Medicare is a big complex health care system, and while over 55.5 million people receive good, essential health coverage through it, its complexity make it both challenging to navigate and ripe for fraud. Our Senior Medicare Patrol (SMP) program helps combat Medicare fraud by educating beneficiaries on how to prevent, detect and report it, and also helps investigate potential fraud cases. Sometimes these cases are honest mistakes on the part of the provider or insurer, and other times they are blatant fraud. Below are 2 success stories that resulted in clients saving a total of over $22,000!
Ambulance Company Double Bills Medicare and Beneficiary
Last June a beneficiary’s son contacted SMP regarding ambulance invoices for 2 dates of service. In working on the case, SMP found that these dates of service were already covered and paid for by Medicare, yet they were also sending invoices to the beneficiary. SMP intervened and saved this beneficiary from having to pay two ambulance invoices of $1178.52 and $1539.07 each, resulting in a combined savings of $2,717.
Enrolled into Wrong Plan via Mis-information
One of our SMP Volunteers, Evelyn Taylor recently worked with a lady who moved from New York to California. She was enrolled in her employer group health plan, and when turning 65, she contacted the plan about getting a supplement for Medicare. When she asked, “do you do that?”, the answer was, “Sure!” And they sent her an insurance card. While the woman assumed the card was for a supplement plan she could use in California, it was actually for a Medicare Advantage Preferred Provider Organization (PPO) in New York. Hence, it did not work in California, and did not cover any of her 20% coinsurance for her doctors visits and procedures. She didn’t realize what had happened until receiving high medical bills. That’s when she contacted Evelyn Taylor with SMP and the Health Insurance Counseling and Advocacy Program (HICAP).
Evelyn helped her get retroactively disenrolled from the MA plan, and get her Original Medicare retroactive to September 2015 when all of this started. The woman was able to purchase a Medigap plan because of a special Medigap guaranteed issue right. This guarantee issue gives beneficiaries the right to purchase certain Medigap plans without a health screening during their “Medicare Trial Period #1”. This is when a person joins a Medicare Advantage plan when first becoming eligible for Medicare at age 65, and then wants to switch to a Medigap policy during their first 12 months in the MA plan. Through helping this client retroactively disenroll from the MA plan and into Original Medicare and get a Medigap plan via this guaranteed issue right, Evelyn helped this woman save over $20,000 in medical bills!