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  • Ask the Ethicist: Reporting Suspected Medicare Fraud

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    Question: I have performed second opinion exams on several patients of a local ophthalmologist. The patients’ main complaints appear to be blurry vision caused by cataracts; however, these patients have all been told that they have glaucoma and are scheduled for combined cataract extraction with iStent implantation. My exams indicate normal or near normal nerve fiber layers and cupping. None of the patients have been started on drops or have recorded high IOPs. I think the planned glaucoma surgery may be fraudulent. I don’t want to say anything negative to the patients, but should I report my suspicions elsewhere?

    Answer: Yes, Medicare/Medicaid fraud is not a victimless crime; fraud raises health care costs for everyone, and unnecessary surgery victimizes patients. Unnecessary surgery and misrepresentation of services are serious ethical violations. While you might want to avoid negative statements about a colleague, it is important to give patients your honest opinion on what you believe is in their best interests. You may want to tell patients that while you agree that they will likely benefit from cataract surgery, the need for an iStent in their case is less clear-cut. Health care fraud is a deliberate deception or misrepresentation of services that results in an unauthorized reimbursement. Health care abuse refers to practices that are inconsistent with accepted medical, business, or fiscal practices.

     You can report suspected Medicare fraud in any of these ways:

    • call 1-800-MEDICARE (1-800-633- 4227),
    • report online to the Office of the Inspector General (OIG) at https://oig. hhs.gov/fraud/report-fraud, or
    • call the OIG at 1-800-HHS-TIPS (1- 800-447-8477).

    Many states have “duty to report” regulations, requiring physicians to report fraud related to state insurance programs. Be responsible and educate yourself about your state’s requirements. For issues related to state regulations, consider reporting your concerns to your state’s Office of the Attorney General. If you have concerns about your liability or protections, seek professional legal counsel. Your malpractice carrier may be able to provide advice as well.

    To read the Code of Ethics in full, visit aao.org/ethics-detail/code-of-ethics.

    To submit a question, email ethics@ aao.org.