California SMP Recovers $5.8 Million to Medicare

California SMP Recovers $5.8 Million to Medicare

Thanks to the persistent and dedicated efforts of our California Senior Medicare Patrol casework team, our SMP recovered over $5.8 million to the Medicare system for just one case.

This case was opened in April 2007 when a beneficiary from Orange County responded to an ad in a Vietnamese publication for free medical services and equipment. He was taken to a doctor who gave him a quick examination and drew blood. The beneficiary received a case of Ensure. Several weeks later when reviewing his Medicare Summary Notice (MSN), however, he noticed that the provider had submitted and Medicare had paid multiple claims for services he did not receive. He promptly reported this situation to our California Senior Medicare Patrol.

Our SMP staff researched the incident and collected all relevant information and documentation for this beneficiary. The case was then referred to the appropriate authorities under the auspices of alleged ‘billing for services or products never received,’ ‘billing for services or products different than those received’, ‘false and deceptive marketing’ and ‘misuse of Medicare number for billing.’

The Centers for Medicare and Medicaid Services (CMS) initiated an investigation into this suspect supplier at the request of the Department of Health and Human Services (DHHS) Office of Inspector General (OIG), which is the law enforcement arm of the DHHS. CMS placed the supplier under payment suspension and requested copies of all the medical records regarding this case. As the supplier failed to provide the requested records, CMS investigators assessed that the entire overpayment for this beneficiary was $5,884,176.20. All of the claims Medicare had initially approved were reversed and denied. The OIG is now in pursuit of the supplier to obtain restitution for the full amount.

This huge success highlights the importance of public education and outreach, and of having dedicated, thorough teamwork and follow-up. The fact that this beneficiary knew to check his MSN and report his suspicious findings is an essential step in combating fraud. And the tenacious yet patient follow up of our SMP casework team is what makes such leads a home run in terms of recovering funds to the Medicare system and preventing future fraud.

For more information on Medicare Fraud and/or to report any scams or suspicious activity, contact our California Senior Medicare Patrol at 855-613-0780.

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.