Skilled Nursing Facility Fraud

Skilled nursing facilities play a crucial role in providing therapy and rehabilitation after you or a loved one has suffered a debilitating illness or stroke. After a qualifying stay in the hospital, Medicare beneficiaries frequently need some time in a rehabilitation center to regain their strength. However, some unscrupulous facilities (even some associated with national chains) have taken to fraudulent billing.

How the Scam Works

  • Fraudulent skilled nursing facilities (SNFs) typically engage in a type of billing fraud called “upcoding.” Upcoding is a misrepresentation of services rendered by using procedure codes not appropriate for the item or service actually furnished. The procedure codes that are used are reimbursed at a higher rate.
  • Another typical scheme used by fraudulent SNFs is where the patient is placed into the highest Resource Utilization Group (RUG) category. This category reimburses the rehab center the most Medicare money. The beneficiary receives excessive therapy time that is billed to the government. This excessive therapy is generally medically unnecessary and could be dangerous to the patient. In addition to physical and occupational therapy, the patient may receive podiatry foot care that may not have been indicated.

How to Fight Back

  • Remember, patients have a right to refuse unwanted and excessive therapy.
  • If you or a loved one is being threatened or coerced by staff to participate in therapy, report this conduct immediately.

From the Office of Inspector General (OIG), U.S. Department of Health & Human Services

Why does Medicare keep calling?

The Missouri SMP receives several complaints a week just like this one:

“I just received a call today from the Medicare Diabetic Supply Company (an 800 number that was blocked out on caller ID), asking about my diabetes supplies.  (I don’t have diabetes nor does anyone else in my household.)  She asked if I had a red, white, and blue Medicare card.  I said yes, and she said she would have someone call me to arrange delivery of free supplies.  This is a waste of our tax dollars.  I asked for the phone number of the company and she declined but said someone would call me.”

Sometimes the reports vary slightly, and the name of the company has been changed, but the story remains the same – telemarketers are calling seniors, representing themselves as Medicare and trying to get personal information such as Medicare numbers and bank account information by offering unnecessary medical supplies.

In order to keep your information safe and be able to access the services and supplies you need, keep in mind the following:

  • Suppliers are prohibited from making unsolicited phone calls, emails, and personal visits to Medicare beneficiaries unless:
    • The beneficiary has given written permission.
    • The supplier has furnished an item to the beneficiary.
  • If you make a call to order supplies or ask about a service, it is ok to give your account information – you placed the call.  However, if the call was made to you, do not provide your information.  Medicare, your bank, your insurance company, and your medical providers have your information and are not allowed to call you and ask for it.
  • It is best to get a prescription from your doctor before receiving any medical supplies or services and to only receive services ordered by your doctor.

If you feel that you have given your information in error or if you have additional questions, please call the Missouri SMP (Senior Medicare Patrol) toll-free at 1-888-515-6565.  SMP Volunteers have been trained and are available to assist you with questions and concerns regarding Medicare and Medicaid fraud and abuse at no cost to you.

The Grandparent Scam, 
Don’t Let It Happen to You

You’re a grandparent, and you get a phone call or an e-mail from someone who identifies himself as your grandson. “I’ve been arrested in another country,” he says, “and need money wired quickly to pay my bail. And oh by the way, don’t tell my mom or dad because they’ll only get upset!”

This is an example of what’s come to be known as “the grandparent scam,” yet another fraud that preys on the elderly, this time by taking advantage of their love and concern for their grandchildren.

The grandparent scam has been around for a few years—our Internet Crime Complaint Center (IC3) has been receiving reports about it since 2008. But the scam and scam artists have become more sophisticated. Thanks to the Internet and social networking sites, a criminal can sometimes uncover personal information about their targets, which makes the impersonations more believable. For example, the actual grandson may mention on his social networking site that he’s a photographer who often travels to Mexico. When contacting the grandparents, the phony grandson will say he’s calling from Mexico, where someone stole his camera equipment and passport.

Common scenarios include:

A grandparent receives a phone call (or sometimes an e-mail) from a “grandchild.” If it is phone call, it’s often late at night or early in the morning when most people aren’t thinking that clearly. Usually, the person claims to be traveling in a foreign country and has gotten into a bad situation, like being arrested for drugs, getting in a car accident, or being mugged…and needs money wired ASAP. And the caller doesn’t want his or her parents told.

Sometimes, instead of the “grandchild” making the phone call, the criminal pretends to be an arresting police officer, a lawyer, a doctor at a hospital, or some other person. And we’ve also received complaints about the phony grandchild talking first and then handing the phone over to an accomplice…to further spin the fake tale.

We’ve also seen military families victimized: after perusing a soldier’s social networking site, a con artist will contact the soldier’s grandparents, sometimes claiming that a problem came up during military leave that requires money to address.

While it’s commonly called the grandparent scam, criminals may also claim to be a family friend, a niece or nephew, or another family member.

What to do if you have been scammed: The financial losses in these cases—while they can be substantial for an individual, usually several thousand dollars per victim—typically don’t meet the FBI’s financial thresholds for opening an investigation. We recommend contacting your local authorities or state consumer protection agency if you think you’ve been victimized. We also suggest you file a complaint with IC3, which not only forwards complaints to the appropriate agencies, but it collates and analyzes the data—looking for common threads that link complaints and help identify the culprits.

And, our advice to avoid being victimized in the first place:

  • Resist the pressure to act quickly.
  • Try to contact your grandchild or another family member to determine whether or not the call is legitimate.
  • Never wire money based on a request made over the phone or in an e-mail….especially overseas. Wiring money is like giving cash—once you send it, you can’t get it back.

Additional Resources:

File a complaint with IC3

Federal Trade Commission

Financial Fraud Enforcement Task Force

American Association of Retired Persons


Don’t Mess with Martha!

It’s another hot summer day and Martha is busy with her daily chores when she hears the phone ring.

She answers with a pleasant “Hello.” A man on the other end of the line says, “Is your name Martha?” “Yes, it is,” she said.

The man goes on to explain that he is calling about a new Medicare card that is being mailed out to all beneficiaries and he needs to verify her correct name and address. Martha spells her name out to make sure he gets it down correctly and then verifies that her address is also correct.

The man thanks her and then says; “Tell me the name of your bank.”

Martha is quick to reply, “Sorry I don’t give out my bank information.”

The man replies, “But I need it to verify your information so we will be able to send out your new Medicare card.”

Martha asks, “Are you from the government? “

The man answers, “Yes.” “Well,” Martha says,” I never received any information from the government saying that I would be contacted asking for this information.”

The man answers,” I still need your bank information.” Martha starts to really get suspicious at this point and asks the man if he has a supervisor.  He responds with a yes. She goes on to tell the caller that she has already had experience with people like him and she is not giving him any more information. The man was silent on the other end of the phone, and then he hung up.

Even at 85 years young, you can’t fool Martha!

Martha handled that call perfectly. Here at the Missouri SMP (Senior Medicare Patrol) we educate seniors on how they should protect their personal information from fraudsters trying to steal their identity.” Protect, Detect, and Report” is our motto. That is exactly what Martha did. During that phone conversation with the fraudster she first protected her personal information by not giving out her bank information, then by asking questions of the caller she detected that he was running a scam. Her next call was to report the scam to the Missouri SMP to alert others of the potential scam.

This article is based on an actual call that an older adult received. Name was changed for privacy.

If you have questions or concerns contact the Missouri SMP at 888-515-6565.

Fraud Alert for People with Diabetes

Criminals who plot to defraud the Government and steal money from the American people have a new target:  people with diabetes.  The Office of Inspector General (OIG) has issued the following fraud alert:

Although the precise method may vary, the scheme generally involves someone pretending to be from the Government, a diabetes association, or even Medicare, calling you.  The caller offers “free” diabetic supplies, such as glucose meters, diabetic test strips, or lancets.  The caller may also offer other supplies such as heating pads, lift seats, foot orthotics, or joint braces, in exchange for the beneficiaries’ Medicare or financial information, or confirmation of this type of personal information.  Additionally, a person may receive items in the mail that were not ordered.

The call is a scam.

If you receive such a call, the following actions are recommended:

Protect Your Medicare and Other Personal Information
Do not provide your Medicare number or other personal information.  Be suspicious of anyone who offers free items or services and then asks for your Medicare or financial information.  These calls are not coming from Medicare, diabetes associations, or other similar organizations.  While the caller says the items are “free,” the items are still billed to Medicare.  Once your Medicare information is in the hands of a dishonest person or supplier, you are susceptible to further scams.  Alert others about this scheme, and remind them not to provide strangers Medicare numbers or other personal information.

Report the Call
Report the call to the Missouri SMP by calling 1-888-515-6565.  The Missouri SMP is funded by the U.S. Department of Health and Human Services’ Administration on Aging to educate beneficiaries and their caregivers about health care fraud and abuse and to help consumers file complaints with the appropriate agencies.   As part of your report, you will need to provide the name of the company that called you, the company’s telephone number and address, and a summary of your conversation with the caller.

Check Your Medicare Summary Notice and Medicare Bills
Check your Medicare Summary Notice and other medical information to see if you were charged for items you did not order or did not receive.  Also, check for items that were billed multiple times, such as glucose meters, diabetes test strips and lancets, and other supplies.  Report any irregular activity to your health care provider and the Missouri SMP at 1-888-515-6565.

Do Not Accept Items That You Did Not Order
You are under no obligation to accept items that you did not order.  Instead, you should refuse the delivery and/or return to the sender.   Keep a record of the sender’s name and the date you returned the item(s) to help identify any future illegal billing.

If you would like to learn more about how you can prevent Medicare and Medicaid fraud and abuse, or how you can help  others, call the Missouri SMP at 1-888-515-6565 for more information.

New Alert System Scheme Targets Seniors

“Help, I’ve fallen and I can’t get up” is a well known phrase that we have heard over and over on the radio and television that advertises an alert product for seniors living alone.  This product can most certainly be a life saver, but it is also easy for schemers to market sound alike products that are actually a bad deal.

Recently, a new scheme targeting seniors has come to light that appears to be a ruse to possible Medicare fraud.  The senior receives a phone call about an alert system that is free for six months, and then it is only $10 a month.  Sounds like a good deal and it certainly beats out the well known national competitor, but with all things too good to be true, is it a real deal?  How does it work?

First, they want to send someone to your home to discuss the system with you.  Then at the appointment, they turn the tables and want to provide you a back brace and a knee brace that will be “free” from Medicare. “This is a good example of how someone can steal money from the Medicare system,” states Barbara Parrott McGinity, Program Director for the Texas Senior Medicare Patrol.  “They offer a simple item, tell you we will get your doctor to approve it, and since Medicare pays for it, why not get it?”

Prior to receiving medical supplies or services, you should have a discussion with your physician about what is best for you.

What can you do to protect yourself and your Medicare benefits?

If you really think you are interested in receiving a service, you should talk to a reputable supplier in your area.  Be very cautious about allowing uninvited salespersons into your home. It might be a good idea to invite a trusted family member or friend to be with you during a sales presentation.  More importantly, please call the Missouri SMP (Senior Medicare Patrol) at 1-888-515-6565 with any questions or concerns.

This website was supported in part by a grant No. 90-SP-0025 from the Administration on Aging (AoA), Administration for Community Living (ACL), U.S. Department of Health and Human Services (DHHS). Grantees carrying out projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions do not necessarily represent official AoA, ACL, or DHHS policy.