hospice fraud success story - Latino woman with hands on heart, grateful

Hospice Fraud – A Case Success Story

Jenny received a call about her mother receiving hospice services. It was late September 2021. As her mother was healthy, and certainly not on hospice, Jenny promptly told them her mom had no need for hospice and hung up. This happened several times, and while annoying, Jenny didn’t think much about it. 

That’s until she started receiving bills for her mother’s medical services that are normally covered by Medicare. Wait, why were all these doctor’s appointments being denied payment? Was she somehow erroneously or fraudulently enrolled in hospice? How could this have happened? There was no home visit or health fair, etc where her mom signed up for hospice. How was she enrolled and where did the agency get her information?

Getting help with hospice fraud

While these are all good questions, Jenny needed to find out what was happening to her mother’s Medicare coverage and get it restored as soon as possible. She called her local Health Insurance Counseling and Advocacy Program (HICAP) in Kern County who then referred the case to their Senior Medicare Patrol (SMP) Liaison, Carolina Oehler. 

Our California Senior Medicare Patrol works to educate and empower people to prevent, detect and report fraud. We also help make things right again if fraud is detected, and we do all this through the stellar work and dedication of our team of staff, volunteers and partners throughout the state. Our SMP liaisons are particularly trained on how to identify potential fraud schemes and how to incorporate and explain scenarios of fraud in areas such as hospice, aggressive insurance agents, bogus back brace offers, etc. in their outreach message to Medicare beneficiaries, their families and caregivers. And they are experts in addressing fraud – gathering the details (bills, Medicare Summary Notices, pertinent names and contacts, etc), documenting them and sending them on to our SMP Case Manager, Sandy Morales for referral and government investigations. 

In this situation, Kern County Health Insurance Counseling and Advocacy Program (HICAP) recognized this case as a one of potential hospice fraud and took immediate action. The HICAP counselor contacted Medicare and confirmed that yes, Jenny’s mother had been enrolled in hospice on 9/1/21 and that the hospice agency had billed Medicare for hospice services never received in September and October. They billed Medicare a total of $12,930 and had received $11,266 in payment. 

The HICAP counselor then had Jenny contact her mom’s providers and ask them for a courtesy temporary hold on the bills while they worked to clear the hospice issue. They also had Jenny call Medicare to report that her mother’s card was compromised and ask for a new Medicare number. After taking these steps, the counselor referred the case to their SMP liaison, Carolina Oehler.

Carolina continued working with Jenny to help make things right again for Jenny’s mom and make sure her Medicare coverage was restored, and then sent this case on to our California SMP Case Manager, Sandy Morales. Sandy then sent it on to the Office of Inspector General and the Centers for Medicare and Medicaid Services (CMS) for investigation, noting that we had already received and referred nine other fraud cases from this same hospice agency. 

Good news!

In mid August, CMS contacted Sandy letting her know that all the hospice claims on Jenny’s mom’s Medicare record have been denied and the monies will be recouped. This is great news! And this case demonstrates the stellar team work that happens between our SMP partners, volunteers and staff. And a special thanks to all our partners at Kern County HICAP for making this hospice fraud case a story of success.

Hospice fraud is serious

Hospice fraud is serious. Not only is it the #1 type of Medicare fraud in California right now, draining Medicare of millions of dollars, but also it can harm beneficiaries. When on hospice, a person cannot access their regular Medicare benefits, as their Medicare benefits can only be used for palliative care, not curative. This means that beneficiaries who unknowingly sign up for hospice can suddenly lose access to their medications, or their coverage for a surgery or to see their doctor or specialist. 

For more information, see our hospice fraud alert translated into eight languages.

If you, or others you know, encounter Medicare fraud, report it to our California Senior Medicare Patrol at 1-855-613-7080.