Medicare open enrollment has begun, bringing with it both the opportunity for seniors to tailor their coverage to their needs and budgets and the opportunity for dishonest people to prey upon those seniors and the taxpayers who contribute to the program.
Fraud is an issue that Medicare continually struggles to address. The federal government estimates taxpayer losses to Medicare fraud at between $60 billion and $90 billion annually.
Seniors fear fraud, and justifiably so. One Harris Poll a few years ago showed that the greatest fear for 37 percent of senior citizens was fraud – ahead of personal health crises and terrorism.
In Oklahoma, Medicare fraud is combated by the Senior Medicare Patrol here at the Oklahoma Insurance Department. The SMP department receives complaints about Medicare fraud from consumers and trains community volunteers to help their friends and neighbors identify Medicare fraud.
The Senior Medicare Patrol is necessary because we know that Medicare fraud and waste do happen in Oklahoma. Some waste is attributable to human error – a procedure is inaccurately coded into the system, or a test is accidentally billed twice. These mistakes can and should be caught and corrected.
But all too often, billing problems are an intentional attempt to defraud the system. In one recent case, an Oklahoma man who operates a prosthetic-device business was indicated by a grand jury on charges that he illegally obtained nearly $5 million from Medicare and more than $600,000 from Medicaid by billing the federal health programs for beneficiaries who did not have prescriptions from licensed physicians for the prosthetics he provided. It is alleged that he submitted physician names and I.D. numbers to Medicare and Medicaid in cases where physicians had never treated the patients.
Medicare fraud can ring your phone or come knocking on your door, as well. Our SMP division reports that the most common form of Medicare fraud in Oklahoma is misrepresentation of the salesperson’s affiliation. The agent either directly states he works for Medicare or at least implies that he does. This might be in the form of a statement such as, “My name is Joe Smith and I’m calling today to help you enroll in a Medicare plan for the coming year.”
Seniors should always remember – Medicare never sells anything.
While OID’s SMP program is here to provide training and support, seniors also should be aware that they are their own first line of defense against fraud. In the words of our SMP trainers, when it comes to Medicare fraud Oklahoma’s seniors should “Protect, Detect and Report.”
- To “Protect” yourself, don’t give your personal information to anyone you don’t know, even if they claim to be from Medicare; don’t print your Social Security Number on checks; and, don’t carry your Medicare card in a purse or wallet.
- To “Detect” Medicare fraud, read your Medicare Summary Notice carefully, looking for duplicate payments for the same service, dates of service on your Medicare Summary Notice that differ from the dates you received services, items or services that you have no record of having received, and billing for medical equipment or services that your doctor did not order.
- Finally, “Report” any discrepancies in billing or concerns about Medicare fraud to the appropriate authorities; in Oklahoma that’s OID’s Senior Medicare Patrol at (888) 967-9100 or online at smp.oid.ok.gov.
Other rules of thumb:
- If a salesperson calls and tries to threaten or pressure you into something, just hang up the phone.
- If someone comes to your door saying they are from Medicare or a health care firm, shut the door: “It’s shrewd to be rude!”
- Don’t keep mail in your mailbox for more than a day and rip up or shred your Medicare or other health care papers before throwing them away. Crooks will raid mailboxes and aren’t above rummaging through garbage.
- If an offer sounds too good to be true, it usually is.
There are very stringent guidelines for how Medicare Advantage and prescription drug plans can be marketed. If you are approached by an agent or company engaging in any of the following practices, refuse to do business with them and report the contact to the Senior Medicare Patrol.
- An agent cannot come to your home to try and sell their product unless you request that visit beforehand.
- Agents cannot call you on the phone unless you have requested they call you ahead of time.
- Salespeople cannot approach potential beneficiaries in a common area, such as parking lot, hallway, or lobby, or in a health care setting like a pharmacy or a hospital waiting room.
- Agents cannot cross-sell; that means, if you invite someone to come into your home and speak to you about a prescription drug plan, they aren’t allowed to discuss other products like annuities, life insurance, etc., at that same appointment.
If you request an agent to come speak with you, they must specify before the appointment the product or products to be discussed at that appointment, and the beneficiary must agree to it before the appointment.
Agents cannot offer beneficiaries a gift in exchange for enrolling in their plan. They can present a nominal gift to attendees at a marketing event – something valued at $15 or less – but they have to give one to all attendees, not just those who enroll in their plan.
Medicare open enrollment runs through Dec. 7 this year, and besides these tips about avoiding fraud, the Oklahoma Insurance Department can answer almost any question seniors might have about the Medicare system and the enrollment process.
To ask questions or get help enrolling in a Medicare plan for the coming year, contact our Senior Health Insurance Counseling Program (SHIP) at (800) 763-2828 For any other questions or concerns about insurance in Oklahoma, contact OID at 1-800-522-0071 .