SMP Success! Riverside Couple’s Case Uncovers Costly Fraud Scheme

SMP Success! Riverside Couple’s Case Uncovers Costly Fraud Scheme

Back in 2009, an unsuspecting husband and wife were picked up for a “complimentary” visit to a Los Angeles health clinic. During their visit, their Medicare numbers were recorded, blood pressure taken and a few other non-invasive procedures performed. A few weeks later, however, this couple had a power wheelchair, a commode and a back support brace delivered to their home, none of which they needed or requested.

Finding this situation odd, the couple reported it to Ann Kasper at their San Bernardino/Riverside Health Insurance Counseling and Advocacy Program (HICAP) in October 2009, and HICAP in turn, reported the case to us, the California Senior Medicare Patrol. Forwarding the case on to our Zone Program Integrity Contractor (ZPIC), we recently received word that they completed the investigation. ZPIC found that this durable medical equipment (DME) vendor had worked with 13 referring physicians, several of whom followed a similar pattern of billing Medicare for the same combination of power wheelchair and accessories for 62% of their beneficiaries. At least 40% of the beneficiaries were also billed for back and knee braces. In completing the investigation, the Centers for Medicare and Medicaid Services assessed an overpayment of $244,689. The DME supplier must pay this back, or a tax lien will be issued.

Putting a stop to fraud takes teamwork; this case demonstrates an example of how it’s done. As more beneficiaries are informed about fraud, and know how to detect it and where to report it, informed investigations begin, fraudsters get taken out of the “game” and integrity gets restored to the Medicare program. If you or others have a similar incident to report or other cases of suspicious activity or fraud, contact us at your California Senior Medicare Patrol, 1-855-613-7080. Together we protect ourselves, our loved ones and our health care.

See Medicare Fraud for more information.
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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.