SOS: Speaking of Seniors – Is This Medicare Advantage Fraud?

On May 25, 2017, I met at my office with a couple from Merrillville, Indiana. The wife’s medical bill problems were routine and simple for me to resolve. But, the husband’s medical bill issues were something that I had never seen in my over 14 years of helping seniors with Medicare related medical bills.

The man received an EXPLANATION OF BENEFITS document from his insurance company for claims on his Medicare Advantage policy. He wanted to know why he was being told that his share of a three day hospital stay was $590 when he was not in the hospital those three days.

With the client present to grant permission for me to speak and question on his behalf, I started making phone calls. The hospital representative told us that she could not find a claim in the hospital’s records for any services from the hospital to our client. We phoned the insurance company and its representative told us that she could not find any claim filed or paid for our client on the days in question. BUT, THE EXPLANATION OF BENEFITS STATED THAT THE MEDICARE ADVANTAGE INSURANCE COMPANY HAD PAID SOMEONE $4.860.54.

Because of the conflict between the EXPLANATION OF BENEFITS and the information we learned on the phone, I helped the client to report this matter to the Medicare Inspector General. I suspect, but cannot prove, that some clever thief found a way to file false claim information and receive thousands of dollars in a fraud against the insurance company. Fraud against insurance companies is one of the factors that cause premiums to increase. What will the federal government do with the information that the client and I sent to alert others of this problem?

The help that I gave these clients was free of charge. This agency “goes the extra mile” to help our senior citizen clients with such medical bill problems. If your insurance agent or agency does not give this high level of service to senior citizens, maybe you should find an agent or agency that does.

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