A Retiree’s Guide to Reporting Insurance or Medicare Fraud: Who to Call and What to Document

Worried your plan or provider is gaming Medicare? Here’s exactly who to call and what to document

Retirees and caregivers face a double fear: losing hard-earned benefits and getting blindsided by fraud that drains taxpayer-funded programs and your own coverage. The 2026 Kaiser Permanente settlement — a record $556 million agreement resolving allegations that the insurer billed Medicare Advantage for conditions patients didn’t have — shows fraud can happen inside familiar systems. If you suspect wrongdoing, acting quickly and documenting thoroughly makes the difference between a dismissed tip and an investigation that protects you and thousands of beneficiaries.

Why the Kaiser case matters to you in 2026

The Kaiser settlement announced in January 2026 reminded many retirees that large health plans can face allegations of systematic overbilling. As U.S. Attorney Craig Missakian said when the settlement was announced,

“Medicare Advantage is a vital program that must serve patients’ needs, not corporate profits.”

That case — and stronger state and national scrutiny in 2026 — means regulators are more responsive, but it also means retirees should be prepared to report suspected fraud the right way. Regulators at the federal and state level (including the National Association of Insurance Commissioners, or NAIC, which coordinates state insurance oversight) are refining tools and leadership to detect and prosecute fraud faster. Your clear, well-documented evidence helps them act.

Top-line: What you must do now (quick action checklist)

1. Preserve records — Keep original Explanation of Benefits (EOBs), bills, letters, appointment notes, and any suspect documents.
2. Document conversations — Log dates, names, phone numbers, and summaries of every call or in-person discussion.
3. Report to your insurer first — Call member services and follow up in writing so there’s an internal record.
4. Report to Medicare and federal hotlines — Use 1-800-MEDICARE and HHS-OIG reporting channels.
5. Contact a whistleblower attorney if the issue looks systemic; a qui tam filing under the False Claims Act may be appropriate.
6. Protect your identity when you can — submit sensitive info securely and ask about confidentiality.

Who to contact — step-by-step with practical scripts

Below are the primary channels to report suspected Medicare or insurance fraud, the order that typically works best, and a short script you can use when you call.

1. Your insurer or Medicare Advantage plan (start here)

Why call: Insurance companies can fix billing errors quickly and launch internal reviews. They create a paper trail, which is essential.

• Call the phone number on your insurance card (member services). Ask for the department that handles billing disputes or fraud.
• Use this script: “I am calling about a charge/diagnosis/service that appears incorrect on my EOB. Please open a formal complaint and give me a reference number. I’d like confirmation in writing.”
• Follow up by email or certified mail and keep copies of everything.

2. Medicare (Original Medicare or Medicare Advantage)

Why call: Medicare needs to know if billing to the federal program is inaccurate or fraudulent.

• Call 1-800-MEDICARE (1-800-633-4227). Explain the issue and ask for the case number.
• Use Medicare’s online reporting at Medicare.gov if you prefer electronic submission.
• If you’re enrolled in Medicare Advantage, tell Medicare whether the issue involves your plan’s risk adjustment or inaccurate diagnoses.

3. HHS Office of Inspector General (OIG)

Why call: The HHS-OIG investigates fraud involving Medicare and Medicaid and accepts tips from beneficiaries.

• Call the OIG hotline at 1-800-HHS-TIPS (1-800-447-8477) or submit a form at oig.hhs.gov.
• Be clear about the scope: single incorrect charge vs. pattern of inflated diagnoses or services across many beneficiaries.

4. Department of Justice (DOJ) and U.S. Attorney’s Office

Why call: The DOJ enforces the False Claims Act (FCA) for large-scale fraud and can pursue civil and criminal penalties. Qui tam whistleblower suits are filed under the FCA and are often how major cases begin.

• Contact the Civil Division’s Fraud Section at the Department of Justice or the U.S. Attorney’s Office for your federal district. If you have an attorney, they will coordinate sealed filings with DOJ for a qui tam action.
• DOJ encourages whistleblowers to use counsel; the case may be filed under seal to allow the government to investigate without public disclosure. Learn more about procedural governance in a practical governance playbook.

5. State insurance regulator and the NAIC

Why call: State insurance departments investigate plan-level violations, licensing issues, and consumer complaints. The NAIC coordinates state-level regulators and in 2026 has renewed leadership focused on oversight of Medicare Advantage-related issues.

• Find your state insurance department through NAIC (national association of state insurance commissioners) consumer resources. File a formal complaint through your state portal.
• Keep copies of your complaint ID and any correspondence.

6. State Attorney General and local consumer protection offices

Why call: State AGs handle consumer fraud and can coordinate with federal authorities in big cases.

• Visit your state AG’s consumer protection website or call the office. Describe the suspected fraud and supply documentation.

7. Senior Medicare Patrol (SMP) and advocacy groups

Why call: SMP programs help seniors detect and report fraud and can assist with documentation and next steps. Advocacy groups can amplify an issue and help you find resources.

• Search for your state SMP program online or contact national Medicare advocacy organizations for assistance if you need help preparing a formal complaint.

Exactly what to document — a practical checklist

Well-documented evidence is the backbone of any credible fraud report. Save and organize everything; investigators rely on specifics:

• All EOBs and bills: Keep originals and scans. Highlight questionable entries and compare billed services to what actually occurred.
• Dates and provider names: Note appointment dates, the clinician’s name, group practice, and any ID numbers from the EOB.
• Notes from visits: Write a short timeline of what happened, who said what, and why the billing looks wrong.
• Prescription and lab records: Keep copies to corroborate or challenge billed services.
• Communications: Print or save emails, letters, and voicemail transcripts. If you call, note the date, time, and person you spoke to and ask for a reference number.
• Patient records: Request your medical records in writing from the provider if you suspect false diagnoses; these are critical in proving mismatches between records and billed codes.
• Witness statements: If family members or caregivers were present, ask them to write short signed statements describing what they observed.

How to protect your identity and privacy

Reporting fraud can feel risky. There are legal protections for whistleblowers, but you should still protect your personal information:

• Avoid oversharing on social media about your complaint.
• Use secure channels — submit documents via encrypted email or secure web portals whenever possible.
• Redact unnecessary sensitive data such as full Social Security numbers when sending copies, unless requested by an investigator who needs them.
• Ask about confidentiality when you report. Federal and state investigators often keep complainants’ identities private during preliminary inquiries.
• Consider counsel — a whistleblower attorney can file a qui tam complaint under seal and protect your identity during the government’s investigation.

Whistleblower routes: How qui tam works and why an attorney helps

If your tip reveals a large-scale scheme — like submitting false diagnosis codes to inflate payments — the False Claims Act allows private citizens to file a qui tam lawsuit on behalf of the government. These cases can result in substantial recoveries and whistleblower awards.

Important points for 2026:

• DOJ and HHS-OIG remain aggressive in health-care fraud enforcement after high-profile settlements such as Kaiser’s.
• Whistleblower filings are typically made under seal so the government can investigate without tipping off the alleged wrongdoer.
• Using counsel ensures procedural compliance, safeguards your identity during the sealed period, and helps evaluate the strength of your evidence.

What to expect after you report

Timelines vary. A complaint may trigger a simple correction, a civil demand, or a multi-year federal investigation. Typical stages:

1. Receipt and triage: Agencies acknowledge and categorize the complaint.
2. Preliminary review: Investigators request additional documents or interview involved parties.
3. Full investigation: May include subpoenas, audits, and coordination with federal and state prosecutors.
4. Resolution: Outcomes range from administrative corrections to settlements, restitution, or criminal prosecutions.

Be patient but persistent. If you’re a complainant, ask for updates and reference numbers so you can follow the case.

Advanced strategies for retirees who find systematic fraud

If you suspect a pattern affecting many beneficiaries, consider these next steps:

• Contact an experienced whistleblower attorney who specializes in health-care FCA cases. They can advise on sealed filings and potential reward eligibility.
• Coordinate with advocacy groups that can help organize affected beneficiaries and bring additional attention to the issue.
• Provide data summaries — investigators love clean, organized evidence. Create a spreadsheet listing dates, EOB IDs, billed codes, and discrepancies.
• Record systemic patterns like repeated upcoding, phantom diagnoses, or services billed that never happened.

2026 trends that help — and new risks to watch

Regulators and technology are evolving. Key 2026 trends affecting fraud reporting:

• Greater federal and state coordination: With NAIC’s renewed 2026 leadership and DOJ’s sustained focus, cross-jurisdictional enforcement is stronger.
• AI-driven detection: Insurers and regulators increasingly use machine learning to flag suspicious billing patterns — your detailed report can trigger deeper algorithmic review.
• More complex schemes: As detection improves, fraudsters may use sophisticated coding strategies; this makes precise documentation even more valuable.
• Whistleblower-friendly enforcement: The FCA remains a powerful tool; experienced counsel can position a tip to succeed in 2026 enforcement climates.

Real-world example: How one beneficiary’s report mattered

Consider a simplified, composite example modeled on how whistleblower matters evolve: An elderly Medicare Advantage enrollee notices multiple EOBs listing chronic conditions she never had. She preserves EOBs, requests her medical record, and documents every phone call. She first alerts her plan, which updates one bill but dismisses the systemic problem. She then reports to Medicare and HHS-OIG with a spreadsheet highlighting discrepancies across 18 months. Investigators later contact her for records; her initial documentation speeds the inquiry. The case expands, and federal investigators coordinate with state regulators — exactly the pathway that led to larger settlements like Kaiser’s.

Dos and don’ts — quick reference

• Act quickly and keep originals.
• Ask for written confirmations and case numbers.
• Use secure channels and get legal advice for large-scale complaints.

• Post sensitive case details publicly.
• Rely on memory alone — write things down immediately.
• Delay reporting because you think “it’s not a big deal” — small details often reveal larger patterns.

Where to start right now — a simple action plan

1. Find and gather the last 12–24 months of EOBs and bills.
2. Call your plan’s member services and open a complaint; request the reference in writing.
3. Report to Medicare at 1-800-MEDICARE and HHS-OIG at 1-800-HHS-TIPS if you believe federal billing is involved.
4. If you see systemic issues, contact a whistleblower attorney before making public disclosures; they can help file a qui tam complaint under seal.

Final thoughts: You can make a difference

Medicare and insurer fraud costs taxpayers and can jeopardize care for millions of retirees. The 2026 Kaiser settlement is a reminder that even large organizations can be held accountable — but government action often begins with a single, well-documented tip. When you preserve records, report through the right channels, and protect your privacy, you help investigators pursue answers and protect your benefits.

Ready to act? Start by collecting your documents and calling your plan today. If the problem looks widespread, consider reaching out to a whistleblower attorney who specializes in health-care fraud to explore sealed qui tam options.

Resources & reporting contacts

• Medicare (general reporting): 1-800-MEDICARE (1-800-633-4227)
• HHS Office of Inspector General Hotline: 1-800-HHS-TIPS (1-800-447-8477)
• State insurance regulator: locate via the NAIC consumer resources (your state insurance department can accept formal complaints)
• Department of Justice (False Claims Act & whistleblower counsel): contact the Civil Division’s Fraud Section or your local U.S. Attorney’s Office
• Senior Medicare Patrol (SMP): local SMP programs help seniors detect and report fraud

Need help organizing your evidence? Start a simple spreadsheet: Date, Provider, Service Billed, Amount, Why it looks wrong, Document filenames. That alone can move your report from “tip” to investigable case.

Call to action

If you suspect insurance or Medicare fraud, do not wait. Collect your documents, call your insurer and 1-800-MEDICARE, and report suspicious billing to HHS-OIG. If the issue is systemic, contact an experienced whistleblower attorney to protect your identity and explore a qui tam filing under the False Claims Act. Your action could stop fraud, recover funds for Medicare, and protect fellow retirees.

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