What can I do about Medicare fraud?

Jay JohnsonDear Marci0 Comments

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Dear Marci,

I just looked at my mother’s latest Explanation of Benefits, and her equipment supplier is continuing to bill Medicare for a knee CPM machine that my mother rented after a fall, but has since returned. Should I look into this further, both to protect my mother and to avoid scamming Medicare?

Karen (Rock Springs, WY)

Dear Karen,

You are right to be concerned about this apparent unnecessary billing. Almost $6 billion in health care fraud cases turn up each year, with abuses that take advantage of patients and federal and state payers. Medicare fraud is when doctors or other providers deceive Medicare into paying when it should not or paying more than it should. This is against the law and should be reported.

Everyone should be aware of how to recognize fraud. When you receive your Medicare Summary Notice (MSN) – or your Explanation of Benefits (EOB) if you are in a Medicare Advantage Plan – look at it carefully to make sure that you actually received all the services listed. Sometimes this can be hard to do if you received services from several providers at the same time.

In the case of durable medical equipment (DME), if you have returned your equipment, your supplier should not continue to charge Medicare for rental fees or maintenance. In your mother’s case, Karen, her EOB seems to indicate that the supplier is still charging Medicare for the rental amount on a continuous passive motion (CPM) machine after its return.

You should also be aware of how to report fraud.

1. If you think a mistake has been made in a bill, call your doctor, hospital, DME supplier, or other provider first. It may have been a simple, honest error.

2. If the answer you receive does not satisfy you, and you are in Original Medicare, you can call the company that paid the Medicare bill. You can find the number for the company on your Medicare Summary Notice (MSN) or by calling Medicare at 1-800-MEDICARE (800-633-4227) and asking for the number. Note that an MSN is a summary of claims that Medicare processed for you within the last three months. It is not a bill.

3. If the answer you receive does not satisfy you, and you are in a Medicare Advantage Plan, you should contact your plan. You can find the phone number for the plan on the back of your Medicare Advantage Plan card. Note that an Explanation of Benefits(EOB) is the notice your plan send you when it has processed a claim for you. It is not a bill.

4. Whether you receive your Medicare benefits from Original Medicare or a Medicare Advantage Plan, you can also call the Inspector General’s fraud hotline at 800-HHS-TIPS (800-447-8477) to report fraud. Before calling the hotline, write down as many details as possible, including names, dates, locations, and the care or services you want to report. When investigating potential fraud, Medicare will not use your name if you do not want it to. You can also contact your local Senior Medicare Patrol (SMP) program. To locate your SMP, call 877-808-2468 or visit www.smpresource.org.

– Marci            

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Developed by the Medicare Rights Center, Dear Marci is a biweekly e-newsletter that helps people with Medicare, their families, and caregivers understand Medicare benefits and options. Each issue features Medicare coverage advice, basic health tips and links to vital health care resources. Sign up today for the next issue.

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