SMP Helps Beneficiary Clear Her Medicare Record of False Claims

SMP Helps Beneficiary Clear Her Medicare Record of False Claims

Our California Senior Medicare Patrol (SMP) staff and volunteers continually work with beneficiaries across the state on cases of suspected fraud. In some situations, beneficiaries experience medical identity theft with their Medicare number being used to bill for services or items never received. Other cases may be a simple, honest billing error from a provider. Others involve scams like getting non-terminally ill beneficiaries to sign up for hospice care, saying that Medicare now pays for “housekeeping services”. When receiving a case, our SMP works with the beneficiary to gather all the pertinent information to assess what happened, whether or not it was fraud, and to outline the steps to resolution and to whom, if necessary, to refer the case to for further investigation. Below are a couple recent SMP success stories.

Case #1 involves a beneficiary who, unbeknownst to her, had a walker charged to her Medicare number in 2014. When she recently needed a Medicare-covered walker, all the suppliers she contacted told her Medicare wouldn’t cover it because she had received one in 2014. This is when she turned to her local Health Insurance Counseling and Advocacy Program (HICAP) for help and the HICAP Counselor discovered that a walker claim she never received had been submitted to Medicare back in 2014. Our SMP then took on the case and worked with Medicare’s Ombudsman office and the Medicare Administrative Contractor (MAC) to further investigate this fraudulent claim. The MAC adjusted this false claim and had all monies paid back to Medicare, therefore cleaning the beneficiary’s record of this claim.

Now, HICAP is assisting the beneficiary with filing her own claim to Medicare in hopes she can receive reimbursement for the walker she recently purchased when she was told Medicare wouldn’t cover it due to the false claim.

Case #2 involves a beneficiary who, in reviewing her Medicare Summary Notice in September 2017, found Medicare was charged for three services she never received. This beneficiary contacted SMP, and SMP made calls to all three providers in question. After months of consistent follow up with both Medicare and the providers in question, SMP was able to get claims adjusted and monies paid back to Medicare. Per the Medicare Summary Notice, SMP successfully had $443.36 returned to Medicare. Margaret England, the 83-year-old beneficiary in this case said, “She is very happy that SMP was able to resolve her billing issues.”

If you or someone you know has spotted suspicious claims or suspects Medicare fraud, contact our California Senior Medicare Patrol at 1-855-613-7080. For more information, see our Medicare Fraud section of our website.

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.