Service Coordinators’ Suspicions of Healthcare Fraud Lead to SMP Cases

Service Coordinators’ Suspicions of Healthcare Fraud Lead to SMP Cases

Wondering what some of the recent fraud trends are? One of our best gauges on what’s “hot” in fraud is by what our partners, volunteers, staff, service coordinators, providers, and community members at large report to us each month. Below are a few highlights from three different service coordinators’ fraud reports in the last quarter. Each case represents one of the top fraud trends our California Senior Medicare Patrol (SMP) is seeing.

 

Durable Medical Equipment (DME) Fraud – Case from Samantha Dar, Service Coordinator in North Hollywood

In this case, a beneficiary received a package containing durable medical equipment from a DME supplier she had never heard of. Concerned that the package contained braces that she had neither ordered nor were prescribed by her doctor, the beneficiary turned to her service coordinator, Samantha Dar. Aware of back brace scams, Ms. Dar turned to Senior Medicare Patrol (SMP). Upon receiving the case, SMP called Medicare and learned that Medicare had already paid hundreds of dollars for back, knee, shoulder, wrist, hand and ankle braces.

This DME case highlights one of the most tenacious types of scams we continue to see and fight, DME fraud. Scammers advertise “free” equipment covered by Medicare in exchange for a Medicare number, which leads to medical theft and Medicare waste. Whether it be a TV commercial, an “urgently marked” postcard or flyer, a phone call, or an unexpected package as in the case above, beneficiaries should never release personal information and should GUARD THEIR MEDICARE CARD. Let’s be mindful of the fact that Medicare only covers durable medical equipment that is medically necessary AND is prescribed by a doctor. If Medicare beneficiaries are in need of some medical equipment, they need to consult with their doctor to discuss it first. This will reduce their risk of medical theft and getting stuck with a pricey bill if Medicare does not pay.

 

Postcard Advertising 2019 Medicare Changes & “New Additional Benefits in Your Area” – Case from Ally Ahyoung Lee, Social Service Coordinator in Anaheim

In this case, Lee reported to our SMP a 2019 Medicare postcard sent to her residents regarding “additional benefits that may now be available in their area”. While we have yet to determine if this is fraud, it serves as a good reminder to be weary of lead generating businesses that sometimes contain misleading information.

Lead generating mailings are often easily mistaken to be from a government entity, and they often claim to have information on Medicare changes, or programs or new additional benefits one may qualify for. They give just enough info to catch the reader’s attention and create a sense of urgency in order to prompt one to send back the card.

If you, or someone you know receives such a postcard asking for personal information, take a closer look. Do you see any small print disclosing the name of a company? If so, look them up on the Better Business Bureau or Federal Trade Commission website to see how they rate, what they do and if there are complaints. And, when in doubt, throw it out. Remember that Social Security, Medicare and other government agencies will not ask you to send them your personal information. They already have it.

If you have questions about your health care insurance options, or any “new benefits” you may qualify for, rather than filling out a card, we encourage you to contact your local Health Insurance Counseling and Advocacy Program (HICAP) in California (1-800-434-0222). HICAP provides free, unbiased Medicare counseling.

 

 

Hospice Fraud – Case from Jill Deraney, Resident Service Coordinator in North Hills

One of Deraney’s residents contacted her about possible hospice fraud and Deraney then reported the case to our SMP. In this case, a beneficiary was approached by a woman she had seen many times visiting her neighbors. The woman claimed to be a nurse and offered free items and services from her program and asked to set up an appointment to sign up. The beneficiary agreed once she was assured that signing up wouldn’t affect her current Medicare coverage.

A couple days later, the nurse showed up with “free” medical products, all in a bag with a hospice company’s name. She explained the kinds of free services the beneficiary was eligible for, including having a visiting nurse come regularly to take her blood pressure. When the nurse then mentioned that a doctor would come by to see her, the beneficiary felt uneasy and said she didn’t want to see any other physician, as she was happy with hers in her MA plan. The beneficiary then realized she had been misled. She reported this incident to Deraney, her Resident Service Coordinator and showed her the hospice bag given to her.

This case has many similarities to most of the hospice fraud cases our California SMP receives. Some of the red flags to watch out for include; being offered “free” services and products in exchange for a Medicare number, and being signed up for hospice when the person has no terminal illness. Medicare’s hospice benefit is only for people terminally ill who have six months or less to live.

 

While there are many types of Medicare fraud and scams out there, the cases from these Service Coordinators demonstrate some of the top scams in California. If you or someone you know comes across any of these scams, or others, please report them to our California Senior Medicare Patrol (SMP) at 1-855-613-7080. See our Fraud Alerts for more information on common scams.

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.