April 01, 2021 Feature

Silence of the Scams

Leasha West

Why is there a deafening silence surrounding a $60 billion-a-year scam?

I’m talking about Medicare fraud, which routinely targets Medicare beneficiaries, causing immeasurable damages. The breadth of these boundless damages extends from abusing the healthcare system to higher premiums for medical services and ultimately identity theft.

Yet no one is talking about this. Here’s why we should all be speaking up and protecting ourselves.

WHAT EXACTLY IS MEDICARE FRAUD?

Medicare fraud occurs when people, suppliers, or companies receive illegal payments from Medicare under false pretenses or manipulate material facts for financial gain. Anyone from doctors, hospitals, pharmacists, home healthcare agencies, nursing homes, medical suppliers, rehabilitation facilities, hospice centers, and even Medicare recipients can be involved.

Here are just a few examples of Medicare fraud:

  • Patients receive a bill from Medicare for services they never received.
  • Medicare is billed for home health services for patients who aren’t homebound.
  • A person uses someone else’s Medicare number or card.
  • A medical provider assigns the wrong diagnosis to obtain payment from Medicare.
  • Medical providers bill patients for medical services other than the care they actually received.
  • Patients are sent for medical services, tests, labs, or procedures they don’t need.
  • Medicare is billed for rented medical equipment that was already returned.
  • Patients receive unnecessary medical equipment for which they don’t qualify.
  • Medicare is billed for services, supplies, or equipment that patients have never received.

And who pays for all of that? Everyone does. The more false claims that are paid out, the lower the amount of funds available for legitimate medical needs. The consequences result in tighter regulations for services, supplies, and equipment for all Medicare recipients.

If you’re a victim of Medicare fraud, you may not realize it right away; however, at some point, you’ll feel the impact of the deceit just when you need your Medicare coverage the most. To ensure the maximum safety and avoid jeopardizing your medical records or being subject to any unjust fiscal liability, follow and implement these 10 protections starting today.

1. Guard your card. Take this seriously. The most important safety protocol is to guard your Medicare number and card. Disclose your Medicare number only to necessary parties, such as your medical providers, a trusted family member or caretaker, or insurance agent.

Don’t carry your Medicare card with you. Store it in a safe place at home, and take it to medical appointments only as needed.

Take note: Your Medicare card will never expire, and your Medicare number will never change. Don’t allow anyone to persuade you to help renew or update your Medicare card, neither of which will ever need to happen.

2. Dodge the phone. A popular Medicare scam is a caller posing to be from Medicare seeking to “update” or “verify” your information for their records. Granted, scammers may already have some basic information, such as your name and address, to convince you of their legitimacy. Don’t fall for it.

Medicare already has your information; they don’t dispatch callers to confirm or collect anything.

Listen up! If you ever receive this type of call, request the caller’s name and contact information, sidestep any conversation, disconnect the call, and block the number. Never reveal your Medicare number, birthday, Social Security number, credit card information, bank account numbers, Medicare provider, your doctors’ names, or family members’ names.

And never discuss any of your medical history or prescriptions over the phone with a stranger—nothing. It takes only a few key pieces of information for a scammer to commit identity theft and Medicare fraud.

3. Avoid debt-collection scams. In a similar vein, scammers will call and identify themselves from either Medicare or your Medicare provider and attempt to pressure you into paying alleged medical bills over the phone as a means of capturing your sensitive information. Some of their underhanded tactics involve threatening to drop your Medicare coverage, denying you future healthcare services, or refusing to refill your prescriptions if you don’t pay on the spot.

Mind you, there are no such collection procedures. If there’s a genuine problem with your Medicare provider, they’ll notify you by mail or email, depending on your chosen communication preference. Or you can contact them directly to see if there’s a problem and work things out.

4. Don’t accept services you don’t need. I’m not telling you to play doctor. But many times, medically unnecessary services are ordered and performed that are categorized as abusive and wasteful. To help you identify potentially needless medical services, check out these instances:

  • A physician prescribes unnecessary or duplicate medications.
  • An ambulance is used when such transportation isn’t needed.
  • A doctor bills for surgical procedures on patients who don’t meet the criteria for the procedures.
  • A provider bills Medicare for more-expensive diagnostic procedures that don’t support the diagnosis.
  • A hospital codes a patient as inpatient to take advantage of the higher inpatient rates when the services should’ve been done outpatient.
  • Medicare is billed for a motorized wheelchair for a patient who doesn’t need one.
  • A pharmacy bills for a higher-tier drug when it wasn’t necessary.

You get the idea. Don’t be afraid to delay and ask for a second opinion before blindly accepting any test, procedure, or prescription that you question or know you don’t need. Moreover, Medicare typically covers second opinions so that you can independently confirm what you do and don’t need.

5. Review the paperwork. Read your explanation of benefits, often called the EOB, and Medicare summary notice, or MSN, and claims. This is extremely important. When Medicare and your Medicare provider send you the EOB and your MSN, it’s critical that you thoroughly examine each statement.

The EOB documents your prescription coverage in the months that your medications were filled; the MSN is provided quarterly and records all the services and supplies billed to Medicare on your behalf as well as what Medicare paid. It’s important to verify that you received exactly what was billed in a timely manner. If there are any errors, report them to Medicare immediately.

6. Keep a medical diary. Any time you receive any kind of medical services or get a prescription filled, keep a detailed record, including the invoice of the services and the prescription receipt. Your personal medical diary should list every appointment and include the date of service; who provided your care (if it’s more than one person, name every one); the services, tests, or procedures you received (even if it’s a follow-up appointment); and how much you paid for it.

For prescriptions, record who issued the prescription, the date it was filled and for how long, any changes to the medication, and how much you paid. If the provider makes an excuse not to give you these details, that’s a red flag. Be diligent in your recordkeeping so you can conduct your own Medicare audit.

7. Beware of anything that’s “free.” Take notice of any advertisement of free stuff, free tests, or free healthcare services. Often, county agencies, nonprofit organizations, insurance companies, or community outreach programs will dangle something for “free” in exchange for your information. You may see this at a senior expo or health fair as an enticement to win a prize, enroll in a raffle, and so on. Although that may appear innocent, avoid a possible scam by not participating or disclosing any of your information. Let’s face it: Nothing is free.

8. Watch for phony Medicare plans. Believe it or not, scammers may contact you to present a phony Medicare plan complete with all the brochures, materials, perks, and benefits. Yes, this can really happen.

If the scammers are successful, they’ll have made off with all your personal and banking information, obtained from the counterfeit application, to complete their fraudulent activity. If the insurance company you’re considering isn’t well-known, check directly with the Plan Finder at Medicare.gov to authenticate the company.

In addition, it’s always a good idea to check with your state insurance department to validate the license of the insurance agent you’re working with. These extra measures will significantly reduce your chances of falling victim to Medicare fraud.

9. Ignore sales at your door. For the most part, the days of door-to-door sales have long passed. If anyone you don’t know unexpectedly appears at your door, for the sake of security, don’t answer. But if you do happen to answer to find someone claiming to want to sell you Medicare plans, supplements, or supplies, don’t invite them inside or accept any medical supplies or gifts.

And more importantly, don’t leak any information—it’s bad enough they know where you live!—about yourself, your living situation, or your family members. Even if people are charming and convincing and present themselves to be trustworthy Medicare sources, the door-to-door sales model is outdated and too risky nowadays.

It might also be wise to instruct your neighbors not to interact with or discuss any information about you with anyone who visits the neighborhood or contacts them to gather information.

10. Knock, knock, it’s Medicare—not! Just as Medicare won’t contact you by phone, it’s no surprise they won’t dispatch representatives to your home, either. Don’t be deceived by anyone who pays a visit claiming to be from Medicare for the purpose of verifying information, conducting a home-safety inspection, delivering products or equipment, or for any other reason. They’re up to no good.

Ask for their contact information, identify what they were driving, and get their license plate number. Bonus points if you snap a picture of them while they’re not looking.

Medicare fraud is big business in America and results in unbearable financial woes for its victims. Stolen Medicare numbers are valuable currency for thieves who unlawfully use those numbers to bill Medicare for unused services, supplies, and equipment and pocket the reimbursement.

Medicare loses an estimated $60 billion each year due to fraud, waste, errors, and abuse.

This fraud hurts every one of us. When crooks steal from Medicare, resources are drastically reduced for the medical care and prescription drugs people really need. Instead, those funds are recklessly allocated for medically unnecessary services and procedures.

And you can personally be harmed and suffer injuries by being subjected to irrelevant tests, taking medicine not right for you, or receiving care you don’t need. Sometimes healthcare professionals, pharmacies, and medical suppliers make honest mistakes and unintentionally bad choices. Other times, they knowingly steal and contribute to the $60 billion annual fraud.

Why isn’t anyone talking about this?

Entity:
Topic:

Leasha West

Leasha West, MSFS, ChFC®, CASL®, NSSA®, CLTC, MDRT, is CEO of West Insurance & Financial Group Inc. in Kalamazoo, Mich. She is a veteran of the U.S. Marine Corps. She was the only female executive to win the Industry Elite Award by National Underwriter Magazine.