Helping to Stop Health Care Fraud

Health care fraud, waste, and abuse cost American taxpayers nearly $60 billion each year. Medicare and Medicaid consumers are an essential element in national fraud fighting efforts. Consumers are best positioned to detect and report abuse and the Senior Medicare Patrol (SMP) aims to empower them to do so through education and advocacy. The Area Agency on Aging hosts the regional SMP to help with this effort in Southern Illinois.  The goal of the SMP Program is to train seniors to recognize and report fraud. 

The national Senior Medicare Patrol program is working to strengthen Medicare by using these regional offices to recruit and train retired professionals and other senior citizens to recognize and report both health care billing errors and suspected instances of health care fraud. Each year nearly 4,500 volunteers, trained by regional SMP offices conduct community outreach and peer-to-peer training to help Medicare consumers:

             • Identify potential scams and other fraudulent activity

                • Protect their personal information including Medicare and Social Security numbers     

                • Detect errors on their Medicare Summary Notices (MSNs) or Explanations of Benefits 

            • Report suspected fraud or abuse to the proper authorities

One might wonder if fraud happens locally.  It does happen.  Recently, a local provider was sentenced to prison for fraudulent billing and money laundering and was sentenced to five years and 10 months in federal prison and three years’ probation after pleading guilty to 14 counts of health care fraud and one count of money laundering.  The provider admitted to keeping almost no records and creating fake documents to bill 14 companies or health insurance funds more than $2 million since 2006.  This provider must pay the money back and forfeit more than $900,000 in cash and property, two minivans and a BMW.  This is just one incident.  Imagine the taxpayer dollars that that can be saved by eliminating all cases of fraud. 

The Affordable Care Act of 2010 provides a number of new tools and resources to prevent fraud and strengthen Medicare. The law improves analysis of health care claims data to flag potential scams, strengthens the screening process for health care providers that wish to participate in Medicare and Medicaid, and provides increased penalties for those committing fraud. These new fraud-fighting tools will help the government identify false claims faster, prosecute health care fraud more effectively, and help prevent fraud from occurring in the first place.  If you suspect fraud contact the Area Agency on Aging at 1-800-326-3221.

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Why We’re Here

He came in walking stiff-legged, a thin little man with cloudy blue eyes devoid of lashes. His face was age-spotted, his hair white and thin. My last session had finished early. I heard someone say, “Let me see who can help you” and stuck my head around the corner.

“I have some free time,” I said, waving. “Come on over and have a seat.”

Mr. G. sat down and placed a plastic bag full of insurance papers on the desk. “I went to Social Security first. They sent me here, “he said. “I didn’t know what to do.”

I asked him what had happened. He began to tell me story I’d heard too many times before.

“This lady came to my house,” he began. “She said she could save me money. She asked me a bunch of questions, which I answered. Then she wrote some things down and asked me for a cancelled check. I gave it to her – but,” he added with a flourish, “I wrote ‘CANCELLED’ across it first!”

I carefully asked him questions to get a fuller picture of what had occurred. Did she call you first and schedule an appointment? The law requires salespeople do this – they may NOT just show up on your doorstep. “Yes,” he admitted, “a lady called and said they’d have someone in my neighborhood.” He rolled his eyes, realizing this was likely a ruse.

“They make nice commissions on sales,” I responded. “In this case, what the salesperson did was unethical.”

“I want back in my old plan, the way it was,” he stated. “My doctors don’t even take this. I just barely make it now on my income, I can’t afford this plan.”

“Don’t worry,” I reassured him. “We can fix this. In fact, I think we can get you out of this plan and into one very similar to the one you had, except the new one will cost you even less.

Mr. G. smiled and nodded. We both thought he had signed up for a Medicare Advantage Plan that his doctors did not accept. On examination, we discovered the plan was a type of supplement that was unnecessary, costly and ineffective. I ran a plan-finder for him and we signed him up with the same company he had before, but a plan that actually cost him less and covered his medicines better.

The commission for an agent who sells a Medicare Advantage (Health) Plan can be upwards of $300 each. Insurance is big business. To protect themselves, Medicare recipients should know the rules agents/salespersons are required to obey:

· They may not come to your home uninvited or without an advance appointment.

· They may not approach prospective clients in parking lots, hallways or lobbies.

· They may not offer gifts worth more than $15 to join their plan.

· They may not provide meals at sales presentations.

· They may not try to sell you a plan at educational events.

I ran over a few of these rules with Mr. G. and reminded him that while some salespeople are helpful, some can be unethical. “The best thing to do,” I smiled, “is come see us. We’re not paid by the insurance companies.” The last thing I did for this consumer was add him to the government DO NOT CALL list. “That should cut back on the sales calls in a couple of weeks.”

Mr. G. wobbled just a bit as he stood to leave. “I have to wait a minute for the blood to flow back into my legs.” He stuck out his hand. “I feel like a big weight has come off my shoulders. Thank you so much!”

“No problem, “I answered. “That’s why we’re here.”

Mr. G. was lucky. The staff at the local branch of the Social Security Administration knew just where to send him. By the time he left, he had accomplished more than he realized. Not only was his situation resolved, but the agent who had sold him the unnecessary plan was now on our radar.

We’ll be watching, and taking notes.

For more information on fraud click here.

to find out more about the Area Agency on Aging click here.

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