SMP: Watch for Medicare fraud listed on Medicare statements

Montana Senior Medicare Patrol — SMP — has issued a release warning people of Medicare fraud that might show up on their Medicare statements.

Hill County Council on Aging reports it is working on several cases of this in Hill County.

It’s important for everyone on Medicare to understand their Medicare statements, the release says. Although it’s impossible to provide the exact amount lost to Medicare fraud and abuse, it is estimated that those who exploit the program cost taxpayers $70 billion each year. The impact increases as Medicare continues to serve a growing number of beneficiaries.

Most providers work ethically, provide high-quality medical care, and submit claims properly, but there are those who abuse Medicare. It’s important not to understate the vital role that you, the person on Medicare, play in protecting Medicare.

There are four general types of improper payments you can watch for:

“Mistakes” are errors, such as incorrect coding that is not widespread; Inefficiencies are waste, such as ordering excessive diagnostic tests; “Intentional Deceptions” are fraud, such as billing for services or supplies that were not provided, and “Bending the Rules” is abuse, like upcoding or unbundling.

Upcoding is when a provider assigns a wrong billing code to a medical procedure or treatment to increase their reimbursement. This could be billing an “Established Patient Follow-up Visit” as a “Comprehensive New-Patient Office Visit.” Another example is if an ambulance provider bills “Medicare for Advanced Life Support Services” when “Basic Life Support Services” were provided.

Unbundling is billing multiple procedure codes instead of as a single, comprehensive code. An example would be billing for a routine electrocardiogram in addition to a cardiovascular stress test. Cardiovascular stress tests already include the ECG and therefore should only show up on your statement as one item.

There are currently almost 7,800 CPT codes used by providers. Medicare might catch some of the improper payments like the one above, but they wouldn’t know whether you received a five-minute consultation with a nurse for a minor medical question, or a more expensive full examination by a doctor that lasted 45-minutes.

According to the U.S. National Library of Medicine, upcoding is one of the most costly and pervasive types of health care fraud and it is difficult to detect. Individual cases can be nearly impossible to find or prove and are more often caught and reported by a whistleblower, like someone who works in the billing department.

The best way a person on Medicare can help is to always review their Medicare statements and look for errors or anything suspicious. If you feel a service or the details listed are incorrect you can call your provider and ask about the charge. The person you speak to may help you better understand the services or supplies you got, or they may realize a billing error was made.

If you’ve contacted the provider and you suspect that Medicare is being charged for health care you didn’t get, call Montana Senior Medicare at 1-800-551-3191.

Always check over your Medicare insurance statements to make sure the services billed are the services you received. The Medicare Summary Notice — MSN — with traditional Medicare, and the Medicare Advantage Explanation of Benefits — EOB — with a Medicare Advantage Plan, are your reports of doctor visits, services, or supplies billed in your name. The MSN is mailed every three months, with the EOB arriving monthly, when Medicare has been billed for services in your name. You can also review your MSN’s online at http://Medicare.gov , or your EOB’s on your Medicare Advantage company’s website. Both statements explain the charges and what will be paid. Check for services or products listed that you did not receive, are different than what your received, or were not ordered by your doctor.

If you find questionable billing, contact the Montana Senior Medicare Patrol, at your closest Office on Aging in Montana by calling 1-800-551-3191.

The Senior Medicare Patrol helps to educate Medicare beneficiaries about ways to prevent, detect, and combat Medicare fraud. For more information about Medicare fraud, visit the Stop Medicare Fraud website at http://www.stopmedicarefraud.org .