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Medicare Fraud Prevention

Did you know $588 billion, or about 15% of the total federal budget, was spent on the Medicare program in 2016? What many people don’t know is that conservative estimates of $60 billion, or 10%, of this spending is lost to fraud, abuse, and errors. This leads to many challenges for people with Medicare and the long-term viability of the program. It is important that you as a beneficiary, or as a caregiver of a person with Medicare, understand Medicare fraud and what you can do to prevent it. Even though most medical providers are honest and want the best care for their patients, Medicare fraud occurs and can happen to you. The Senior Medicare Patrol (SMP) program is your partner in fighting health care fraud.

Because Medicare is a complex system, it is easy for innocent errors to be made, such as duplicate claims, incorrect billing codes, or submitting a claim on the wrong Medicare account. Fraud, however, is different from these errors because it involves knowingly and willfully billing Medicare to obtain inappropriate payments. Some examples include billing for services or supplies that were not provided, prescribing unnecessary tests and services, or misrepresenting a diagnosis to justify a payment. Fraud may cause you to end up with higher out of pocket costs. Fraud may also negatively impact your health, in part by decreasing the quality of care you receive. In addition, you could receive unnecessary and potentially harmful care from unscrupulous providers who misdiagnose beneficiaries to justify a treatment. Conversely, you could be denied necessary treatment or equipment. For instance, under the current system, you are entitled to one “Annual Wellness Visit” every 12 months. If this benefit has been fraudulently coded by a provider at a so called “free community event” or urgent care center, Medicare will deny coverage when the visit is actually needed at your doctor’s office, leaving you with an unexpected bill.

Two very common scams right now focus on durable medical equipment such as braces, and genetic testing kits. Beneficiaries across the country have been inundated with unsolicited calls by people trying to sell these products. Medicare has very specific rules about when these products will be paid for. Braces must have a prescription from your doctor. Genetic testing kits are only covered under very specific conditions. If you need equipment, or feel a genetic test would benefit you, talk to your doctor first. Don’t respond to a phone call, email, TV ad or in-person at a vendor’s table. Your Medicare could be charged thousands of dollars for something you don’t need, and you could wind up being billed. And remember: if a caller tells you it’s a limited time offer, or that you could lose your benefits by not accepting their product, it’s a scam. Just hang up! As we say, “it’s shrewd to be rude!”

So, what can you do to protect yourself from fraud, errors and abuse?  Luckily, there are some simple steps that every person with Medicare and their loved ones can do to prevent Medicare fraud. Protect, Detect, Report!

The PA Senior Medicare Patrol at CARIE is here to help. If you have questions about Medicare fraud, would like to volunteer with the program, or just want more information, please call toll-free: 1-800-356-3606 or visit Help is always free and confidential.

Henry Kaiser Foundation

Article provided by Senior Medicare Patrol


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