Category Archives: Healthcare Fraud

Beware of Scams and Fraud during Medicare Open Enrollment

by Barbara Parrott McGinity, LMSW

It is that time of year again, open enrollment for Medicare Part D and Medicare Advantage plans takes place from October 15 to December 7. Because it is so important that you review your Medicare Part D plans and your Medicare Advantage plan (if you have one) every year, I am repeating this column from last year.
This is your opportunity to review your current health needs and make adjustments based on your needs and your healthcare costs. But it is also an opportunity for scam artists and unscrupulous people to take advantage of you so here are some pointers on what you should and should not do.
You should always shop for a drug plan each year. Plans change more than the cost of their premiums; they also change the drugs they cover. You need to make sure you are getting the best price for your medication by going to http://www.medicare.gov for your search. Get a family member to help if you don’t use the Internet or call the Area Agency on Aging at 832-393-4301 and speak to a qualified Benefits Counselor.
What you should NEVER do, is give personal information over the phone or in person to a stranger just because they are telling you Medicare is changing. All the information you need to now from Medicare comes to you in your Medicare and You Handbook every October. There are no “new” Medicare cards, there are no “new” drug cards, so hang up if you get one of these calls.
You should also evaluate your overall health care costs and decide which is best for you, traditional Medicare or enrolling in a Medicare Advantage plan. When it comes to Medicare Advantage plans, Medicare has strict marketing guidelines that insurance agents and plans must follow. Agents and or brokers:
• Cannot say they are from Medicare or imply that Medicare endorses them,
• Cannot solicit by going door-to-door,
• Cannot send unwanted emails or voicemails or call you unless you have asked to be called.
• Cannot approach you in a parking lot, lobby, mall, or other common areas.
• Cannot approach you in an exam room, dialysis center or pharmacy counter.
• Cannot provide meals at sales presentations.
• Cannot conduct marketing or sales activities at an educational event.
• Cannot market non-health related products such as life insurance during educational sessions.
• Cannot offer you a gift worth more than $15.

You should also be aware of changes to Medicare in The Affordable Care Act. Benefits rolled out in 2012 but, remember to watch out for scam artists. Change brings confusion and scam artists are standing by to capitalize on that confusion.
If you are unsure about a phone call or want to check out a company, please call me first at 713-341-6184. If you need assistance to enroll in a Part D plan, you can contact the Area Agency on Aging by calling the United Way Information and Referral Hotline at 211 and asking for the local number. We want you to be safe…not sorry.

Change in Medicare Numbers can be Bonanza for Scammers

By Barbara Parrott McGinity, LMSW

Good news! Congress passed a bill in April 2015 to replace the Social Security numbers on Medicare cards with a randomly selected number. They have four years to set up the system for new cards, and four more years to reissue cards to current Medicare beneficiaries. Bad news! Scammers will exploit this information to confuse older adults in an effort to get them to give out their Medicare information over the phone.

The calls will likely sound like this; “Hello, this is Medicare and we have good news for you, we are changing your Medicare number and it will no longer be your Social Security number. This will make you safe from identity theft. BUT, before we make the switch, we need to verify your current information.” Big red flag that this is a scam, asking you to verify information.

Whenever you get a call or email from someone asking to verify information, especially personal information like Social Security Numbers, bank account numbers or credit card numbers, it is a scam. They may have a little information about you, but they need more to complete the picture. The information they are asking from you is the piece of the puzzle they need to complete their file on you; and they will take this information and either steal your identity or bill Medicare for items and services you do not need.

As the October Medicare open enrollment date approaches, the scammers start calling and use a number of tricks to confuse people. Barbara Parrott McGinity, Program Director for the Texas Senior Medicare Patrol (SMP) advises you to “to never give any kind of personal information to anyone who calls you on the phone, no matter how convincing they sound. Remember that Medicare and Social Security and the IRS will never call you on the phone.” Be alert to potential scams. Do not fall for calls, postcards, or emails that offer to help you get your new Medicare card.

Contact the Texas Senior Medicare Patrol (SMP) if you have any questions or if you would like to receive information about how to protect, detect and report fraud and abuse at 1-888-341-6184.

WARNING: Individuals promoting genetic testing of Medicare Patients may be committing Medicare fraud and abuse.

by Barbara Parrott McGinity, LMSW

What is Pharmacogenomic Testing?
Pharmacogenomic testing is a new tool in medicine. It is the testing of certain genes to determine how any given individual will respond to specific medications. Drugs are metabolized slowly in individuals carrying genetic polymorphisms that reduce enzyme activity, and these individuals are at an increased risk for adverse drug reactions or therapeutic failure. Alternatively, a genetic polymorphism that increases metabolism could result in ineffective drug treatment.

Genetic testing covered by Medicare?
As long as Medicare is the patient’s primary insurance, and the test is deemed medically necessary, it is currently covered by Medicare with no co-pay or deducible. Title XVIII of the Social Security Act, Section 1862(a) (1) (A) states “…no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis and treatment of illness or injury…”.

Furthermore, it has been a longstanding CMS policy that “tests that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered unless explicitly authorized by statute.”

Screening services, such as pre-symptomatic genetic tests and services, or those used to detect an undiagnosed disease or disease predisposition, are not a Medicare benefit and are not covered by Medicare. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk for and/or of a condition unless the risk assessment clearly and directly effects the management of the patient.

How Could this be Medicare fraud or abuse?
When an individual offers to provide an educational session to a group of seniors, takes their Medicare number, then does a DNA swab, this does not meet Medicare’s criteria of medical necessity. They are offering a service to the general population without determining actual need and they are doing it outside the guidance of the Medicare beneficiary’s own physician.

The group will bill Medicare for services that do not meet medical necessity and do not have a referring physician familiar with the patient’s health needs. The amount they will receive from Medicare is over $1,100. They are abusing the Medicare system by billing for services that are not reasonable or necessary. They could potentially be committing fraud by intentionally billing Medicare for services they know are not necessary.

What can you do?
1) If you are approached by someone, decline their services because you should not give access to your seniors to individuals who take their personal information. Then call and report this to the Texas Senior Medicare Patrol.
2) If you have already been visited by someone taking DNA swabs, contact the Texas Senior Medicare Patrol to discuss action at 1-888-341-6187,

Durable Medical Equipment Fraud – Knee Brace

The Scheme: Medicare beneficiary receives a phone call stating their doctor has approved them for a knee brace and is asked for their Medicare number. Knee brace will be mailed to them. Beneficiary receives an item they assume is correct.

The Fraud: The company bills Medicare for two “adjustable knee joints, positional orthosis with rigid support,” but they send the beneficiary neoprene knee braces.

Medicare’s approved amount for the neoprene product is – $144. 88
Medicare’s approved amount for the knee joints is – $840.50
Dollars stolen from Medicare = $695.62

1833 knee brace example3
Actual item Medicare paid for but beneficiary did not receive this brace.
Item sent to beneficiary and paid for by Medicare
Item sent to beneficiary and paid for by Medicare

Understanding Medicare Hospice Benefits Can Help Eliminate Fraud

by Barbara Parrott McGinity, LMSW, Program Director, Texas Senior Medicare Patrol

What is Hospice care?
Hospice care is designed for patients with six months or less to live if their disease runs its natural course. It is typically given in the comfort of the patient’s home or in a Medicare approved hospice facility.
A patient receives hospice care in two 90-day “benefit periods” followed by an unlimited number of 60-day benefit periods if the patient is still eligible for hospice care. A patient can continue to receive hospice care after the six month period as long as they are recertified by a hospice medical director or hospice doctor. The certification must be provided before every benefit period.

Who is eligible?
To qualify for the Medicare Hospice benefit, a patient must meet the following criteria:
1) is eligible for Medicare Part A;
2) doctor and medical hospice director certify the patient is terminally ill (six months or less to live if the disease runs its natural course);
3) patient signs a statement choosing hospice care over any other Medicare-covered benefits to treat the illness; and
4) must receive care from a Medicare-approved hospice .

What happens when a patient chooses hospice care?
When a patient selects to receive hospice care, they are waiving their rights to Medicare payment for:
1) hospice care provided by a different program during the same time frame;
2 ) services related to the treatment of the patient’s terminal illness, and
3) services considered equivalent to their hospice care, except the services provided by the hospice program or the attending physician. Important: Medicare will still pay for covered benefits for health problems not related to a terminal illness, like care for an injury.

How does a patient stop hospice care?
If a patient is no longer terminally ill or their illness goes into remission, they no longer qualify for hospice care. In addition, a patient can elect to stop hospice care at any time and resume the Medicare coverage they had before hospice care. A patient can also elect to return to hospice care for any benefit periods they are eligible to receive.

What is Hospice Fraud?
All areas of hospice care may be subject to fraud of some kind. When dealing with hospice care it is important to remember that the frequency and types of services are to be determined by the NEEDS of the patient, not the staffing limitations of the agency.

Examples of hospice fraud:

  • Reducing the frequency of home health aide visits.
  • Using less qualified staff in roles which requiring the skills of a Registered Nurse.
  • Reducing the frequency of case manager visits to the patient. A telephone call from a Registered Nurse is not a substitute for an on-site assessment of the patient’s condition.
  • Skimping on pain medication.
  • Providing equipment that the patient does not need.
  • Refusing to provide oxygen to patients who are short of breath or who need oxygen for other reasons.
  • During a crisis, refusing to provide continuous, around the clock care in the patient’s own home.
  • Telling the family and patient that the hospice doesn’t have enough staff to provide in home care and they need to move to a facility.
  • Moving a patient to a facility allows them to bill Medicare at a higher rate for continuous nursing care plus fees for room and board.
  • Asking the family to pay out of their own pocket for services covered by Medicare and Medicaid. The family may not see what is billed or the bill may arrive after the patient is deceased and they do not read the statements or understand what has been double-billed.
  • Hospices receives a kickback for referrals from a hospital or nursing home.

What to Look For:

  • If your loved one is NOT getting the services needed.
  • If the hospice is trying to talk you into transferring your loved one to their facility.
  • If your loved one is NOT being kept comfortable
  • If there is inadequate staff and you are doing most of the care giving.
  • Demand that the hospice provide the services needed to meet the needs of the family and patient. The law requires the hospice to meet the needs of the patient and the family!

What to Do:

  • Read all the printed literature, documents and contracts you received from the hospice.
  • Know what services are required to be provided. This will help you protect your loved one from exploitation.
    Report potential fraud. Contact the Texas Senior Medicare Patrol at 1-888-341-6187.

Medicare Beneficiaries are Prime Target for Scammers

by Barbara Parrott McGinity, LMSW

The phone calls are endless. You get offers of back braces and medical alerts. Someone calls and wants to help you save money on your Medicare costs. Maybe you have gotten a call that Medicare has changed and you need a new card. The open enrollment periods for both Medicare Part D and the Affordable Care Act insurance exchange are fast approaching, and this is prime time for scammers to call with confusing messages that put you at risk.

“The con artists are always looking for new opportunities to trick you,” states Barbara McGinity, Program Director, Texas Senior Medicare Patrol. “Understanding the different scams can help you not be a victim.”

Here are some of the most common scams and what you can do to avoid them.
1) A caller claims to be a federal employee and states that you need a new Medicare card because of Obamacare. To receive this card, you must provide your banking information.
McGinity says, “Medicare has nothing to do with your bank account. If you receive a call such as this, immediately hang up.”

2) An individual calls and says that your doctor wants you to have a back brace or to receive services in your home, but first, they need your Medicare information. Another trick is to tell you a family member ordered an item for you. Never give your Medicare number to anyone over the telephone or to anyone you do not know who comes to your door.
“Individuals should never take the word of a stranger who says your doctor told them to call,” states McGinity. “Take their name and telephone number and hang up. Then call your doctor and ask if they told them to call you. These people trick you into believing something that is not true.”

3) You receive a robo call offering you a “free” medical alert. To get more information just punch one or to get off their list, punch two.
“Never punch any numbers when you receive an automated call. When you follow these directions you are telling the scammers that this is a good telephone number answered by a live person,” says McGinity. “When you follow these directions, you put yourself on a list to be called by a real person who will then try to get personal information or money from you.”

4) A caller says you are paying too much for your Medicare and they want to help you. “This is most likely someone wanting to come to your home to discuss your Medicare insurance,” states McGinity. “If you are interested in talking to an insurance agency about Medicare coverage that is ok, but you need to make sure you understand all the changes that might take place with your coverage. Be sure to check with your doctor first before making any major changes, and get all information in writing before the agent leaves your home.”

The Texas Senior Medicare Patrol wants Medicare beneficiaries to protect themselves and their Medicare information. According to McGinity, “the best way to protect yourself is to not answer your phone. Screen all your calls. Remember that Medicare will not call you, and most importantly, Medicare is not free, Medicare is real money. It is taxpayer dollars and it is healthcare dollars.”

If you have questions about a phone call you have received, or want more information about Medicare fraud contact the Texas Senior Medicare Patrol at 1-888-341-6184.

Medical Discount Plan vs Health Insurance Don’t get Scammed in the Confusion

Affordable Health Care Plan! Pre-existing conditions? No problem! No Deductible or Co-pays! Thousands of providers in our PPO network! Discounts up to 60%! Sounds like insurance you can get through the Healthcare Exchange aka Obamacare? NO, it is not! These are health or medical discount plans and they can cost you lots of money and you get NOTHING in return.

The national focus on health insurance provides an opportunity for these shady companies to confuse people and sign you up for a product that is not health insurance. One way to know the difference is to realize no one selling health insurance through the government exchange will make a cold call to sign you up.

If someone does call to offer you a medical discount plan or if you see an ad for such a plan on the Internet or in a newspaper, be alert to these red flags.

  • They do not use the word insurance, but they will use the words health plan and medical plan to confuse you.
  • Ask for a list of providers who participate in the plan. If they cannot mail you a list or provide you a website, then you are dealing with a scammer.
  • They ask for a credit card or bank account number immediately for enrollment. You should NEVER provide that information to a stranger calling on the phone. The legitimate plans will mail you coverage information first, then a statement after you have enrolled.
  • Understand that a discount plan is not insurance and therefore you will still be subject the federal penalty for not having health insurance.
  • Call the Better Business Bureau at 713-868-9500 to check to see if it is a legitimate company.

If you are interested in learning more about health insurance available through the Health Insurance Exchange go to http://www.healthcare.gov or call 1-800-318-2596.