Our Senior Medicare Patrol (SMP) project receives over 10 Medicare fraud cases a month. The case highlighted below, recently reported by the Health Insurance Counseling & Advocacy Program (HICAP) in Chico, is a scenario that most likely happens on a daily basis throughout California and nationwide. In such scenarios, Medicare beneficiaries are often told they can receive new shoes for “free” and that Medicare will pay for them, regardless of whether they need them. Below are the details of the scam followed by the details of what Medicare really covers and where to go for help if you or your client encounters a similar fraudulent-looking situation.
A Fraudulent Case: Free Shoes
A durable medical equipment (DME) supplier was allowed to enter and approach residents at a skilled nursing facility in Chico. He told the residents they were entitled to new shoes that would be covered and paid by Medicare Part B. He emphasized that the government wants them to have these shoes, and that they could get them at not cost to them. Residents who hesitated or doubted his offer were told that their feet were deformed and that they would benefit from these shoes. The DME supplier even sold shoes to people who could not walk by telling them they would be able to walk if they got the shoes.
What Medicare Actually Covers
Medicare has specific coverage guidelines regarding what shoes it will cover and for what conditions. In general, if a beneficiary has Medicare Part B, has diabetes, and meets the specific conditions outlined below, Medicare will cover one pair of therapeutic shoes per calendar year, as long as the qualifying conditions continue to be met.
The types of shoes Medicare covers on a yearly basis include one of the following:
- One pair of depth-inlay shoes and 3 pairs of inserts; or
- One pair of custom-molded shoes (including inserts) if a beneficiary can’t wear depth-inlay shoes because of a foot deformity, and 2 additional pairs of inserts.
In order for Medicare to pay for a beneficiary’s therapeutic shoes, the doctor treating his/her diabetes must certify that the beneficiary:
- Has diabetes and that:
- A podiatrist or other qualified doctor prescribes the shoes, and
- A doctor or other qualified individual like a pedorthist, orthotist, or prosthetist fits and provides the shoes.
- Has at least one of the following conditions in one or both feet:
- Partial or complete foot amputation
- Past foot ulcers
- Calluses that could lead to foot ulcers
- Nerve damage caused by diabetes with evidence of callus formation
- Poor circulation
- Deformed foot (feet)
- Is being treated under a comprehensive diabetes care plan and needs therapeutic shoes and/or inserts because of diabetes.
If any of these 3 conditions are not met, Medicare will not cover theraputic shoes. DME suppliers who tell you or your clients otherwise are either misinformed or are potentially engaged in fraud.
If you or your clients encounter a similar condition, call your local Senior Medicare Patrol (SMP) project. You can do this by calling the Health Insurance Counseling & Advocacy Program (HICAP) in your area at 1-800-434-0222. Each HICAP program has SMP counselors to assist you.
The case highlighted above is currently under thorough investigation from the DME Program Safeguard Contractor, SafeGuard Services.