If someone calls and asks for your Medicare number, hang up. It’s likely Medicare fraud

For decades, Medicare fraud has plagued South Florida, taking a huge financial toll — and it’s persisting despite federal crackdowns and public education.

“It’s like a virus. It spreads,” said Kirk Ogrosky, a former assistant U.S. attorney in Miami and supervisor of the first Medicare Fraud Strike Force in South Florida.

In 2018, about $800 billion was spent on healthcare. However, roughly 10 percent, or $60 to $90 billion, was lost to fraud, waste and abuse, according to a report from the state Department of Elder Affairs and Florida’s SHINE program.

While it’s a problem across the country, “Miami is known as the Medicare fraud capital of the world,” said Max Rothman, president and CEO of the Alliance for Aging in Miami-Dade and Monroe counties.

Whether perpetrated by a single opportunist or sophisticated scammers, Medicare fraud has impacted nearly every area of healthcare, from genetic testing to physical therapy.

‘How easy it is to rip off’ Medicare

“The reason Miami-Dade stands out is not tied to the number of older folks or retirees,” said Ogrosky, now a partner in a Washington law firm. “It has to do with criminal conduct and how easy it is to rip off the system. Criminals go from other types of crimes like drug dealing to Medicare fraud. Medicare fraud is simply attractive to people who are criminal because it is lucrative and easy.”

The state Department of Elder Affairs defines Medicare fraud this way: It’s “purposely billing for services that were never given or to bill for a service that has a higher reimbursement than the service produced.”

It includes knowingly soliciting, receiving, offering, or paying compensation (kickbacks, bribes, or rebates) “to induce or reward referrals for items or services reimbursed by Federal health care programs” and “making prohibited referrals for certain designated health services,” according to the U.S. Centers for Medicare & Medicaid Services.

The illegal practice can take many forms.

In April 2019, Miami Beach healthcare mogul Philip Esformes was found guilty of 20 charges, including paying bribes and kickbacks, in a scheme in which he billed Medicare $1 billion for services that patients didn’t need or never got, prosecutors said.

Esformes was sentenced to 20 years and ordered to pay $44 million to the Medicare program.

In a more recent case, Carlos Belone, the owner of a Coral Springs pharmacy, was charged in July with wire fraud, conspiracy to commit healthcare fraud, payment of healthcare kickbacks and making false statements to a financial institution.

Belone is accused of submitting $5.6 million in claims to Medicare for orthotic braces that were medically unnecessary or not provided, according to a criminal complaint. He was also accused of falsifying loan applications through the Small Business Administration’s Payroll Protection Program. The case is still working its way through the court system.

The spectrum of cases keeps growing.

Orthotics Medicare scams

The scam du jour may change, but “orthotics is one of those that comes back into style every few years,” said Ogrosky.

It’s certainly on the uptick again, said Kathleen Sarmiento, SHINE Liaison in Miami-Dade and Monroe counties.

“Medicare beneficiaries are being sent braces when they don’t need them,” she said.

Sarmiento is director of SHINE and Senior Medicare Patrols, both under the Alliance for Aging in Miami-Dade and Monroe, two programs that help Medicare beneficiaries, their families and caregivers navigate the complicated healthcare system.

SHINE (Serving Health Insurance Needs of Elders) trains volunteers to provide free, unbiased and confidential one-on-one healthcare counseling, helping seniors understand their options.

Senior Medicare Patrols also utilizes volunteers to be the “eyes and ears” in the community through outreach, counseling, and education.

“Our purpose is to prevent, detect and report Medicare fraud,” said Sarmiento.

Telephone, TV scammers prey on elderly

Some elderly are taken in by schemes like this: Scammers may broadcast TV commercials or contact Medicare beneficiaries by phone to offer “free or low cost” knee, back and other orthotic braces.

“If you disclose your Medicare number, you can end up with boxes of unwanted and unneeded braces, a compromised Medicare number, and potential denied Medicare claims if you require such braces in the future,” states an alert published by Senior Medicare Patrols.

Medicare only pays for durable medical equipment based on medical necessity so these items require a prescription from your doctor, “not a doctor you’ve never met or a doctor on TV.”

“It’s a big problem right now — just one of them,” said Sarmiento.

COVID-19 Medicare scams

COVID-19 has also brought its share of perpetrators, offering testing equipment, cures and vaccines — even a purported pandemic survival kit.

“Unfortunately, scammers come out of the woodwork during times of uncertainty and change,” Seema Verma, administrator of the U.S. Centers for Medicare & Medicare Services, wrote in an opinion piece.

The agency notes that if your doctor orders a COVID-19 test, for instance, Medicare covers all the costs. You should not have any cost-sharing.

Elderly lured in by scammers

One issue of Medicare fraud is that older, vulnerable people may be lured in by congenial and convincing perpetrators.

For instance, when some elderly Medicare recipients were not showing up at a senior meal site, it turned out that a company was offering them $400 a week to get an infusion “of God knows what” every Wednesday, said Sarmiento, who has been presenting educational programs on Medicare fraud.

At times, elderly people may not have family members and they can be influenced by people who call or knock on the door, said Bernardo Rodriguez, former assistant special agent in charge with Health and Human Services-Office of Inspector General, Miami Regional Office.

These perpetrators may offer transportation, “even groceries” or cash to snag a Medicare card or number.

And “they’ll sell your information to someone else,” said Rodriguez.

Medicare Fraud Strike Force

Fraud became such a crucial problem in South Florida that Rodriguez and other investigators joined forces to create the Medicare Fraud Strike Force.

“It was very aggressive here,” Rodriguez said.

The Miami task force, the first and largest, was launched in 2007. Today, there are 15 strike force teams operating in 24 districts that have charged nearly 4,000 defendants who have collectively billed the Medicare program for more than $14 billion, according to the Department of Justice.

The task force brings together the Office of Inspector General, the DOJ, Offices of the United States Attorneys, the Federal Bureau of Investigation and local law enforcement.

Yet, the scourge of Medicare fraud is still festering.

“If someone wanted to steal a million dollars, they could do it in less than a month with a small group of patients, 10 to 20, a physician’s ID number, and an active DME (Durable Medical Equipment) billing number,” said Ogrosky. “It’s an easy crime, easily replicated. It’s been going on for years.”

How to not become a victim of Medicare fraud

There are many ways to prevent Medicare fraud. Here are tips from the U.S. Centers for Medicare & Medicaid Services, the Senior Medicare Patrols, SHINE, the Florida Department of Elder Affairs and other advocates.

▪ Protect your Medicare number and treat your Medicare card like it’s a credit card. Don’t let anyone except your physician’s office handle your Medicare card.

▪ Don’t accept offers of money, gifts, supposedly “free” equipment or medical care in exchange for your Medicare number.

▪ Be suspicious of anyone who offers you free medical equipment and then requests your Medicare number. If your personal information is compromised, it may be used in other fraud schemes.

▪ Don’t let anyone persuade you to receive healthcare services you don’t need. Only your doctor should prescribe and/or approve any requests for durable medical equipment (equipment like wheelchairs, back braces, catheters).

▪ Review your Explanation of Benefits paperwork for items that appear that you did not order or receive and report any discrepancies immediately.

▪ Beware of scammers who may be contacting you through cold calls, unannounced home visits, postcards, TV and newspaper ads, solicitations in public places, and/or presentations and health fair events.

▪ When you are looking for a durable medical equipment, orthotic or prosthetic supplier, keep in mind that if you have Original Medicare (Parts A & B), you can select any provider on the list.

▪ If you have a Medicare Advantage Plan, find out which DME providers you can use.

▪ If you receive a call from someone offering you a “free” brace covered by Medicare, hang up immediately.

▪ If medical equipment is delivered to you, don’t accept it unless it was ordered by your physician. Refuse the delivery or return it to the sender. Keep a record of the sender’s name and the date you returned the items.

Key groups to contact for Medicare questions

▪ If you have questions or concerns, you can call SHINE at 1-800-963-5337, 1-800-633-4227 or the hotline at the Office of Inspector General at 1-800-447-8477.

This story was originally published October 14, 2020 at 9:00 AM.