Jon was a retiree who had moved to the warm, sunny climes of South Florida.
He went to the orthopedic doctor one day for a creaky knee. The doctor examined his knee, determined to give him a steroid shot, and sent Jon on his merry way.
A few weeks later, Jon got the doctor’s bill in the mail. All looked rather normal (and boring), except for one thing:
He saw that he had been billed for “durable medical equipment” (DME).
After a quick Google search, John learned that Durable Medical Equipment is, “Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.” (healthcare.gov)
Jon didn’t remember his doctor saying anything about him needing DME.
To double-check, he whipped out his phone and reviewed the notes he had taken from his doctor’s appointment. Sure enough, the doc had said nothing about him needing any DME, just a follow-up appointment in six weeks and some ibuprofen as needed.
He then opened his wallet and unzipped the pouch where he kept all his identifying documents: driver’s license, Social Security card, credit card, and Medicare card. Sure enough, they were all there.
Next, he called the orthopedic office where he had had the exam. He spoke with the front desk about the durable medical equipment charge on his bill, and they confirmed that the charge was on their end too. He expressed that the doctor had said nothing about this and he had never received or been sent to be fitted for DME. They promised to look into the issue on their end.
Lastly, Jon hopped online and submitted a formal complaint at https://oig.hhs.gov/fraud/report-fraud/
After several months of going back and forth with the Inspector General and the doctor’s office, Jon realized he had almost been the victim of Medicare fraud. One of the billing specialists at the doctor’s office was found to be in cahoots with a fraudster. This employee had been terminated and the fraudster was being indicted.
Our fake hero of this story, Jon, did a lot of things right. To recap Jon’s strategy, we’ll use the four R’s of Fraud Prevention:
(1) Record appointments and services: After Jon’s doctor’s appointment, he recorded what happened, what was said, and what was prescribed in the notes app on his phone.
(2) Review services provided: When Jon got the fishy bill, he reviewed the services provided in his notes.
(3) Report suspected fraud: Jon called the doctor’s office and made them aware of the problem, then officially submitted a complaint using the proper channels.
(4) Remember to protect personal information, like your Medicare, Medicaid, Social Security, credit card, and bank account numbers: Jon kept his cards and personal information safe in a zippered pouch in his wallet – away from prying eyes.
It’s easy to write a silly story with a character like Jon doing all the right things at the right time. It can be much harder in real life to navigate the slippery fish of Medicare fraud.
The biggest advice I can give is this: go with your gut.
If something feels weird – it probably is. Don’t ignore that feeling. Do a little digging and talk to a professional. No one should have to navigate these issues alone.