For Professionals: Medicare fraud and abuse

Los Angeles County Home Health Agency Identifies Potential Fraud Scam

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Published: August 2006

The administrator of a Los Angeles County home health agency recently called the Cahaba Safeguard Administrators (one of Medicare’s program safeguard contractors) to report a potential fraud incident. A patient informed the administrator that a man wearing a suit had shown up at her doorstep claiming to be a "Physical Therapy Inspector for Medicare." The man had no identification or business cards, didn't ask for the patient's signature but did ask questions regarding her physical status. A couple days after that incident, around 9:00 p.m., a man called the patient's house and spoke with her husband – ultimately setting up an appointment to come out the next morning and provide "free physical therapy." The patient's husband accepted the man's offer and arranged for him to come the following day.

The man who showed up was a different person than the one who had been to their residence before. He called himself a "Physical Therapy Trainer," said their doctor sent him, and knew their doctor’s name. He was not wearing a suit, but, like the first man, he had no identification or business card. He helped the patient "walk around" and then asked that she sign what appeared to be a preprinted check-box to ensure payment for his services. Feeling a bit suspicious about this situation, the patient's husband did not give out her Medicare number and called the home health agency’s nurse. She, in turn, informed the agency’s administrator.

While the home health agency reported the incident to the police, they were unable to do anything as "no crime was committed." The administrator informed all of the agency’s patients that someone was going around "knocking on doors" and offering therapy services. She reminded them that all of the home health agency's employees have identification badges and stressed that the patients ask to see this badge before letting anyone in their homes. The administrator indicated she was having their badge security updated as well and that she was going to inform the Center for Healthcare Rights, home of the Los Angeles County Health Insurance Counseling & Advocacy Program (HICAP).

Beneficiaries and advocates should know that any safeguard administration or Office of Inspector General (OIG) staff that conduct audits in the field, will also have identification with them and present it to the patients. Therefore, if someone comes to a person’s door without identification and offers ‘Medicare-covered’ services, that person should suspect possible fraud and contact California’s Senior Medicare Patrol project, or their local HICAP to report the incident. People who have heard of or witnessed similar incidences to the one described above can also report cases to the Cahaba Safeguard Administrators. They have a running list of California cases pertaining to stolen or sold Medicare numbers and have lists of physicians and patients that are potentially suspect.

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