Medicare Fraud in Washington: Open Enrollment Scams, Your Statement, and Where to Report
Medicare will not call you to verify your Medicare number or to enroll you in a plan. That one sentence, from the Washington Office of the Insurance Commissioner's Open Enrollment fraud sheet, is enough to shut down most of the phone scripts on SHIBA's list.
Open Enrollment runs until December 7, which leaves 33 days from today. SHIBA's fraud sheet describes the season plainly: TV and internet ads and phone calls, all trying to get you to switch to their plan. The OIC puts the cost of Medicare fraud at about $60 billion a year. That's an estimate, not an audited figure, but the enforcement numbers below show the scale is real.
In Washington, the group whose job is catching this is SHIBA. The OIC's Medicare counseling program is also the state's Senior Medicare Patrol, and its number is 800-562-6900. Below: the scripts scammers use, what Medicare's marketing rules actually forbid, how to read your Medicare statements for fraud, and exactly who to report what to.
Source: OIC, Report Medicare fraud; Medicare.gov, Marketing rules; HHS-OIG, Report fraud; OIC news release, Oct. 14, 2026.
The seven scripts to hang up on
SHIBA publishes a one-page list of the fraud schemes it sees during Open Enrollment. The most recent version I found (October 2025) lists seven. I've put each next to what's actually true:
| What the caller or website says | What's actually true |
|---|---|
| “New Medicare cards are being issued.” | Medicare issued new cards in 2018, without Social Security numbers, and has no plan to issue new ones again. |
| “Your Medicare is about to be canceled. We need to verify your ID.” | A fear tactic to get your Medicare number, date of birth, Social Security number or bank details. Call 1-800-MEDICARE yourself if you're worried. |
| “You're preapproved for a better, cheaper plan.” | A lure for your personal and Medicare information. Even if they enroll you, the plan may not cover your doctors or prescriptions. |
| “You're owed a refund for an overpayment.” | A way to get your banking information for a refund that never comes. |
| “You qualify for free medical supplies” (braces, genetic tests) | They want your Medicare ID to bill for the items. On Original Medicare you need a doctor's order and a Medicare-contracted supplier. |
| “Our plan is preferred by Medicare.” | False. Medicare and Medicaid do not and cannot endorse any plan. |
| A website that looks like Medicare or a plan site | Spoof sites collect your name, address, birth date and Medicare ID. Some are run from outside the U.S. |
Source: OIC/SHIBA, Be safe during Medicare Open Enrollment (SHP886, 10/2025).
One nuance the OIC adds, and it's fair: if you're in a Medicare Advantage plan, some calls from companies you don't recognize are legitimate. The OIC says many of those calls come from companies the plan hired to help its members, and it publishes a short guide called Who's calling? on its fraud page to help you tell the difference. My rule is simpler: never give your Medicare number, Social Security number or bank details to someone who called you. Hang up and call the number on the back of your card.
What Medicare's marketing rules forbid
Not every bad sales call is fraud. Some are licensed agents or plan call centers breaking Medicare's marketing rules. Those rules are federal regulations: 42 CFR 422.2264 for Medicare Advantage and 423.2264 for Part D drug plans. They apply to plans and to the agents and brokers who sell them, including independent agents like me.
Under those sections, a plan or its agent can't contact you in these ways unless you asked for it first:
- Knock on your door, or leave materials at your door (unless you scheduled an appointment and weren't home)
- Cold call you, robocall you, or leave you a voicemail or text, including calls "based on a referral"
- Message you directly on social media
- Approach you in a parking lot, hallway or lobby
"Unless you asked" matters. If you mailed back a reply card, called the plan, or gave permission, a call back is allowed. If you never asked and someone calls about switching your Medicare plan, that call is either a rules violation or a scam. Either way, it's worth reporting.
| A plan or agent can | A plan or agent can't |
|---|---|
| Mail you ads, or email you (with an opt-out) | Call, text or visit you uninvited |
| Meet with you after you agree to a scope of appointment | Talk about products you didn't agree to discuss in that meeting |
| Give you plan materials and an enrollment form | Charge you an enrollment fee |
| Explain the options they represent | Discuss specific plan benefits before telling you how many organizations and plans they represent, and pointing you to Medicare.gov or 1-800-MEDICARE |
| Hold an educational event about Medicare | Sell plans or take applications at that educational event |
| Bill you for premiums by mail | Ask you to pay over the phone or online; the plan must send a bill |
| Give you their business card | Offer cash, gifts worth more than $15, or free meals to get you to join |
| Call you about Medicare plans if you're already their client for other insurance (like auto or home) | Make unsolicited calls about other lines of insurance as a way to generate Medicare leads |
| Explain plan options during an agreed appointment | Sell you an annuity or life insurance during a Medicare sales pitch |
Source: Medicare.gov, Marketing rules for Medicare health and drug plans; 42 CFR 422.2264 (eCFR); 42 CFR 423.2264 (eCFR).
The OIC adds two more lines on its own fraud page: insurance companies, agents and brokers can't offer gifts or enticements to enroll, and plan representatives can't use pressure or scare tactics. Medicare.gov says agents and brokers must be licensed by your state. You can check a Washington agent's license with the OIC's agent and company lookup on its Medicare fraud page.
A rules violation by a licensed agent is something the OIC can act on, so it goes to the OIC as a complaint. Our guide to filing a complaint with the Washington Insurance Commissioner walks through how that works.
Braces, genetic tests and other things you never ordered
The phone pitch is only half of it. The money in most Medicare fraud is in the billing: someone uses your Medicare number to bill for equipment, lab tests or services you never needed or never got.
The national Senior Medicare Patrol network sees the same patterns year after year. In its 2024 performance data, the HHS Office of Inspector General reported that SMP projects ran 607 group events on genetic testing fraud, reaching 31,490 people, plus separate alerts on hospice and Medicaid renewal scams. The SMP program's reports to OIG that year flagged fraudulent hospice enrollment, remote patient monitoring, urinary catheters, GLP-1 drug diversion and durable medical equipment.
One case shows how much a single tip can be worth. Nearly all of the $35.1 million in expected Medicare recoveries that SMPs reported for 2024 came from one project that identified a doctor signing orders for cancer genetic testing and medical equipment without seeing, speaking to or treating the patients. The provider was ordered to pay nearly $34.8 million in restitution.
Source: HHS-OIG, 2024 Performance Data for the SMP Projects (OEI-02-25-00160); OIC, Medicare Fraud Prevention Month article (2026); Medicare.gov, Reporting fraud and abuse.
How to read your Medicare statement for fraud
Your statement is where fraud shows up, and almost nobody reads it. Which statement you get depends on your coverage:
- Original Medicare (Parts A and B): a Medicare Summary Notice (MSN). It is not a bill. Medicare mails it every six months if you had any services in that period. You can switch to electronic MSNs and get an email for any month with a processed claim.
- Medicare Advantage or a Part D drug plan: an Explanation of Benefits (EOB) from the plan, usually monthly when you've used benefits.
- Medigap: an EOB from the Medigap insurer showing what it paid after Medicare.
Six months is a long time to wait to spot a bogus charge. A Medicare.gov account shows Original Medicare claims as soon as they're processed, and the OIC notes you can look back over 36 months of claims there.
| Line on the MSN (Part B) | What to check |
|---|---|
| Date of service | Were you actually seen that day? Compare it with your calendar. |
| Provider name and address | Do you know this provider? A lab or supplier you've never heard of is a red flag. |
| Service provided and billing code | Is it what you got? Watch for braces, test kits, catheters or monitoring you never received. |
| Amount the provider charged | Matches the bill or receipt you have? |
| Medicare-approved amount and amount Medicare paid | Large payments for things you don't recognize are worth a call. |
| Maximum you may be billed | Never pay more than this to that provider for that line. |
| Notes and appeals information | The last page explains how to appeal a denial. |
Source: OIC/SMP, Medicare Statements: Tips for Protecting Yourself and Medicare; Medicare.gov, Medicare Summary Notice.
If a line looks wrong, call the provider's office first. Plenty of problems are billing errors, not fraud: a wrong code, a duplicate claim. If the office can't explain it, or the provider is one you've never used, report it (next section). If a claim was denied and you think it should have been paid, that's an appeal rather than a fraud report; see our guide to the Medicare appeal process.
You can request a My Health Care Tracker from SHIBA to log appointments and equipment, which makes the comparison much faster.
Where to report what
Report to the wrong place and you lose time. Here's how the pieces fit in Washington:
| What happened | Report it to | How |
|---|---|---|
| Suspicious call, a charge you don't recognize, or you're not sure | SHIBA (Washington Senior Medicare Patrol) | 800-562-6900, or the OIC's online fraud report form |
| Suspected fraud on an Original Medicare claim | Medicare | 1-800-MEDICARE (1-800-633-4227) or online |
| Suspected fraud involving a Medicare Advantage or Part D plan | I-MEDIC (Medicare's drug and health plan fraud contractor) | 1-877-7SAFERX (1-877-772-3379) |
| Fraud, kickbacks or abuse in Medicare or Medicaid you want investigated | HHS Office of Inspector General | 1-800-HHS-TIPS or online hotline complaint |
| An agent pressured you, enrolled you without consent, or broke marketing rules | Washington OIC | File a complaint online or call 800-562-6900 |
| Apple Health (Medicaid) fraud | Washington Health Care Authority | 1-833-794-2345 or hottips@hca.wa.gov |
Source: OIC, How to identify and report Medicare fraud and abuse; Medicare.gov, Reporting fraud and abuse; HHS-OIG, Report fraud; OIC, File a complaint.
If you only make one call, make it SHIBA. The SMP Resource Center's national locator lists 800-562-6900 as Washington's number for Senior Medicare Patrol services, and the OIC says its volunteers "will help answer your questions and report your concerns to investigators." More on how SHIBA works is in our SHIBA guide.
Before you call anyone, gather what OIG says makes a tip useful: the name and contact details of the person or business involved; a short account of what happened and when; and copies of anything that backs it up, like the statement, a letter, billing records or photos. Don't expect a personal follow-up from OIG. Its hotline page says it can't contact every complainant, and if what you want is a refund, you should go through the provider, the plan, or an appeal instead.
The enforcement numbers
Every June the Justice Department announces a coordinated national health care fraud action with HHS-OIG, the FBI and state partners. The 2026 Takedown, announced June 23, charged 455 defendants, including 90 doctors and other licensed medical professionals, in schemes involving more than $6.5 billion in false claims. Cases ran in 56 federal districts. CMS suspended 1,079 providers and revoked billing privileges for 1,403.
Source: DOJ/HHS-OIG, June 27, 2024; DOJ, June 30, 2025; DOJ, June 23, 2026
Show the numbers
| Defendants charged | |
|---|---|
| 2024 | 193 |
| 2025 | 324 |
| 2026 | 455 |
Source: DOJ/HHS-OIG, 2024; DOJ, 2025; DOJ, 2026
Show the numbers
| $ billions | |
|---|---|
| 2024 | $2.75B |
| 2025 | $14.6B |
| 2026 | $6.5B |
Don't read the dollar bars as a trend. The 2025 figure was dominated by a few very large alleged schemes (DOJ said 29 defendants tied to transnational criminal organizations were alleged to have submitted over $12 billion in fraudulent claims), and DOJ counted "intended loss" in 2024 and 2025 but "false claims" in 2026. The defendant count is the steadier measure, and it has gone up each year.
The 2026 cases also show where the money goes. DOJ highlighted wound-care allografts (one company's products were billed to Medicare for over $4 billion between December 2021 and June 2024), hospice enrollment of patients who weren't terminally ill, catheters and other medical equipment that was never delivered, and genetic testing. Those are the same categories SMP volunteers warn about at senior centers. The Medicare number is the raw material for all of them.
Washington's Senior Medicare Patrol, by the numbers
Each of the 54 SMP projects is funded by a federal grant through the Administration for Community Living, and HHS-OIG reports their results every year. In OIG's appendix the Washington project is listed as the Washington State Insurance Commissioner, meaning SHIBA.
| 2024 | Washington | All 54 SMPs |
|---|---|---|
| Active team members | 70 | 5,643 |
| Team member hours | 2,739 | 579,904 |
| Group education events | 166 | 22,752 |
| People reached at events (est.) | 6,530 | 1,172,875 |
| One-on-one interactions | 2,012 | 283,724 |
| Expected Medicare recoveries | $0 | $35.1 million |
Source: HHS-OIG, 2024 Performance Data for the SMP Projects, Appendices A, D and E (June 2025).
My read: Washington's SMP is small. It reported 70 active team members for 2024, against 313 in Florida, and no recoveries. I wouldn't conclude from that it isn't working. OIG itself says SMP projects "may not be receiving full credit" for their work, because nobody can track every referral a trained beneficiary makes on their own, or the fraud that never happens because people check their statements. The national total also swings on single cases: it fell from $111.3 million in 2023 to $35.1 million in 2024, and nearly all of the 2024 figure came from that one genetic-testing case.
What the numbers do say is that the SMP's capacity is limited, so the first line of defense is you, your statement and a hung-up phone.
If you're sorting out coverage choices during Open Enrollment, our Washington Medicare overview and Part D page for Washington explain the basics.
FAQ
How do I report Medicare fraud in Washington State?
Call SHIBA, Washington's Senior Medicare Patrol, at 800-562-6900, or use the OIC's online fraud report form. You can also report to 1-800-MEDICARE (1-800-633-4227) or the HHS Office of Inspector General at 1-800-HHS-TIPS.
Will Medicare call me about my card or my plan?
No. Medicare will not call you to verify or update your Medicare number or to enroll you in a plan, and Medicare will never call to sell you anything or visit your home. If a caller says they're from Medicare, hang up and call 1-800-MEDICARE yourself.
Can an insurance agent call me about Medicare plans?
Not unless you gave permission or contacted them first. Federal rules at 42 CFR 422.2264 and 423.2264 bar unsolicited cold calls, robocalls, texts, voicemails and door-to-door visits by Medicare Advantage and Part D plans and their agents.
Are new Medicare cards being issued?
No. Medicare issued new cards without Social Security numbers in 2018 and has no plan to issue new cards again. A call about a new card is a scam to get your Medicare number.
Who runs the Senior Medicare Patrol in Washington?
The Washington Office of the Insurance Commissioner runs it through SHIBA, its Medicare counseling program. The number is 800-562-6900.
Medicare rules, Washington law and your own plan documents control what applies to you. Confirm your situation with SHIBA, 1-800-MEDICARE, the Washington Office of the Insurance Commissioner or a licensed agent, and talk to an attorney about legal questions.
Sources
- Washington OIC/SHIBA: Be safe during Medicare Open Enrollment, seven common fraud schemes (SHP886, 10/2025)
- Washington OIC: How to identify and report Medicare fraud and abuse
- Washington OIC: Report Medicare fraud
- Washington OIC/SMP: Medicare Statements, Tips for Protecting Yourself and Medicare
- Washington OIC: Medicare Fraud Prevention Month kickoff article (2026)
- Washington OIC: File a complaint or check your complaint status
- Washington OIC: Medicare Open Enrollment starts Oct. 15 for 2027 plans (Oct. 14, 2026)
- SMP Resource Center: Washington SMP locator
- HHS-OIG: 2024 Performance Data for the Senior Medicare Patrol Projects, OEI-02-25-00160 (June 2025)
- HHS-OIG: Report fraud, waste and abuse
- U.S. Department of Justice: 2026 National Health Care Fraud Takedown (June 23, 2026)
- U.S. Department of Justice: 2025 National Health Care Fraud Takedown (June 30, 2025)
- HHS-OIG / DOJ: 2024 National Health Care Fraud Enforcement Action (June 27, 2024)
- Medicare.gov: Reporting Medicare fraud and abuse
- Medicare.gov: Marketing rules for Medicare health and drug plans
- Medicare.gov: Medicare Summary Notice
- 42 CFR 422.2264: Beneficiary contact, Medicare Advantage (eCFR)
- 42 CFR 423.2264: Beneficiary contact, Part D (eCFR)
This article is for general educational purposes only and is not legal, tax or insurance advice. Coverage depends on the actual policy, its terms, conditions and exclusions, and state law. Maru Insurance · WA License (WAOIC) #1365574 · FL License #G363233 · NPN 22261820.