I mentioned in my recent post about Life Insurance, that my mother had passed away in early October and the State Insurance Office was so helpful resolving trouble I was having collecting her Life Insurance. I also posted recently about the outrageous increase in and difficulty with unreasonable inspections for Home Owners Insurance.
Today, I’d like to talk about some Healthcare Insurance fraud I discovered after my mother passed away.
My mother passed away 10/13/2024. She was living in a memory care unit, under lockdown, as she was 90 and suffered significantly from dementia. She could not assist herself with much of anything, could not walk, could not use a phone, could no longer manage to use her own glasses, etc.
She was also on hospice the last several months of her life.
As her medical power-of-attorney, I managed all of her medical care, medical insurance and insurance payments, attended all doctor and nurse visits, and approved all medications, procedures, and expenses. She was insured by Medicare, through a United Healthcare, AARP Medicare Advantage plan.
On January 3rd, I received her final EOB, and was stunned to see that UHC had paid on her behalf, a claim for nearly a thousand dollars for several sets of contact lenses. The date of service was in early August, the claim had been submitted in late November, and processed and paid by UHC in December.
This was clearly a fraudulent claim, as my mother could not use, or even handle contacts, and I had not approved any expenditure. I checked with the facility in which she had been living and the nurses and hospice nurse verified that she had not been given any contacts, nor had anyone assisted her with any. The facility also verified that she had not been seen by anyone in that time frame, other than myself, and the hospice nurse and doctor.
I immediately called UHC, but since it was a new Medicare year, her policy was no longer active and they could not even look up any details. I tried to open a fraudulent claim investigation, but since she was no longer insured they would not do so.
I was not allowed to open a claim with Medicare, as it was a Medicare advantage plan, and when I spoke with I-medic, the contract organization that handles Medicare Advantage fraud claims for the Medicare Inspector General, I was told I needed first to have United Healthcare investigate it. After several days of failing again to get anywhere within the UHC organization, I did get I-Medic to file a claim, but they have never given me any feedback, and when I check now, I’ve been told unofficially, that they will not be investigating any further claim. I suppose they are inactive or being shut down, as their Inspector General has been fired and not replaced.
I contacted the Salt Lake County Aging office, as I had been told they had someone who would assist the elderly with Medicare fraud. The very helpful woman initiated a claim directly with the Inspector General’s office at Medicare, but warned me that since the IG had been terminated a few days previous, her usual feedback channel was no longer available, and she was not certain of what to expect going forward. She said she would let me know if/when she had feedback, bug also mentioned that she was uncertain of her own job, as federal funding which paid almost half of her salary had been put on hold.
I called back today, to see if she had any update, and was told by the receptionist, that she was no longer with the organization and they had no replacement for her function.
As a last resort, I sent a brief email, with all of the details to a couple of the consumer reporters in our market asking if they had any suggestion of who I might get to investigate this. No word back.
It appears that no one is going to investigate this, and as dedicated as I’ve been to trying to see something done, I simply don’t know what else to do.
It is possible, that this claim was a simple mistake. However, as I have a 10 year background in software development in the medical industry, specifically working a portion of that time with Medicare, I see some patterns here that convince me that this is organized fraud:
- the claim was submitted approximately 6 weeks after the date of service. Providers rarely let things go that long.
- It was submitted after it would have been easily determined that she had died, had been on Hospice, and it was submitted for a date of service nearly 6 weeks prior to her death.
- It billed for benefits, that are rarely used by an elderly individual suffering from cognitive problems and on Hospice, so the insured was likely to still have a complete year’s benefits in that category available.
- It was billed for a total, just under the maximum amount covered in a given year for this specific benefit.
- The claim was submitted late enough in the year, that by the time it was processed and an EOB generated, it would be received by the family after the end of the year, and the Insurance company would no long have an active account. I’m also guess that most people simply would not go to much trouble to try to report this as the insurance company paid the entire bill, the consumer owed nothing.
- And finally, the provider, is not registered in the state of Utah, seems to live in rural Colorado or Oklahoma, claims to be a traveling OD, and does not have an office. His only web presence is through a OD web front end company in the Northeast which provides only old/invalid contact info.
I’d bet he does not even practice, but rather submits enough of these claims to make a decent living working a handful of hours a week researching death and hospice records, Advantage Plan coverage, and filing a huge of claims near the end of the year.
If anyone has any suggestion about any other organization that I could get to pay any attention to this, I would love to hear about it.
BTW - I specifically did not make any comments of a political nature, just the facts, as I’d like to see the post remain in a non-political thread. I may, and if others would like to, please follow up with political comments in one of those threads.