California SMP Produces Results ~ Success Stories in Stopping Medicare Fraud

California SMP Produces Results ~ Success Stories in Stopping Medicare Fraud

Santa Ana, CA — California’s Senior Medicare Patrol (SMP) produces concrete results with persistent and consistent outreach, education and training to its volunteers, providers and the general public.
“The more people know about fraud, how to detect it and where to report it,” said Julie Schoen, Project Director for the California Senior Medicare Patrol project, “the faster we can end this vicious fraud cycle. And we have several recent case successes demonstrating just this trend.”

A few highlights include:

Hospice case investigation results in recovered funds

  • This case was brought to California’s Senior Medicare Patrol in 2010.
  • A Los Angeles county beneficiary was talked into signing up for hospice even though she was not terminally ill.
  • She was told that, “everything would be free if she signed on the dotted line.” So she signed.
  • A resulting investigation then discovered many unqualified beneficiaries were enrolled in this particular hospice.
  • In June 2012, investigations by one of the Centers for Medicare and Medicaid Services (CMS) contractors, ZPIC, and Medi-Cal resulted in $620,000 and $102,000 recovered funds to Medicare and Medi-Cal respectively.

Kern County capping case results in doctors’ suspension and clinic closure

  • Kern County’s Health Insurance Counseling and Advocacy Program (HICAP) and Adult Protective Services brought this case to California’s SMP in March 2012.
  • Several beneficiaries were promised durable medical equipment in exchange for their Medicare numbers.
  • These beneficiaries were then taken to shoddy, bogus clinics over 300 miles away from home.
  • While no medical procedures were performed at these clinics, multiple fraudulent Medicare claims were submitted and paid for.
  • After HICAP and Adult Protective Services turned this case over to SMP, SMP referred it immediately to CMS and the Office of Inspector General.
  • To date, the investigation has resulted in 2 doctors being suspended from Medicare and 2 bogus clinics being closed.

Medicare reimbursed for charges on services never rendered to Orange County beneficiary

  • Early in 2011, during a routine HICAP counseling session, a beneficiary showed his HICAP counselor a fraudulent charge on his Medicare Summary Notice.
  • The beneficiary claimed that the services charged and paid for by Medicare were never rendered.
  • HICAP turned the case over to California’s SMP.
  • SMP referred the case to a CMS contractor for investigation.
  • The resulting investigation found the provider’s records insufficient, and as a result Medicare was recently reimbursed $2,651.

Santa Cruz County beneficiary’s durable medical equipment record cleared

  • In 2011, a social worker notified the Santa Cruz County HICAP that a beneficiary had a wheelchair on his record yet she found no evidence of a wheelchair in his home.
  • Santa Cruz County HICAP turned this case over to California’s Senior Medicare Patrol.
  • SMP researched case and referred it to CMS’ contractor for investigation.
  • CMS found that this beneficiary’s Medicare number was indeed fraudulently used.
  • CMS recently cleared this beneficiary’s record so he can obtain the equipment he needs in the future.

As seen in the above examples, “producing results such as these takes a team approach, working together with volunteers, HICAP counselors, beneficiaries in the community, service providers, and government and law enforcement agencies,” stated Diane Caradeuc, CMS Liaison. “This allows for a quick, integrated and thorough response to reports on fraud.” Fraud often starts at the “grassroots” level with fraudsters using a variety of nefarious methods to collect beneficiaries’ Medicare numbers, then billing for services never rendered. This means that fraud can also end at the grassroots level. SMP volunteers across the state remind their peers to protect their Medicare numbers as they do their credit cards. And that in doing so, they have the power to stop fraud.

People who have a fraud case to report or have questions about fraud can contact the California Senior Medicare Patrol at 855-613-7080. They can also visit the SMP website for more information and examples on Medicare Fraud. People interested in volunteering with their local Senior Medicare Patrol can sign up here.

The California SMP program was awarded to California Health Advocates in 1997 when the SMP program was first established by federal law in 1997. California Health Advocates is an independent non-profit organization that provides quality Medicare and related health care coverage information, education and policy advocacy. SMP volunteers are available in each county through the Health Insurance Counseling and Advocacy Program (HICAP), which provides benefits counseling and community education directly to those with Medicare and their families. For more information, visit its website at cahealthadvocates.org.

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Contact:

Julie Schoen
SMP Project Director
(714) 560-0309

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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