Medicare Fraud Costs Taxpayers, Creates Problems For Seniors

Medicare is a lifeline for many seniors, but scammers and even medical providers can attempt to get Medicare numbers and defraud the program. June 5-9 is Medicare Fraud Awareness Week, and the West Virginia Bureau of Senior Services is out to draw attention to the problem. 

For his series “Getting Into Their Reality: Caring For Aging Parents,” News Director Eric Douglas spoke with Senior Services Medicare Programs State Director Rebecca Gouty and Denise Worley, the commissioner of West Virginia Bureau of Senior Services to get a better understanding of the problem and what to do if you feel you have been scammed. 

This interview has been lightly edited for clarity. 

Douglas: What’s the scale of the problem? You hear the numbers tossed around – millions, billions, trillions. How big of a problem is it?

Gouty: Medicare fraud costs $60 billion, with a B, each year. So it’s a very big problem. A lot of times Medicare pays the claims first, and then goes back to recoup the money. So that can oftentimes be difficult to get it back after it’s paid. 

Douglas: Any idea what the impact is in West Virginia? 

Gouty: We don’t have a number now, but we are constantly being contacted by beneficiaries who have fallen victim to Medicare fraud. There’s lots of different aspects to fraud. There’s provider fraud, where an actual provider is committing fraud, but then there’s the scammers that are really out there to try and get the personal information from the beneficiaries to defraud Medicare out of lots of different things. And that’s the biggest thing that we see. 

Douglas: That’s my next question. Providers, I assume, are billing for services not rendered and that sort of thing. How are scammers scamming people to get their information to commit Medicare fraud? What’s going on? 

Gouty: The biggest scams are phone-based scams. They’re calling beneficiaries and telling them many different things, but the biggest ones we see are, “Did you get your new Medicare card for the year?” which Medicare doesn’t send out new cards annually. But with other insurance that people have, other cards, you do normally get them annually. Somebody’s like, “Oh, no, I didn’t.” And so they give out their information. 

The biggest thing with that is that Medicare never calls you. So anytime that you get a phone call from somebody who says they’re calling to update your Medicare information, or make sure that you have all the Medicare coverage you’re supposed to have, or if you don’t do this, you’re going to  lose your Medicare coverage. None of that is legitimate. None of it is real. They’re just simply trying to get that Medicare number because it is very valuable.

Douglas: We’re not talking Social Security numbers, we’re talking a Medicare number.

Gouty: Back in 2018, Medicare numbers were changed from Social Security numbers to new numbers, but those still have a lot of value to them, because scammers can use that to commit medical identity theft and bill Medicare for services that you didn’t receive. Or it might be for an item that you did receive in the mail, but what was actually billed to Medicare as an item that was thousands of dollars, where what you got was a $20 item. 

Douglas: These are not medical providers doing the scamming, or at least hopefully not, these are just scammers who are getting that number and somehow they’re billing Medicaid directly.

Gouty: There are actually providers involved in the scams. They’re usually from other parts of the country that the beneficiary has never seen, doesn’t know their name, but unfortunately, they are bad actors as well. They sign the orders because Medicare does require certain orders for different things. So they do and then there’s the suppliers. If it’s related to durable medical equipment, there are some suppliers that get involved. So there’s a lot of times you’ll see something come out from the Office of Inspector General who investigates the fraud. And they’ll say, “We took down this many providers or this many suppliers.”

Douglas: So these are legitimate businesses. These are legitimate people who supply wheelchairs and walkers and that kind of thing. And doctors. So these are legitimate businesses legit with people, such as somebody from Arizona writing these orders for people in West Virginia?

Gouty: Right. That’s one of the big things that beneficiaries, their families and caregivers can really look at is when they get their Medicare Summary notices. If they see services that are from another state, a doctor that wrote something from another state or ordered something from another state, that should send up a red flag, because that’s definitely not something that should be happening, you really should be working with providers in your area. Obviously, we’re in a state that’s surrounded by many other states so it would make sense if you were getting some from Pennsylvania, and you lived on the border, but no you shouldn’t be getting a doctor’s order from California.

Douglas: Does this affect the person’s Medicare services at all? Or is it just they are billing the government, it’s a government fraud, the government goes after them? 

Gouty: It definitely can impact the Medicare beneficiary depending on the type of fraud that it is. Luckily, we haven’t seen this too much in West Virginia. But other states have seen hospice fraud, where people get put on hospice when they are not eligible for hospice. And then Medicare is not going to cover certain services when you’ve got a hospice on your record. So if you need heart surgery, but you have hospice, Medicare is not going to pay for that. So it can definitely cause problems for people not getting the services that they need.

Douglas: If it comes down to it, what do I do?

Gouty: It depends on the type of fraud. It could be a simple billing error. You might reach out to your provider’s office. But if you did have a scam phone call come in, and you gave out your Medicare number, and as soon as you gave it out, you’re like, “Oh, I probably shouldn’t have done that.” We get those all the time, so you can definitely reach out to the Senior Medicare Patrol. We have a toll free number. We have a website. You can also go to your local senior center to talk to somebody, but we’re going to walk you through that conversation. What did they ask you about? What did you talk about? If you gave out your Medicare number, we can talk to you about how to report that to Medicare as a compromised number. You can request a new number from Medicare now that they’re not Social Security based, you can get a new number if needed. And then if there was potential fraud or abuse that took place, we can report that on to the Office of Inspector General. 

We don’t investigate the fraud ourselves and it is at their discretion whether or not it’s chosen to be investigated, but every little case helps build for it to be investigated. 

One thing that we saw a lot approaching May 11, with the ending of the public health emergency, was lots of beneficiaries were getting over the counter COVID test kits and their mail — boxes and boxes of them. And while that was covered by Medicare up until May 11, it is no longer covered. It seemed like there was a lot of getting rid of supplies. We’ve seen that across the country. And that’s definitely something that’s being reported as Medicare fraud

Douglas: Commissioner Worley, tell me tell me what your agency does to help combat this.

Worley: With the Bureau of Senior Services here in West Virginia, our goal is to raise the awareness and make the seniors in our state aware of what may potentially be out there that could impact them. And, just in general, providing them with educational material information, making ourselves available to them to answer any questions and support them in any way that they may need. Making people aware of the Senior Medicare Patrol, they’re here to assist us in safeguarding against Medicare fraud, errors and abuse. So we just definitely want to raise that awareness to our seniors.

Douglas: Big picture, what does the Bureau of Senior Services do? 

Worley: The Bureau of Senior Services in West Virginia offers support to all of the senior centers that are located in the counties throughout our state. Each of the 55 counties have senior centers located within their county, and our role at the bureau is to support them and the programs that they offer to seniors. All of the senior centers offer a variety of different programs based on the needs of the center, the seniors in their county. And so our role is to support them with their program operations. 

Douglas: Both financially and physically, or how does that work?

Worley: There are both federal and state dollars that are funneled into the senior centers for the services that they provide. So we have oversight of the grants and funding sources that feed into the senior centers. And then we have the policies and procedures and program operational manuals that guide and govern each of the particular programs that fall under the different grant funds that are out there. Our job is to provide oversight to ensure that the programs are operating as they are set forth in the guidelines of the grants that fund those programs.

To learn more about Medicare fraud, call the toll-free number at 1-855-254-1720 or visit www.wvship.org for additional information.