Real Medicare bills denied. Fake claims paid

That’s what happened in the hospice fraud case. The daughter of the Medicare beneficiary who was fraudulently enrolled in hospice contacted the State Health Insurance Assistance Program (SHIP) in Kern County, California. The group is known as SHIP throughout the country, but California calls its organization the Health Insurance Counseling and Advocacy Program (HICAP).

The daughter reported that her mother suddenly started receiving an alarming number of bills for services that Medicare would usually cover. She had no idea why those claims were being denied.

After some digging, the HICAP Senior Medicare Patrol volunteers uncovered that the mother had been enrolled in hospice without her knowledge. The older woman wasn’t terminally ill.

As egregious as it seems, hospice can be ripe for fraud because Medicare pays for many expenses when you receive end-of-life care, including doctor’s services, drugs to help control pain, health aides, medical equipment and other services your hospice team recommends to manage your terminal illness. Unlike other care, Medicare’s regular copayments and deductibles don’t apply to hospice.

But once you enroll in hospice, Medicare won’t pay to cure your terminal illness. That explains why so many of the woman’s claims were denied.

Volunteers dig into the details, uncover a pattern

Senior Medicare Patrol volunteers started troubleshooting and requesting copies of the bills. Through their research, they found that 13 of her legitimate claims had been denied, says Carolina Oehler, the Senior Medicare Patrol liaison for the Kern County Aging & Adult Services Department.

The Senior Medicare Patrol volunteers worked with the Centers for Medicare & Medicaid Services to put a 30-day hold on the bills while they worked on the case. They also reported to Medicare that the woman’s card was compromised and helped her get a new Medicare number.

In total, the patrol members discovered that the hospice agency had billed Medicare for more than $12,000 and about $11,000 had been paid.

“The California Senior Medicare Patrol diligently assisted with this case and investigation, and with the help of the Office of Inspector General [OIG] and Centers for Medicare & Medicaid Services, the beneficiary’s hospice claims were denied, all monies were recovered, her provider claims were paid, and her Medicare coverage was restored,” Oehler says. They reported the case to the OIG, which initiated an investigation and issued a national alert warning people about similar cases.

Network of participants have roots in their cities, towns

Senior Medicare Patrol volunteers live where they serve, helping Medicare beneficiaries and their caregivers directly. So they’re often the first ones to uncover new scams.

“Law enforcement does great work once the fraud has happened, but we’re able to get out in the community to talk to folks and really get a sense of what is happening,” says Director Rebecca Kinney of the federal Administration for Community Living’s office of health care information and counseling, the U.S. Department of Health and Human Services (HHS) division that finances the Senior Medicare Patrol program.

“Because of that perspective, we are often able to pick up on new trends and issues before law enforcement and insurers see things happening in the data,” she says. “We’re getting the stories directly from beneficiaries on the local level.”

Frequently, people feel more comfortable asking local volunteers questions about suspicious activity that might be criminals at work.

“The volunteers help spread the word into their communities, and sometimes in diverse communities that we may not otherwise have access to,” says Tiffany Erhard, New York state Senior Medicare Patrol director.

You can always report Medicare fraud to 800-MEDICARE. But Senior Medicare Patrol volunteers can answer questions, provide a personal connection, and walk you through the process of gathering evidence and building a case to send to HHS’ Office of Inspector General, which investigates Medicare fraud.

“When it’s sent to the OIG, it’s flagged as a Senior Medicare Patrol case, which shows that somebody has already looked at this who knows what pieces of information to put together that the OIG needs,” Kinney says.