There has been a lot a talk lately in the news about Medicare fraud. But how do you protect yourself? Before we can talk Medicare fraud, we have to discuss Medicare. Medicare is federal major medical insurance program principally for seniors and disabled individuals.
If you are over the age of 65, you usually will have a red, white and blue Medicare card. The original Medicare since 1965 when it began, and until 1997, the only Medicare, is Parts A and B.
Part A mostly covers hospitalizations, certain home health services following a hospital stay, hospice care and rehabilitative skilled nursing care.
Part B usually covers medically necessary services or supplies for the diagnosis or treatment of your medical condition and certain preventative services. These may include doctors’ visits, outpatient therapy, durable medical equipment, laboratory diagnostic services and home health services.
Original Medicare was not ever designed to pay all your medical expenses, only about 80%. Because of these non-covered expenses, you generally can buy a Medicare supplement private health insurance policy that will cover some of these expenses that are not covered by Medicare Parts A and B.
Since 2003, if you are eligible for Medicare Parts A and B, you can opt-out of the original Medicare Parts A and B and have those replaced by Medicare Part C, also called a Medicare Advantage plan. The Medicare Advantage program is essentially a repackaging of the Medicare+Choice program which has been around since 1997. Your Medicare coverage is now governed by the private health insurance contract you entered into with the insurance company.
Starting in 2006, if you are eligible for Medicare Parts A and B, you are also eligible for a Medicare Part D prescription drug plan for an additional monthly premium paid to a private insurance company.
Medicare fraud unfortunately is pervasive and running rampant. It is estimated that taxpayer losses due to Medicare fraud are $75-$250 billion annually. Government enforcement actions in fiscal year 2014 returned only about $2 billion to Medicare Trust Funds.
In addition to Medicare fraud, there is Medicare abuse and Medicare errors. Medicare fraud is intentionally billing Medicare for services that were not provided or billing at excessive rates. Medicare abuse is supplying products or services that are not medically necessary or are sub-standard. Because of the complexity of providing Medicare services and billing for them, it can lead to Medicare errors. Basically, Medicare fraud is lying, Medicare abuse is cheating and Medicare errors is making a mistake.
All three, Medicare fraud, Medicare abuse and Medicare errors, can lead to enforcement action. This enforcement action could be civil and/or criminal and may include fines, restitution and being a guest at a Federal facility where you get three meals a day and a cot.
The bigger result of Medicare fraud, abuse and errors is to you. Because Medicare Trust Funds are being depleted, there is less money available for benefits, there are higher Medicare premiums and benefits are being adjusted (downward of course).
What can you do? Michigan Medicare/Medicaid Assistance Program (MMAP) recommends that you Protect, Detect and Report.
One item to protect is your Medicare Card. If your Medicare number is fraudulently used, it may affect your benefits. Your Medicare number cannot be cancelled or changed by Medicare, even if it is stolen. Improper use of your Medicare number may result in your account being flagged “do not pay.” Medical history errors may lead to denial of needed benefits.
Another thing you can do to protect yourself is to not carry your original Medicare card. Make a color copy, black out all but the last four digits of your Medicare number and laminate the copy so it doesn’t get destroyed in your wallet or pocketbook. Then file away the original card. When you do file it away, make sure it is in a place where you will remember to retrieve it when needed.
One more thing that you can do to protect yourself is to keep a log or journal of your personal health care activities. Record everything, including doctor’s visits, labs, tests and procedures. Take the log or journal with you to all appointments. Keep copies of all pathology and other reports and lab and other test results.
Write down all your questions and the doctor’s answers to those questions. You may want to take another person with you to your appointments. A second set of ears is almost always helpful in remembering what the doctor or other health care provider said. Have a healthy dialogue with your doctor. Make sure that you understand your treatment plan.
Another way to protect yourself is to get a second opinion. It has been recently reported that very few cancer patients ever get second opinions. This is one of the biggest reasons that Dr. Fata was able to provide cancer treatments to hundreds of patients who did not have cancer and bilked insurers and Medicare of more than $35 million. Medicare will often cover 80% of the costs of a second opinion as medically necessary. If the second opinion differs from the first, Medicare will typically pay 80% of the third opinion.
If you keep a log or journal of your health care activities, it will be much easier to detect fraud, abuse and errors. When you receive your quarterly Medicare Summary Notices (MSNs), you can then compare your journal to the services and products listed that your received on the MSNs. You can check your MSNs more frequently by reviewing your account online at wwwMyMedicare.gov.
Other red flags to detect Medicare fraud, abuse or errors is when the doctor does not want to engage in a healthy dialog, objects to a second opinion, refuses to explain your treatment in terms you understand or repeatedly shoots down your concerns.
If you do detect Medicare errors, call the health care provider to correct the error. If the provider refuses to correct the error or you detect Medicare fraud or abuse, call the State Medicare Patrol (SMP), which in Michigan is MMAP, at 1-800-803-7174. You can also call the Inspector General’s Hotline at 1-800-447-8477. More information about MMAP, Michigan’s SMP, can be found at www.mmapinc.org.
Remember, when it comes to Medicare fraud, abuse and errors, Protect, Detect and Report.
By: Matthew M. Wallace, CPA, JD
Published edited July 12, 2015 in The Times Herald, Port Huron, Michigan as: Protecting yourself from Medicare fraud