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Vol. 13, Issue 18  • September 8, 2014

How can I protect myself from Medicare fraud?

Dear Marci,

I recently found out that my doctor billed Medicare for several medical tests that I never actually received. What steps can I take going forward to protect myself from Medicare fraud?

- Grace (Anchorage, AK)

Dear Grace,

Medicare fraud happens when doctors, providers, or individuals deceive Medicare into paying more than it should, or paying for services when it should not. This is against the law, and it can put the health and wellbeing of Medicare beneficiaries at risk.

There are steps that you can take to protect yourself from Medicare fraud and ensure that you still receive appropriate medical care. Here are some important tips:

  1. Protect your medical information: This includes your Medicare number, Social Security number, and medical information. Only give this information to your doctors and health care providers. Be careful about giving your personal information to people who offer free services or other incentives in return for your Medicare number or Social Security number. Similarly, if people who are not medical professionals want to see your medical records or recommend medical services, do not let them. Social Security and Medicare will never call you to ask you for personal information, so be wary of scammers posing as government agencies or banks trying to request this information.
  2. Do not accept services that you do not need: Some dishonest providers might pressure you into receiving tests or services that are not medically necessary. Billing Medicare for unnecessary services and equipment is a type of Medicare fraud. You can report pressure from health care providers to receive extra services.
  3. Review your Medicare Summary Notices (MSN) or Explanation of Benefits (EOB): Reviewing these documents can help you to verify that you actually received the services listed. For example, if your Explanation of Benefits from your Part D plan indicates that the plan paid for a medication you didn’t receive, this could be a sign of fraud. Keep in mind that it can be difficult to tell whether charges are legitimate if you received services from several doctors around the same time or you take many medications. One way to keep track is to use a health care journal to record all medical services and items you receive.  You can compare your notes to notices above to help you detect possible fraud.
  4. Verify information that you receive about Medicare Advantage and Part D plans:  You should verify everything that a plan broker tells you regarding a Medicare Advantage plan. For example, if a broker tells you that your doctor is in the plan’s network, call your doctor to confirm this. If you feel that you are receiving false information from a Medicare Advantage plan or Part D plan representative, you can contact 800-Medicare to verify a plan’s information. Medicare Advantage plans must follow specific guidelines when marketing their plans, and cannot provide you misleading or false information to get you to enroll in their plan.

If you receive a suspicious or confusing MSN or EOB, contact your provider or pharmacy first to ask for an explanation. Medical claims can be complicated to read, and reviewing them with your provider or pharmacy might reveal that the charges were legitimate or that a billing error was to blame.

If you are still unsatisfied with the answer you receive, or if you suspect fraud, you should report the issue. It is helpful to have as many details as possible when reporting suspected fraud, such as specific names, locations, and times. If you have Original Medicare, you can call 800-Medicare to report the suspected fraud. If you have a Medicare Advantage plan, you can call your plan directly. Regardless of whether you have Original Medicare or a Medicare Advantage plan, you can contact the Office of the Inspector General (OIG) at 800-447-8477. When Medicare investigates the potential fraud, your name will not be used if you do not want it to be. In many cases, Medicare will be unable to confirm the occurrence of fraud without your help.


Health Tip
Adults need vaccines in the same way that kids do, and it is important to check your health records to be sure that you are up to date on your shots. The U.S. Department of Health and Human Services publishes recommendations for the vaccines that adults should receive on a regular basis. They recommend that adults receive certain vaccines, including:

  • A flu shot every year, especially if you are an adult age 65 or older or are at high risk for getting the flu
  • A Td shot every 10 years to protect against tetanus and diphtheria
  • A shot to prevent shingles if you are age 60 or older. Shingles causes a painful rash that can last for an extended period of time.
  • A shot to prevent pneumonia if you are age 65 or older, sometimes called a PPSV. Some adults will need a shot to prevent pneumonia before age 65.

Keeping your vaccines up to date is important to help protect you from serious diseases. The protections that you get from vaccines received as a child can wear off over time, and as you get older, you may be at higher risk for certain illnesses. Speak with your primary care doctor to make sure that your vaccines are up to date, and that you are receiving vaccines appropriate for your age and state of health.

Medicare Part B covers the flu shot for free once every flu season, and it will also cover the pneumonia shot for free at least once in your lifetime. Medicare Part D also covers Td and Shingles vaccines; call your Part D plan for the costs of these vaccines

Click here to read the full article from Healthfinder.gov.

Need to Know
Medicare Rights University, a comprehensive online training curriculum for professionals, provides a guided learning experience complete with a self-assessment tool, in-depth and user-friendly Medicare content, quizzes to test your knowledge, and downloadable materials.

This unique resource provides professionals with a clear path to learning Medicare through a Core Curriculum—four levels of Medicare instruction designed to build on information learned as you progress through each level. Medicare Rights University also offers a Special Topics section which provides an in-depth look at subjects not covered in the Core Curriculum, such as Medicare’s coverage of durable medical equipment and Medicare from a policy perspective.

Check out Medicare Rights University today by going online and visiting www.medicarerightsuniversity.org.

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