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Risk Fraud & Compliance

Medicare fraud scams target seniors and expose personal information

Melissa D. Berry  Lead Compliance Attorney Editor / Regulatory Intelligence / Thomson Reuters

· 5 minute read

Melissa D. Berry  Lead Compliance Attorney Editor / Regulatory Intelligence / Thomson Reuters

· 5 minute read

Fraudsters are continuing to take advantage of seniors by obtaining their private Medicare information after promising services or products that may never be delivered, making it more important than ever to guard against this type of scam

Healthcare fraud schemes often entice Medicare enrollees with offers of “free services, medical equipment, or gift cards,” if the enrollee will confirm their personal information and eligibility for specific Medicare services. Fraudsters target enrollees through phone calls, internet ads, and text messages that promised the enrollees are “qualified” for “free” or “no cost services.”

In the most recent scheme, scammers are using enrollees’ personal information to submit monthly bills to Medicare for “medically unnecessary” urinary catheters that may or may not actually be sent to the Medicare enrollee, according to a recent consumer alert from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).

In this scam, an “unscrupulous” durable medical equipment company will claim that “they work for Medicare or are calling on behalf of Medicare”, yet the fraudster’s goal is to obtain the enrollee’s Medicare number. Often, the durable medical equipment company pays a provider with no relationship with the enrollee to sign an authorization for the durable medical equipment.

Medicare fraud might not be the only risk — these illicit actors can also use the Medicare enrollee’s personal information to perpetrate other financial fraud schemes.

Other recent durable medical equipment fraud schemes

Although the Medicare fraud catheter scam is the most recent, durable medical equipment schemes are a favorite of healthcare fraudsters. Often relying on kickbacks to unethical medical professionals, telemedicine and telemarketers will partner to mislead seniors into providing their personal information and Medicare numbers. The scammers then use that information to submit false claims for reimbursement to the federal Medicare program.

Knee and back brace scam

The owner of two telemedicine companies, Steven Richardson of Parkland, Fla., agreed to plead guilty to one count of conspiracy to commit healthcare fraud in February, for his role in a $110 million telemedicine fraud scheme involving medically unnecessary durable medical equipment, including back and knee braces.

Over several years, Richardson’s companies entered into business arrangements with telemarketing companies that “generated leads by targeting” Medicare enrollees. The telemarketers then paid Richardson’s companies on a “per-order basis” to generate physician orders for durable medical equipment for the enrollees.

In order to perpetrate the fraud, Richardson worked with medical staffing companies to find doctors and nurses who would “review and sign prepopulated orders.” Although the medical records falsely documented that these medical providers had performed medical examinations of the enrollees, in reality, they rarely had any contact with the enrollees.

Richardson then provided the signed orders to the telemarketing companies so they could sell the falsified orders to durable medical equipment suppliers. The suppliers would then bill Medicare for providing the medically unnecessary knee and back braces whether or not they actually sent the braces to enrollees.

Richardson faces up to 10 years in prison and a fine of up to $250,000 or “twice the gross gain or loss” from the scheme, whichever is greater.

Orthotic brace scam

In a similar scheme involve fraud of $136 million, Jean Wilson, of Richmond Hill, Georgia, pleaded guilty to conspiracy to commit healthcare fraud and wire fraud on March 8. Wilson was a licensed nurse practitioner in New Jersey who owned two telemedicine companies and two orthotic brace suppliers.

Through her companies, Wilson recruited and bribed medical professionals to “sign prescriptions” for Medicare enrollees for “orthotic braces and prescription drugs” that were medically unnecessary, not covered by Medicare, or not provided to enrollees. During the conspiracy, Wilson and others submitted false and fraudulent claims to Medicare in excess of $136 million. The Medicare program paid “at least $66 million for these claims.”

Wilson faces up to 20 years in prison and has agreed to pay more than $66 million in restitution to Medicare and the IRS.

Preventing Medicare durable medical equipment fraud schemes

Medicare enrollees can protect themselves and taxpayer dollars from durable medical equipment fraud schemes. The OIG offers the following tips:

      • If you receive a call from someone offering you free durable medical equipment or services that will be billed to Medicare, hang up immediately.
      • Be suspicious of anyone who offers you free medical equipment and then requests your Medicare number. If your personal information is compromised, it may be used in other fraud schemes.
      • If medical equipment is delivered to you, don’t accept it unless it was ordered by your personal physician. You can refuse the delivery or return it to the sender. You should also keep a record of the sender’s name and the date that you returned the items.
      • Carefully review any explanation of medical benefits documents you receive. Look for any durable medical equipment or services you did not order or did not receive.
      • Medicare enrollees should be cautious of unsolicited requests for Medicare numbers. No one other than your provider’s office should ever request your Medicare information.

The pervasive use of telemarketing and targeted internet and television ads can leave Medicare enrollees vulnerable to healthcare fraudsters and awareness of these schemes may be the best protection.

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