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Medicare Advantage Plans / Fraudulent enrollment

3 United States Review updated:

I have been searching the web today concerning fraudulent and/or unethical enrollments into Medicare Advantage plans.

I am a claims rep for a Medicare Beneficiary Customer Contact Center. I receive calls on a daily basis from seniors who have been conned into signing up for Medicare Advantage plans by unscrupulous insurance agents.

I hear a variety of stories. People are being told that the agent is offering better prescription drug coverage at no cost to the beneficiary, that they are being offered a supplemental policy, that their Medicare card is no longer valid, and the senior better take this policy if they want to have any health coverage at all.

In one case last week, a man was told he could sign up for additional drug coverage for free. This man is illiterate, so could not read the policy. Since the agent was sitting in the doctor's waiting room, he trusted her. Turned out he signed up for a PFFS plan which his doctor doesn't accept. His doctor ordered several tests that day, and the man is facing a huge bill which he cannot pay.

In another case, a couple was signed up for a PFFS plan only to discover that the nearest hospital which accepted the plan was over 160 miles away.

I am only a couple of years away from being on Medicare myself, have family members on Medicare, and this is really making me MAD!!! I want to know who is investigating this kind of abuse of our senior citizens. I'm in the mood to get proactive. Can you direct me to agencies or organizations who are trying to combat this?

Thank you for your consideration,

Rev Charles Deck
Chesterfield, VA

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  • Er
      7th of Mar, 2008
    0 Votes

    You state that the man signed up in his doctor's office and that they performed many tests that day that were not covered because of the PFFS plan. He would of had to of been approved by the PFFS plan before those tests could of even been covered by the advantage plan in the first place. His plan he had going into the office that day is guilty of not paying the doctor bill, not the PFFS. Anyone who is in the insurance business knows that if someone signs up for an advantage plan, say Feb 15th, then it doesn't go into effect until March 1st. The PFFS plan must contact CMS to verify they are eligible before getting accepted. The person who wrote this is not educated to make assumptions regarding this matter.

  • Ly
      8th of May, 2008
    0 Votes

    The last comment was correct about the plan not being in effect on the day of the tests. However, persons with medicare are not being told how to pick the plan most suited for them and most clients I speak to have no idea what they have chosen. For example, I work for a home care agency and we have clients with straight medicare that we are able to bill and get paid. We have many clients and it would be impossible to check everyone's coverage on a daily basis. We check when they are admitted, readmitted and/or return to us from the hospital. We get surprised quite often lately that a client now has a medicare advantage plan that does not cover home care or has a $20 per day copay. When the clients are asked about this they say all they thought they were signing up for was a Medicare D perscription plan!!! If you look at some of the health care publications lately there is talk of legislation being introduced to the senate that will strengthen the standards for marketing of HMO contracts to prevent any decptive or coercive marketing methods. Apparently this is a problem. Where else can we go to make comments that will be heard. Thank you.

  • Sh
      25th of Oct, 2008
    0 Votes

    I am a Medicare sales agent at the nations largest health insurer. If the doctor was willing to see the patient, then he is required by law to bill the PFFS plan and to accept Medicare assignment. Any provider who sees a PFFS enrollee is 'deemed' to have accepted the plans terms and conditions; and thus, the enrollee is responsible for nothing other than their copay/coinsurance.

    For some people, Medicare Advantage is the best option by far; whereas, some people should really stay away from these plans. For the majority of people who enroll, they are left in a far better situation.

    However, like everything else, there are unethical agents, and if you have a concern about specific agents, those should be directed to the State's department of insurance.

  • Mi
      15th of Oct, 2009
    0 Votes


  • Rr
      27th of Jan, 2010
    0 Votes

    "Better" is not the same for every person in every situation. It completely depends on what you want your health insurance tp be.

    I also am a medicare CSR. I can attest to the authenticity of the above comments. It's sad how many unscrupulous "agents" are getting paid to dupe seniors into plans they neither want nor understand. They are bombarded with adds from the day they turn 65 and every plan scares them into thinking they are missing something. Many of them are under the impression they MUST have an advantage plan.

  • 19
      11th of Nov, 2015
    0 Votes

    I am trying to make everyone aware of Medicare Advantage Plans. I will not post the name as I am fighting them and have filed an appeal. The reason for the appeal is that this companies Call center told me this doctor is in Network. The Call Center is completely remote from the Billing Department. The Call Center gets their in Network Status from the same Web site I use for this Company. The issue is that this company depends on Doctors to take their name off or on the Network. This company has no one to cleanse their provider list.
    So therefor, even though I am told by the Call Center a doctor is in Network, the Billing Center is the only one with the clean Provider List. I have cleansed a few names from this list I am provided. Some Clinics and Doctors were still on the list and have not participated for over two years. Again, this company says it depends on Doctors, Hospitals and clinics to cleanse this phony list. I am appealing because 5 times the Call Center told me he was in the Provider Network. I would not have had this procedure done if he wasn't. Wish me luck all and be careful of Medicare Advantage Plans. Document all conversations with their Call Center. I am going to Medigap in 2016. $20.00 more a month but I bet more trustworthy. Be wary seniors, everyone wants your money. Any suggestions anyone?

  • Mi
      6th of Feb, 2016
    0 Votes

    I have no suggestions, but I wish you the best of Luck.

  • Ps
      30th of Sep, 2017
    0 Votes

    Where can a provider file a complaint against a Medicare advantage plan for their failure to process a claim? Please email me your response:

    Thank you!

  • Ce
      28th of May, 2018
    0 Votes

    I am ditching my local Advantagecare this year (2018). Everything you said is true. It is very difficult researching the truth when initially signing for Medicare and making a decision. I discovered the truth in trial-by-fire. I would suggest everyone sign up for Medicare plus a supplement INITIALLY. They are far more predictable and trustworthy than Advantagecare plans, which are just a ruse for privatizing Medicare and the operate like pre-ACA individual healthcare companies, with half-truths, denials, and lies. Be aware.

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