How Does Medicare Fraud And Abuse Affect Me?

First what is the difference between Medicare Fraud and Medicare Abuse. Abuse is when Medicare is overcharged or unnecessary services are billed to Medicare. The net effect extra tax-payer funds are spent which depletes the Medicare Trust Fund. Medicare abuse is not always intentional but its effect on the Medicare program is the same. Examples of Medicare abuse are up-coding of a Medicare claim to a more complicated service or for longer time frames or adding billing modifiers for a higher level of service. Other examples include unbundling of services to avoid Medicare’s flat rate or ordering unnecessary tests, supplies or medications. Medicare Abuse constitutes fraud when the entity or provider knowingly goes against Medicare policy.

Medicare Fraud is rampant. According to the Centers for Medicare and Medicaid (CMS) nearly $43 billion in improper payments were paid in 2020 alone! Medicare Fraud differs from Abuse in that it is always intentional. Medicare Fraud includes billing for services or items the beneficiary did not order or did not receive. Other examples are inappropriate billing for services that are supposed to be free or providing incentives to get more patient referrals.

The bottom line is that if the beneficiary’s Medicare number is used in fraudulent claims the beneficiary’s number can be shared with other fraudsters and that number becomes a meal ticket to fraudsters all over the U.S. Medicare Fraud constitutes Medical Identity Theft. Other impacts are false diagnosis in the beneficiary’s medical records, showing treatments that never occurred, misinformation about allergies and incorrect lab results. In addition, fraudulent claims could affect the beneficiary’s ability to get a needed item or service that has limits. If Medicare was already billed, they may deny services later even if the service is now legitimate. The beneficiary may also be billed for co-pays on a fraudulent claim.

What can beneficiary’s do to help fight Medicare fraud and abuse? The biggest step that should be taken is to open your Medicare Summary Notices (MSN) or Medicare Explanation of Benefits (EOB). Ask yourself did I receive services on these dates, did I receive care from this provider or facility or are any of these charges duplicates? Also, do my receipts show that I paid more than the maximum that I can be billed? If you question something you should first talk to your provider as it could be a simple billing issue that can be corrected.

To report potential fraud and abuse a beneficiary can call the Senior Medicare Patrol 800-551-3191 or self-report by calling Medicare 800-633-4227. The Senior Medicare patrol can help beneficiaries read their Medicare summary notices and can help investigate, file and assist beneficiaries in getting a new Medicare card. Your Medicare number no longer includes your Social Security number so it can be voided and flagged and you can have a new card issued. Note you use your old card for services until your new card is issued so you will not be without a card. Reporting to an SMP or to Medicare it will open up an investigation. This is truly the only way to slow down fraud

One of the current scams happening throughout Montana is the COVID test kit scam. Medicare beneficiaries are getting billed for COVID test kits they did not order and often don’t get or get by the bucket loads. These test kits are being billed and paid for at about $95 a time. One individual had been billed by five different doctors and labs for test kits! It’s obvious that either the Medicare number is being sold or the fraudster is using several different aliases! This is a prime example of fraud. An example of abuse was when one individual only had an x-ray and in checking her explanation of benefits she was also billed for a urinalysis. If you don’t report because you feel it doesn’t affect you, now you know it does!

It takes a village to stop Medicare Fraud and Abuse but the most important role is that of the Medicare beneficiary in first noticing it on their Medicare Beneficiary notices and reporting it.