Bamboozled June 9, 2016: The Medicare fraud army you’ve never heard of

Medicare fraud, errors and abuse amount to $60 billion in losses each year, according to the National Health Care Anti-Fraud Association.

That’s a whole lot of moolah.

The government and taxpayers get cheated out of money, and so do individual consumers.

So how would you like to have your very own Medicare advocate? An expert who can scrutinize your bills line by line, who is trained to spot mistakes and pick up on fraud?

You’ve got one: The Senior Medicare Patrol, or SMP.

SMP, according to the feds, has recovered more than $106 million in savings to Medicare, Medicaid and individual beneficiaries since 1997. The numbers for 2015 are expected to be $2.5 million, a recent federal report said.

Every state has an SMP program — they’re all federally funded — and New Jersey’s is based in Milltown. Its 45 volunteers blanket the state with presentations and community events about fraud.

Just as important, they take complaints from consumers and start investigations into costly medical billing scams and other schemes, SMP project director Charles Clarkson said.

You can get them to work for you.

boozle_SMP_miller_71.JPGAt left, Charles Clarkson, Project Director for Senior Medicare Patrol (SMP), a program funded by the U.S. Administration For Community Living, is handed their newsletter by Ed Campell, a volunteer Coordinator of Complex Interactions. SMP is designed to improve the quality of healthcare for senior citizens in New Jersey by educating seniors about Medicare and Medicaid fraud, waste and abuse.

If a Medicare beneficiary believes he or she is a victim of fraud, waste or abuse, the consumer would give SMP consent to act on the consumer’s behalf and work on the case, Clarkson said. The consumer would give the group relevant documents, such as Medicare Summary Notices and other statements.

“We will then assign the matter to a volunteer whose task is to discover all the facts, deal with the provider and take steps to resolve the issue, usually recovering funds for the Medicare trust fund or a refund or savings to the beneficiary,” Clarkson said.

New Jersey’s SMP has had real results.

In a recent case, Clarkson said, SMP started receiving calls from beneficiaries about a group that was visiting senior residents to offer free genetic testing.

Medicare will only pay for genetic tests if they are ordered by your doctor and are medically necessary, Clarkson said, calling the coverage very limited.

“They would ask random beneficiaries to take this test by providing a cheek swab and send it to a lab for testing and bill Medicare, usually in the amount of $2,600,” Clarkson said. “Medicare would usually approve payment of over $900.”

He said the claims were being signed off by a physician’s assistant who had no relation to the beneficiary and had no knowledge of the beneficiary’s medical history.

“After amassing a significant number of Medicare Summary Notices (MSNs) we forwarded this case to the Office of Inspector General, which oversees Medicare fraud, and which is in the process of investigating this scam,” he said. “In December of 2015 the head of this group was arrested and the case is ongoing. More arrests are expected.”

You can read the criminal complaint here.

Not all cases involve intentional fraud.

Take what Clarkson calls “The Case of the Patient Nun.”

boozle_SMP_miller_72.JPGSenior Medicare Patrol (SMP), a program funded by the U.S. Administration For Community Living. SMP is designed to improve the quality of healthcare for senior citizens in New Jersey by educating seniors about Medicare and Medicaid fraud, waste and abuse.

The nun reported that her Medicare Summary Notices showed she was being billed for nursing home services, but the woman had never been a nursing home patient. She was, though, the patient of a doctor who visited patients in that nursing home.

The nun asked the doctor’s office to look into the odd billing multiple times, but nothing changed or was corrected.

Finally, the nun enlisted SMP. Working with the doctor’s office, they realized the doctor had four patients with the same first name as the nun, and the wrong person was selected for bills because of carelessness with a drop-down menu that listed patient names.

The doctor’s office made the corrections and the nun was no longer billed for services she didn’t receive.

Clarkson, 69, was never a Medicare specialist or an investigator of any kind. As an SMP volunteer, he and his cohorts receive extensive training about Medicare, common scams that hit Medicare and its beneficiaries, how to make presentations and how to work one-on-one with individuals who may be a victim.

boozle_SMP_miller_77.JPGCharles Clarkson, Project Director for Senior Medicare Patrol (SMP), poses for a portrait at SMP headquarters.

Clarkson wants consumers to watch out for some of the scams SMP has seen in the past year, including those that promise free medical alert systems. Medicare doesn’t cover these. Same for genetic testing, like the case that led to those arrests.

It’s also common for Medicare recipients to receive phone calls advising them that Medicare is issuing new Medicare cards, and that if they do not receive the card, they will lose their Medicare benefits.

“This scares beneficiaries,” Clarkson said. “In addition, the caller will advise the beneficiary that the new card, which will be a smart card, has a fee of $299 or $399 dollars and this fee must be deducted from their checking account and that they must provide the checking account number.”

Of course when a bank account number is provided, the scammer cleans out the account and it’s tough, if not impossible, to recover the funds.

Also watch for post cards in the mail that tell Medicare beneficiaries they’re eligible for a back or knee support system covered by Medicare, usually with a claim deadline.

“Back and knee supports should only be ordered by your doctor if medically necessary,” Clarkson said. “The SMP advises beneficiaries to ignore all such marketing scams.”

You can learn more about SMP and its efforts online, or call (877) SMP-4359.

Have you been Bamboozled? Reach Karin Price Mueller atBamboozled@NJAdvanceMedia.com. Follow her on Twitter @KPMueller. FindBamboozled on Facebook. Mueller is also the founder of NJMoneyHelp.com. Stay informed and sign up for NJMoneyHelp.com’s weekly e-newsletter.