Life After 50 Expo

Dear Marci,

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Dear Marci,

I have Original Medicare. While looking over my Medicare Summary Notice (MSN) for a recent inpatient hospital stay, I noticed that there are multiple charges for the same day, and that there were some charges for services I do not think I received. Am I a victim of fraud or abuse? What steps can I take to find out and get help?

– Carson (Grand Forks, ND)

Dear Carson,

Medicare statements and provider bills can be confusing and may include many charges you do not recognize. It may be difficult to tell whether or not charges are legitimate, the result of human error, or an instance of fraud and/or abuse. While most health professionals have the best interests of Medicare beneficiaries in mind, Medicare billing fraud and abuse do still occur. Here are some steps to take to get to the bottom of your billing questions and to protect yourself from fraud and/or abuse.

First, call your hospital, doctor, or other provider to review the charges on your MSN and get more information about these services. Keep in mind that multiple claims may be submitted for an inpatient hospital stay. Not only can the hospital bill for the inpatient stay itself under Part A, but each physician—even those you do not recall seeing—can separately bill for his or her services under Medicare Part B. For example, an MSN may show a charge for the radiologist who read your x-ray, even if they were not physically present at the hospital where you received care. You may not realize that you received that service because you did not see it take place. Your hospital administrator or provider can explain the different charges to you and give you more information about the services you received during your inpatient hospital stay.

Additionally, the charges you don’t recognize could have been the result of a simple billing issue. Your provider may have entered the wrong information when sending the claim to Medicare, which is why you do not know what the charge is for. Again, speaking to your hospital administrator or provider first is important in case the discrepancy on your MSN is the result of one of these situations.

Finally, if you find out that you have been wrongfully billed for a service, the charge could be a result of fraud or abuse. Fraud is usually characterized by someone knowingly misrepresenting the truth in order to receive payment for something they are not entitled to. Abuse includes practices that cause unnecessary costs to the Medicare program. Some examples of fraud and abuse include a health care provider pressuring you into receiving expensive health services or items that you do not need, a provider billing you for services you never received, or someone calling you pretending to be from Social Security or Medicare and asking for your Medicare or Social Security information.

There are a few tips that can help you avoid Medicare fraud and abuse.

  • First, never provide your Medicare information to anyone but your trusted health care providers. Social Security and Medicare will never call you to ask for your personal information.
  • You should always review the summary of claims sent to you by Medicare or your plan in order to compare the services received with the ones for which you were charged.
  • Lastly, keep a health care journal with the names of all the services and procedures you receive. You can compare this journal to the MSNs you receive.

To report fraud and abuse, you can contact 800-Medicare or the Office of the Inspector General (OIG) at 800-447-8477. Before calling the OIG, write down as many details as possible, including names, dates, locations, and the care or services received. You can also contact your local Senior Medicare Patrol (SMP) program. To locate your SMP, call 877-898-2468 or visitwww.smpresource.org.

– Marci

Medicare Reminder !

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How Medicare covers vaccines depends on the type of vaccine and the reason it is prescribed. Medicare Part B (either through Original Medicare or a Medicare Advantage plan) covers vaccines after you are exposed to a dangerous virus or disease. For example, it will cover tetanus shots after you step on a rusty nail. It also covers three vaccines under the preventive care benefit – flu, pneumonia, and hepatitis B. All other vaccines should be covered by your Part D prescription drug plan. Every Part D plan must have all commercially available vaccines on its list of covered drugs (formulary), but costs may differ.

Brief Analyzes Competition in Medicare Advantage Plan Market

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Many see competition in Medicare Advantage (MA) plan markets as necessary to keep premiums low, control spending, and expand benefits. With many health plans planning to consolidate, the Commonwealth Fund recently released a new brief examining how much competition exists in the MA plan market across the country.

According to the brief, 97 percent of MA plan markets in counties across the US “are highly concentrated and therefore lacking significant competition.” While rural areas have less competition than urban areas, in the 100 counties with the highest number of Medicare beneficiaries, 81 percent lack a competitive MA market. Nationwide, the plan market is centered on only three insurance companies in these 100 counties.

The Commonwealth Fund relied on the Herfindahl-Hirschman Index (HHI) to determine the level of concentration in individual markets by analyzing the number of MA insurance companies in a particular market and comparing that with the number of people enrolled. Markets with an HHI below 1,500 are considered nonconcentrated, those with an HHI between 1,500 and 2,500 are moderately concentrated, and markets above 2,500 are highly concentrated.

According to the findings, urban counties make up 95 percent of all MA enrollees and have an average HHI of 3,712 (highly concentrated) while rural counties have an average HHI of 5,245 (also highly concentrated). The national MA market has an average HHI of 3,783. While these results suggest that the MA market is not that competitive, it remains unclear what effect this has on Medicare costs and the quality of services offered.

CMS Announces Value-Based Insurance Design Medicare Advantage Model

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This week, the Centers for Medicare & Medicaid Services (CMS) announced the Medicare Advantage Value-Based Insurance Design Model (MA-VBID), which will test whether giving Medicare Advantage plans flexibility to offer targeted extra supplemental benefits or reduced cost sharing can lead to higher-quality, lower-cost care.

According to CMS, the goals of the model are to improve health, reduce avoidable high-cost care, and reduce costs. The model focuses on beneficiaries with diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories. It will begin January 1, 2017 and run for five years in Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee.

Value-Based Insurance Design (VBID) generally refers to efforts to structure cost-sharing and plan design elements to encourage enrollees to use high-value services—those services that have the greatest potential to positively impact enrollee health at a lower cost than alternatives. “The Medicare Advantage Value-Based Insurance Design Model fills an immediate need for testing ways to improve care and reduce cost in Medicare Advantage Plans and offers the prospect of lower out-of-pocket costs and premiums along with better benefits for enrollees in Medicare Advantage,” said Patrick Conway, M.D., MSc, CMS deputy administrator and chief medical officer.

Health Tip !

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Over the past 40 or so years, the positive effects of animal-assisted therapy have become increasingly recognized by medical professionals. For example, therapy dogs can have cardiovascular, cognitive, and psychological benefits for patients at long-term care facilities. Additionally, a six-year study completed earlier this year at Mount Sinai Beth Israel hospital found that therapy dogs can help cancer patients, too. Patients who underwent chemotherapy treatment with a therapy dog were more likely to follow through with their treatments, and their emotional wellbeing improved as well. Through their social nature and seemingly endless happiness, dogs lessen the burden of intense cancer treatment and help patients maintain a positive attitude