Medicare Fraud

Recently there has been an upswing of Medicare fraud being done by unscrupulous insurance brokers and others, and as a broker myself I resent this and want to help stop it.

It might be unfair but all the evidence I’ve seen is coming from telephone sweatshops all over the US. They call seniors and tell them they can get something free or money back from Social Security monthly. This is happening on a too frequent basis and needs fixing. This has happened about 5 times in the past month alone and I am upset that this is continuing to happen, and nothing is being done about it.

Today a broker friend of mine called to ask advice because her 90-year-old parent just got conned by a telephone solicitor. She called the company that made the initial contact with her father. She was transferred around so she called me. The answer simple, call the company back, ask to speak to a manager, and tell them you are filing a grievance with CMS because of what they did to her parent.

They changed the parent’s MAPD plan and the parent wasn’t sure what happened so-called the daughter. Tell the MAPD plan that their broker made the call and the client didn’t understand what happened. If they still give her a runaround, call CMS and file the grievance. CMS doesn’t want seniors abused or taken advantage of either and under the law must complete an investigation about the grievance. Over the years I have seen grievances resolved for the claimant about 95% of the time.

Once the company hears the magic word, grievance, they usually will do whatever it takes to resolve because CMS has the authority to terminate the company’s Medicare contract if it happens too often. If it is an insurance agency, CMS will notify the state insurance department to start an investigation into their business practices.

I recently had an experience with a client where during AEP we changed the drug plan. We waited almost a month to hear from the new company. When I called them, they told me the client’s Medicare number was incorrect and they couldn’t proceed. I spoke to the client and she sent in a request to not proceed with the application. That was done in late December. In late February the client gets a notice that she was approved retroactively to January 1st. Meanwhile, the client never got a notice of acceptance, nor her ID card, nor a bill. We called CMS to file a grievance against the company.

CMS immediately reinstated the client in the old plan and canceled the new one. When they did this, it eliminated the current broker, me, from commissions. That part is unfair but the way it had to be played. Then I got a call from the MAPD plan we contracted with to understand what happened, so it won’t happen again. They also called the client to get their side of the story. The complaint department of the insurance company was appalled by what transpired and by law must investigate it and make any necessary corrections, so it doesn’t happen again. The MAPD plan is rated by CMS using a Star rating from 1-5. Five is the best and any company with a 2 for two years in a row gets their Medicare contract termed. So, the star ratings are important, and the higher the star the more money they can get. 4 or 5 stars pay them extra and each company strives to achieve that status. The star ratings affect a lot of things including compensation and the ability to remain a Medicare vendor.

Fraud is part of our society, but I cannot and will not forgive anyone committing these acts against our seniors. It is unacceptable and simply wrong. Glad there is a process in place to correct such situations. Lastly, as mentioned previously, these situations are rare but happen. The client always comes first.


Len Barend, broker

The Barend Agency Inc.


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