Medicare Recipients Can Be Watchdogs For Fraud

By Jan Howard

Residents receiving Medicare benefits should be aware of the potential for fraud and abuse of the system.

Virginia Parsloe, a volunteer counselor for the Medi$ave program of the Department of Social Services and Area Agencies on Aging, spoke about “Insurance Fraud and Abuse” during a seminar November 29 at the Newtown Senior Center.

Mrs Parsloe advised senior Medicare recipients to be informed consumers. They should carefully check all health care billing statements to make sure they received all the services for which they were billed.

Know the services the doctor has ordered and ask questions about the services received, she said.

She noted that while most health care providers are honest, those who may defraud and abuse the Medicare system are found in all areas of healthcare, including doctors, hospitals, nursing homes, pharmacies, medical equipment suppliers, home healthcare companies, and laboratories.

She said Medicare recipients could help prevent fraud and abuse by reporting any of the following:

Billing more than once for the same service.

Charging for services never performed.

Performing inappropriate or unnecessary services.

Offering free services or medical equipment in exchange for Medicare, Medicaid, or private insurance number. Some of the schemes used to obtain Medicare or other insurance numbers include the exchange of number for money or gifts, money in exchange for visiting a doctor’s office, or offers of free medical equipment.

“Do not give anybody that number,” Mrs Parsloe said.

Waiving patient co-insurance. “They cannot waive a co-pay,” she said.

Mrs Parsloe discussed a sample Medicare Summary Notice (MSN), advising how to identify questionable charges. The MSN is a form that notifies a person that a claim has been processed on their behalf. It is important to know how to read the form and to examine it for any fraudulent billing.

If a claim has been denied, information regarding the denial, as well as a person’s appeal rights, will appear on the MSN.

“Don’t be afraid to ask questions,” Mrs Parsloe said.

Check the MSN for the following: Did you receive the service or product? Did your doctor order the service or product?

Also, she noted, ask if the service or product is relevant to your diagnosis or treatment. Medicare does not pay for experimental medical care, she said.

Check the form for hospital and outpatient claims. They are listed separately. Compare the dates of service with the dates shown on the hospital bill. Check the description of services and supplies provided and service codes. 

 “Question if you think a test was not done,” Mrs Parsloe said.

Check your name and Medicare number on the MSN. “You may be denied a claim because it is the wrong number,” she said.

Check the control number the doctor is required to submit.

If the MSN indicated a bill was sent to a secondary carrier, don’t do anything, Mrs Parsloe advised.

The actual bill for services will show what Medicare paid and what the secondary insurance paid.

“Check your Medicare book if you have questions,” she said.

Mrs Parsloe said fraud and abuse of the Medicare and Medicaid system costs its recipients money. It may cause higher costs in increased premiums, co-payments, and deductibles. Losses due to fraud also prevent Medicare from offering more covered services and could result in lower quality of care.

 Before reporting a potential fraud, Medicare recipients should collect as much information as they can, including:

Provider’s name and identifying number from the Medicare Summary Notice.

Type of service or item billed and the date of service.

Amount approved and paid by Medicare.

Date of the Medicare Summary Notice.

Name and Medicare number of the person who received the item or service.

Why you think Medicare should not have paid.

Suspected cases of Medicare and Medicaid fraud abuse or questionable charges should be reported to Medi$ave at 877/728-3477.

 Mrs Parsloe is available at the Newtown Senior Center Mondays from 1 to 2 pm for anyone who has questions.