Don’t Be a Pawn in Medicare Fraud

Medicare fraud is not a new topic of discussion, but it’s one that most of us know little about it. Here are two examples of fraud that aren’t directed at the individual, but that use him or her as part of the scheme to illegally profit from Medicare.

Home healthcare

The fraudster, whom we’ll call “crook” for shorter syllables, makes a cold-call to the home. The crook claims he is a representative with “ABC Home Health,” offering home health services for free, because Medicare pays it all. All he needs is the person’s Medicare number.

He may return to check the person’s vitals and then bill Medicare for additional services during the visit, all fabricated to inflate the cost. To complete the fraud, the crook obtains the doctor’s NPI, or National Provider Identifier, a ten-digit number issued to healthcare providers in the United States by the Centers for Medicare and Medicaid Services, or CMS.

He then fraudulently documents the doctor’s request for home healthcare for several, maybe dozens, of seniors at a time. In turn, and before services are rendered, Medicare pays part of home healthcare up front.

The crook has the money and of course, the services to the individual never happen. The life of the fraud may run six months or so before the crook closes shop and opens again somewhere else under another company name and with a new owner’s name.

Remember: a doctor’s referral is the correct way for obtaining home healthcare with Medicare.

DME or Durable Medical Equipment

Another popular Medicare fraud involves Durable Medical Equipment, or DME, consisting of knee, back, ankle braces and so on. Many older adults, interviewed by investigators, say they receive up to 10 calls a day from DME companies offering various braces, all paid for by Medicare.

As with home healthcare, the correct way to do this is to receive a referral or prescription from your doctor for a specific piece of DME.

The crook contacts a senior, asking general questions such as “Does your back ever hurt?” At our age, everything hurts, so most will answer “yes” to at least one of the questions.

The crook records the conversation and then edits it, making it sound like the person is asking for the brace. The edited tape goes to the doctors who do business with the company for confirmation that the individual qualifies for a brace. The company ships the brace and Medicare is on the hook for the payment.

Some companies take it a step further. To increase the profit from Medicare, they send the individual several braces for the back, knee, ankle and elbow. Medicare investigators call this “The Mummy Kit.”

Doctors are supposed to meet face to face with someone before recommending a brace. However, some simply listen to a phone conversation and sign off. Even when the senior tells the company that they don’t need the additional DME — and even when they return the items to the company — the company still bills Medicare.

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Of course, these are issues well beyond most efforts on the part of a Medicare recipient. You do have an opportunity to make a difference, however, if you insist on speaking to your doctor about issues such as home healthcare and equipment.

Most providers of home healthcare and most DME companies are completely legitimate. But it’s naïve to think that no sharks swim among us as we navigate through these sometimes-rough seas.

Be smart, verify, don’t give in to high-pressure sales pitches and use your politely skeptical senses.