions in Subtitle E "Medicare, Medicaid, and CHIP Program Integrity Provisions." Section 6401 ("Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid, and CHIP") strengthened provider enrollment requirements:

• Risk-based provider screening (limited, moderate, high categories with corresponding screening requirements)
• Fingerprint-based criminal background checks for high-risk categories
• Site visits for moderate and high-risk providers
• Application fees
• Provider revalidation every 3-5 years
• Authority for temporary moratoria on new enrollment in high-fraud geographies/categories
• Compliance program requirements (made compliance programs mandatory for Medicare/Medicaid providers, though detailed CMS implementing regulations have been issued category by category)

Section 6402 ("Enhanced Medicare and Medicaid Program Integrity Provisions") included:

• 60-day overpayment refund requirement
• AKS-FCA linkage (any claim resulting from AKS violation is a false claim for FCA purposes)
• Authority to suspend payment to providers based on credible allegations of fraud
• Self-Disclosure Protocol enhancements
• Other authorities

Section 6403, 6404, and 6405 added additional integrity authorities (national provider databases, expanded screening, durable medical equipment provisions, etc.).

The Federal Enforcement Structure

HHS Office of Inspector General (OIG)

HHS OIG, established by the Inspector General Act of 1978, is the principal federal civil enforcement authority for Medicare and Medicaid fraud. OIG's core functions:

• Civil enforcement: imposing CMPs, executing exclusions, negotiating Corporate Integrity Agreements (CIAs)
• Criminal referrals: OIG investigators are sworn federal law enforcement officers who refer criminal cases to DOJ
• Audits and evaluations: program integrity audits, beneficiary impact studies, and the OIG Advisory Opinion Program
• Compliance guidance: Provider-type compliance program guidance, special fraud alerts, advisory opinions
• Operations: National Office (Washington, D.C.), Office of Investigations field offices nationwide including an Atlanta Regional Office

OIG's annual budget is funded jointly through congressional appropriations and the HCFAC Program.

Department of Justice (DOJ) Health Care Fraud Unit

DOJ's Criminal Division Fraud Section Health Care Fraud Unit is the principal federal prosecutor for criminal health care fraud. Created in 2007 to operate the Medicare Fraud Strike Force, the Unit prosecutes complex criminal health care fraud cases nationally. DOJ's Civil Division Commercial Litigation Branch Fraud Section handles civil FCA litigation.

Georgia's three U.S. Attorney's Offices, the Northern District of Georgia (Atlanta-based), the Middle District of Georgia (Macon-based), and the Southern District of Georgia (Savannah-based), also prosecute Medicare fraud cases independently and in coordination with the Health Care Fraud Unit.

Medicare Fraud Strike Force

The Medicare Fraud Strike Force, launched in Miami in 2007, is a DOJ/HHS OIG joint task force model that uses data-driven analytics to identify aberrant billing patterns, target organized fraud schemes, and prosecute cases at scale. Strike Force operations have since spread from Miami to other cities around the country.

Strike Force cases typically involve coordinated takedowns of dozens or hundreds of defendants. Since 2007, Strike Force operations have led to thousands of criminal prosecutions and billions of dollars in restitution and recoveries.

CMS Center for Program Integrity (CPI)

CMS's Center for Program Integrity coordinates federal program integrity operations:

• Manages the Unified Program Integrity Contractor (UPIC) network
• Operates the Fraud Prevention System (FPS), which runs predictive analytics on Medicare claims
• Administers the National Provider Identifier (NPI), provider enrollment, and screening systems
• Coordinates with HHS OIG, DOJ, MACs, and state Medicaid Fraud Control Units
• Issues policy guidance, transmittals, and program integrity rulemakings

Unified Program Integrity Contractors (UPICs)

UPICs are contractors that perform program integrity work for CMS, including investigation of suspected fraud, waste, and abuse; audits; data analysis; provider education; and referral to law enforcement. UPICs operate in regional jurisdictions covering Medicare Parts A/B/C/D and Medicaid. The Southeast UPIC covers Georgia and most southeastern states; the specific contractor holding that award is set by CMS and can change with each contract cycle, so confirm the current contractor through CMS if you need it.

Medicare Administrative Contractors (MACs)

MACs process Medicare claims and conduct claim-level program integrity work. For Georgia:

• Palmetto GBA: Part A/B MAC Jurisdiction J (AL, GA, TN)
• CGS Administrators: DME MAC Jurisdiction C (covers 17 states and territories, including Georgia)5

MAC functions include claim payment, provider enrollment processing, prepayment and postpayment reviews, overpayment recovery, and referral of suspected fraud to UPICs and OIG.

Senior Medicare Patrol (SMP)

The Senior Medicare Patrol (SMP) is a beneficiary-facing fraud prevention program administered by the HHS Administration for Community Living (ACL) that operates in every state through grants to State Health Insurance Assistance Programs (SHIPs) or other community organizations.

In Georgia, SMP operates through GeorgiaCares SHIP, administered by the Georgia Department of Human Services Division of Aging Services. GeorgiaCares phone: 1-866-552-4464.1

SMP volunteers and counselors:

• Educate Medicare beneficiaries about fraud detection
• Help beneficiaries review MSNs and EOBs
• Receive and triage suspected fraud reports
• Refer complaints to HHS OIG, MACs, UPICs, or law enforcement as appropriate
• Conduct community presentations and outreach

SMP is free, independent of insurers, and a safe channel for beneficiaries to report concerns without fear of retaliation.

Georgia-Specific Anti-Fraud Infrastructure

U.S. Attorney's Offices

Georgia has three U.S. Attorney's Offices, one for each federal judicial district, and each can bring health care fraud cases:

• U.S. Attorney's Office Northern District of Georgia (Atlanta): north Georgia, including Fulton, DeKalb, Cobb, and Gwinnett counties
• U.S. Attorney's Office Middle District of Georgia (Macon): central Georgia, including Bibb, Houston, and Muscogee counties
• U.S. Attorney's Office Southern District of Georgia (Savannah): south and southeast Georgia, including Chatham County and the Brunswick area

FBI Atlanta

The FBI Atlanta Field Office covers the entire state of Georgia and works with HHS OIG, DOJ, and state law enforcement on health care fraud investigations.

HHS OIG Atlanta Regional Office

HHS OIG operates a regional office in Atlanta covering the Southeast region, conducting civil and criminal investigations of Medicare and Medicaid fraud.

Georgia Medicaid Fraud Control Unit (MFCU)

The Georgia Medicaid Fraud Control Unit sits in the Office of the Attorney General (the Georgia Department of Law) and now operates as the Medicaid Fraud and Patient Protection Division. It investigates and prosecutes provider fraud in Georgia Medicaid and protects patients from abuse. Its complaint line is (404) 458-2878, ext. 664, Monday through Friday, 8:30 a.m. to 5:00 p.m.7

GeorgiaCares SHIP (administering Georgia SMP)

GeorgiaCares, reachable at 1-866-552-4464, administers Georgia's Senior Medicare Patrol. Its certified counselors are free, unbiased, and not affiliated with any insurance company, and they can be reached Monday through Friday, 8 a.m. to 5 p.m. (option 4 on the phone menu).1

Palmetto GBA and CGS Administrators

The two MACs serving Georgia:

• Palmetto GBA Part A/B MAC Jurisdiction J: fraud referral via Palmetto's program integrity team
• CGS Administrators DME MAC Jurisdiction C: fraud referral via CGS program integrity team

Common Medicare Fraud Schemes Affecting Georgia Beneficiaries

These are the Medicare fraud schemes Georgia beneficiaries are most likely to run into. Several of them, "free" genetic tests, "free" braces, and Medicare number theft, are the subject of HHS OIG's national consumer alerts:2

1. Genetic Testing Fraud (CGx Schemes)

HHS OIG warns that "free" genetic-testing screenings or cheek swabs are offered to obtain a Medicare number for identity theft or fraudulent billing, pushed through telemarketing calls, booths at public events, health fairs, and door-to-door visits.2 Schemes billed as "Cancer Genomics" (CGx), cardiac, or neurology genetic testing follow a similar pattern:

• Telemarketers cold-call Medicare beneficiaries offering "free" genetic screening
• Beneficiaries are pressured to give MBI and other personal information
• Cheek swab kit is mailed
• A doctor, often via fly-by-night telemedicine, orders the test without medically necessary indication
• The lab bills Medicare for thousands of dollars per test
• Kickbacks flow back to the telemarketer/marketer

2. DMEPOS Fraud (Braces, Catheters, CGMs)

HHS OIG warns about unsolicited calls offering a "free brace" that will be billed to Medicare, and tells beneficiaries to hang up immediately.2 Common DMEPOS patterns:

• Unsolicited delivery of orthotic braces (back, knee, neck, wrist, ankle) ordered through fraudulent telemedicine consults
• Urinary catheter fraud: billing for catheters never ordered or never delivered
• Continuous glucose monitor (CGM) fraud: billing CGMs for beneficiaries who don't have diabetes or don't meet medical necessity criteria
• Power mobility device (PMD) fraud: billing for power wheelchairs not ordered or not medically necessary

CGS Administrators, the DME MAC for Jurisdiction C, processes Georgia's durable medical equipment claims.5

3. Telemedicine Kickback Schemes

The expansion of telemedicine flexibilities during COVID-19 created new fraud vectors:

• Telemedicine "consults" lasting minutes that order thousands of dollars of unnecessary genetic tests, DMEPOS, or other items
• Marketers paying physicians per signed order
• Telemedicine practitioners ordering for patients they never spoke with

4. Hospice Fraud

Hospice fraud schemes include:

• Recruiting non-terminally-ill beneficiaries into hospice
• Falsifying physician certifications of terminal illness
• Billing for hospice services never delivered
• Kickbacks for hospice referrals

5. Home Health Fraud

Home health fraud schemes include:

• Falsifying face-to-face (F2F) encounters
• Forging physician signatures on plans of care
• Billing for visits not made
• Kickbacks for home health referrals

6. Pain Management Pill Mill Schemes

"Pill mill" schemes involve controlled substance prescribing without legitimate medical necessity, often with cash payments, and often combined with Medicare Part D billing for the prescriptions.

7. Identity Theft and MBI Misuse

Identity theft schemes use stolen Medicare Beneficiary Identifiers (MBIs) to bill for items and services never delivered. Following the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) SSN-removal transition, MBI confidentiality is itself a critical anti-fraud protection.

8. Skilled Nursing Facility (SNF) Billing Fraud

SNF schemes include upcoding therapy minutes under the PDPM payment system, billing for services not rendered, and other patterns.

9. Laboratory and Pathology Fraud

Lab schemes include billing for tests not performed, billing for medically unnecessary panel tests, and kickbacks to ordering physicians.

10. Pharmacy Fraud

Pharmacy fraud schemes include billing for medications not dispensed, drug switching, autoship without consent, and other patterns.

Reporting Suspected Medicare Fraud

Georgia beneficiaries and providers can report suspected Medicare fraud through multiple channels:

1. Senior Medicare Patrol (SMP) via GeorgiaCares SHIP: 1-866-552-44641
2. HHS OIG Hotline: 1-800-HHS-TIPS (1-800-447-8477) or oig.hhs.gov/fraud/report-fraud2
3. 1-800-MEDICARE (1-800-633-4227): report directly to Medicare8
4. Palmetto GBA Program Integrity: through palmettogba.com
5. CGS Administrators DME MAC Program Integrity
6. FBI Atlanta: 404-679-9000
7. U.S. Attorney's Office (one of Georgia's federal districts)
8. Georgia Medicaid Fraud Control Unit (for Medicaid-related fraud)
9. Federal Trade Commission: ReportFraud.ftc.gov, or IdentityTheft.gov for identity theft9
10. Qui tam attorney: for individuals with insider knowledge of provider fraud who wish to file an FCA whistleblower suit

SMP counselors will help beneficiaries identify whether a claim is suspicious and assist with reporting. Know what the OIG Hotline does and does not do: not every report leads to an investigation, OIG cannot contact every complainant, and it is a route for reporting fraud, not for getting a refund from a provider.2

Medicare Fraud Protection for Georgia Beneficiaries

Federal law protects Medicare beneficiaries in several ways:

• MBI Confidentiality: Medicare.gov tells beneficiaries to protect the Medicare Number like a credit card and not to share it with anyone who contacts them unless they made the contact first.2
• Whistleblower Anti-Retaliation: FCA § 3730(h) protects employees who report fraud from retaliation.
• Right to Appeal: Beneficiaries have appeal rights for any denied claim, including claims denied because the underlying provider was excluded.
• Free SMP Counseling: GeorgiaCares SMP counselors are free and independent.
• CMS Beneficiary Education: Medicare.gov and the Medicare & You handbook provide annual fraud awareness materials.

Provider Compliance Obligations

Medicare providers have substantial compliance obligations:

• Provider Enrollment Screening: Under Section 6401 of ACA, providers undergo risk-based screening at enrollment and revalidation
• Compliance Programs: Section 6401 of ACA made compliance programs mandatory; OIG has published compliance program guidance for many provider types
• LEIE Screening: providers must check the OIG List of Excluded Individuals/Entities at hire and monthly
• 60-Day Overpayment Refund: ACA Section 6402(a) requires refund of identified overpayments within 60 days
• OIG Self-Disclosure Protocol: OIG operates a Self-Disclosure Protocol for providers to disclose potential CMP/AKS violations with reduced penalties
• CMS Self-Referral Disclosure Protocol (SRDP): separate CMS protocol for Stark Law disclosures

Failure to maintain compliance can lead to civil and criminal liability.

Worked Examples

Example 1: Fulton County, Age 70, Genetic Testing Scam Call

A 70-year-old Atlanta beneficiary in Fulton County receives an unsolicited telephone call from a marketer offering "free cancer genetic screening that Medicare covers." The caller asks for the beneficiary's MBI to "verify eligibility." The beneficiary, suspicious, declines and hangs up. She calls GeorgiaCares SHIP (1-866-552-4464). The SMP counselor confirms this is a known CGx fraud pattern, helps the beneficiary file a report to HHS OIG via 1-800-HHS-TIPS, and provides identity theft monitoring guidance through IdentityTheft.gov.2,1

Example 2: DeKalb County, Age 75, DMEPOS Brace Scheme

A 75-year-old DeKalb County beneficiary receives an unsolicited delivery of an orthotic back brace he never ordered. The package includes paperwork referencing a "telemedicine consultation" he doesn't recall. Two weeks later, his Medicare Summary Notice shows a charge of more than a thousand dollars for the brace plus a physician evaluation fee. He calls SMP, who helps him dispute the charge with Medicare, refuse the delivery (with package returned), report the suspected fraud to HHS OIG, and document the case for potential identity theft monitoring.

Example 3: Cobb County, Age 68, Telemedicine Kickback Case

A 68-year-old Cobb County beneficiary attends a community center "free Medicare screening" event. The "doctor," appearing remotely via video, speaks with her for three minutes and orders genetic testing, a back brace, and a knee brace. Concerned, she shows the visit paperwork to her primary care physician at her next appointment. The PCP recognizes the marketing pattern, helps her dispute the orders with Medicare, and supports a report to HHS OIG. (Such schemes commonly result in DOJ Strike Force prosecutions.)

Example 4: Worth County, Age 72, Hospice Fraud

A 72-year-old beneficiary in Worth County (rural south Georgia) is approached by a marketer offering "free in-home services and supplies through hospice." The marketer pressures enrollment in hospice care despite the beneficiary not having a terminal illness. The beneficiary's daughter, suspicious, calls GeorgiaCares SHIP. The SMP counselor explains that hospice enrollment requires a physician certification of terminal illness with prognosis of 6 months or less, that hospice election waives Medicare coverage of curative treatment for the terminal condition, and that the marketing pattern is consistent with prosecuted hospice fraud cases.10 The daughter helps her father disenroll from hospice and file a fraud report with HHS OIG.

Example 5: Bibb County, Age 80, Home Health Sham Face-to-Face

An 80-year-old Bibb County beneficiary signs a face-to-face encounter form presented by a home health agency marketer who claims to be a "physician's assistant" but never actually examines him. Two months later, his MSN shows extensive home health services he never received. SMP helps him compare the dates on the MSN with his actual visits, identify discrepancies, and report the suspected fraud. Pattern is consistent with prosecuted home health F2F fraud schemes.

Example 6: Hall County, Age 67, Reporting Fraud Through SMP

A 67-year-old Hall County beneficiary notices on her MSN that Medicare paid several thousand dollars for a genetic test labeled "hereditary cancer panel" that she does not recall ever taking. She calls GeorgiaCares SHIP (1-866-552-4464). The SMP counselor walks her through the MSN line by line, helps her contact the billing lab to request the underlying order documentation, helps file a fraud report to HHS OIG, and provides identity theft monitoring guidance. The lab's response (or non-response) becomes evidence in a federal fraud investigation.1

Best Practices

1. Review every Medicare Summary Notice (MSN) and Explanation of Benefits (EOB). Compare the dates and services on your calendar with each statement to make sure you got every service listed.2
2. Never give your Medicare number (MBI) to unsolicited callers. Medicare will never call you uninvited and ask for personal or private information.2
3. Never give your MBI in exchange for "free" services. There are no free items contingent on giving the MBI.
4. Use the GeorgiaCares SMP at 1-866-552-4464 for any suspicious activity. Counselors are free and not affiliated with any insurance company.1
5. Check that any DMEPOS supplier is enrolled in Medicare and has a legitimate prescription from your treating physician before accepting delivery.
6. Refuse and return unsolicited DMEPOS deliveries. Accepting unsolicited items can complicate fraud disputes.
7. Be skeptical of community-based "free Medicare screening" events that involve telehealth visits with unknown providers ordering tests or equipment.
8. Verify that providers are enrolled in Medicare by checking Medicare.gov physician and provider lookup tools.
9. Keep your own appointment and treatment log for comparison with MSNs.
10. Report suspected fraud promptly. Early reports help OIG identify and stop schemes affecting many beneficiaries.
11. Use HHS OIG Hotline 1-800-HHS-TIPS for direct federal reporting.
12. Use IdentityTheft.gov if your MBI may have been compromised.9
13. For providers: maintain a compliance program with LEIE screening, monthly OIG list checks, and provider enrollment compliance.
14. For providers: respect the 60-day overpayment refund clock under ACA Section 6402(a).

Common Issues

1. Being a scam victim is not committing fraud. Most schemes misuse a beneficiary's Medicare number; you are not a perpetrator when your number is stolen, and you should never hesitate to report out of fear of being blamed.
2. Report even when unsure. SMP counselors emphasize that reporting suspected fraud is encouraged, not penalized, and they will help you decide whether a claim is actually suspicious.
3. Identity theft can continue after you report. Even once a scheme is reported, your number may keep being misused, so keep reviewing your MSNs. CMS does not routinely issue a new Medicare number, though it may in limited compromise cases.
4. "Free" items are rarely free. Beneficiaries sometimes accept unsolicited braces or a quick telehealth "visit," not realizing Medicare is being billed hundreds or thousands of dollars for equipment or tests they never needed.
5. SMP versus OIG. SMP (GeorgiaCares, 1-866-552-4464) is the preferred first channel for beneficiaries; the HHS OIG Hotline is the direct federal channel. Both are valid, and you can use either.1

Contacts and Resources

If you suspect Medicare fraud, your information has been compromised, or you need help reviewing a Medicare claim, start with the free channels below. GeorgiaCares Senior Medicare Patrol is the best first call for beneficiaries.2

The three U.S. Attorney's Offices in Georgia, the Northern District (Atlanta), Middle District (Macon), and Southern District (Savannah), also prosecute Medicare fraud, usually on referral from the agencies above. For beneficiaries, Medicare fraud protection begins with the same basic practices: protect your Medicare number, review your MSN and EOB quarterly, be skeptical of unsolicited calls and "free" offers, and use SMP for free help. For providers, compliance programs, LEIE screening, the 60-day overpayment rule, and adherence to the Anti-Kickback Statute and Stark Law are non-negotiable. Reporting suspected fraud is how every Georgia beneficiary helps protect the program and the more than two million Georgians who depend on it.3

Learn More

Find personalized help understanding Medicare fraud protection in Georgia at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.