A doctor from Texas was sentenced to over 10 years in prison on Oct. 29 for being involved in a scheme to defraud Medicare, according to the U.S. Department of Justice (DOJ).
The Medicare beneficiaries for whom Canchola prescribed genetic testing and DME were “targeted by telemarketing campaigns and at health fairs,” the DOJ stated. The individuals were “induced to submit to the cancer genetic testing and to receive the DME regardless of medical necessity.” The doctor never saw, spoke to, or treated the patients.
In total, $54 million worth of false and fraudulent claims were submitted to Medicare using the doctor’s orders.
In October 2022, Canchola pleaded guilty to a conspiracy to commit wire fraud. In addition to 10 years and one month in prison, he will also have to pay $34 million in restitution for his role in the scheme.
Four of the individuals allegedly filed false and fraudulent claims to Medicare for amniotic wound grafts used on Medicare patients. These claims totaled $900 million, with Medicare ending up paying over $600 million in the scheme, according to the Justice Department.
Thirty-six people were charged in connection with another scam, allegedly submitting more than $1.1 billion in fake claims to Medicare.
The Health Care Fraud Unit’s Data Analytics Team supported these investigations.
Medicare Scams
According to an October 2023 post by the advocacy group National Council on Aging, Medicare fraud usually increases during the program’s Open Enrollment Period between Oct.17 and Dec. 7. This is the time when beneficiaries review and change their health coverage.
“With a Medicare scam, criminals pretending to be from Medicare or another known organization try to trick a beneficiary into sharing their Medicare or Social Security number,” said Brandy Bauer, former Director of NCOA’s MIPPA Resource Center.
“Most often, this information is used to commit identity theft. Crooks submit bogus Medicare claims in the beneficiary’s name to obtain health care services, supplies, or even prescription drugs.”
There are several red flags that could suggest an individual is being targeted in a Medicare fraud scheme. The scammers often promise free items or services to older adults in order to entice them to share their Medicare number. Once the detail is revealed, they will use the number to file for high-cost claims in the victims’ names.
Some fraudsters try to pressure a target to switch their Medicare, claiming they are pre-approved for a new plan with better benefits.
The agency advises people not to give their “Medicare card, Medicare number, Social Security card, or Social Security number to anyone except your doctor or people you know should have it (like insurers acting on your behalf or people who work with Medicare, like your State Health Insurance Assistance Program).”
“Remember that Medicare will never call you to sell you anything or visit you at your home. Medicare, or someone representing Medicare, will only call and ask for personal information in limited situations,” it said. For instance, a Medicare plan could contact a person if the individual filed a report of suspected fraud.
In case a Medicare member suspects they have been scammed or are the target of a scam, they are advised to call 1-800-MEDICARE (1-800-633-4227).
