Medicare fraud and abuse costs Medicare and taxpayers nearly 60 billion dollars annually. This fraud and abuse could potentially affect your Medicare benefits resulting in delayed or denied benefits. Medicare fraud and abuse occurs when a doctor or provider knowingly deceives Medicare to receive a payment they are not entitled to or to receive a payment for a higher amount than they should actually receive. Fortunately, Medicare provides tools to help you prevent Medicare fraud and abuse from potentially affecting your benefits.
If you have Original Medicare and have used your Medicare benefits in the past three months, CMS (Centers for Medicare and Medicaid Services) will send you a Medicare Summary Notice (MSN). The MSN is sent quarterly and is not a bill. The MSN is a document that details charges billed to Medicare, the amount paid by Medicare and the amount you may owe. If you have not used your Medicare benefits in the prior three months, you will not receive a MSN.
You should review the information on your MSN to ensure Medicare is paying for services you actually received. The MSN shows the date services were received, the doctor or provider seen, and a brief description of the services provided. The MSN will also list any services that are excluded or denied by Medicare. If you disagree with a non-covered charge, you can file an appeal. Instructions are included on the final page of the Medicare Summary Notice.
In addition to the MSN, you will also receive an Explanation of Benefits (EOB) from your Medicare Prescription Drug Plan or your Medicare Advantage Plan provider. The EOB is sent every month, if you have used your Medicare benefits. The EOB is different from the MSN and is not a bill. The EOB summarizes the services and items you have received and how much you may owe for them. This information includes the amount your provider charged, the approved amount to be paid by the plan and what you may owe.
You should examine the Explanation of Benefits to ensure all charges are correct. All EOBs provide the same information, but the layout and other specifics may vary by plan. If your EOB shows an item or service is not covered, you should look for a note or comment section. Sometimes this information is found in the footnotes and will show the reason for denial. You can contact the plan for more information about a denied service or item. If you disagree with a denial you can file an appeal. Instructions are available in the EOB.
You should keep a healthcare journal, detailing the date, the doctor or provider seen, and the services you received. You should compare your healthcare journal to your MSNs and EOBs, to ensure all charges are correct. If you have questions you can contact your plan. If you suspect you have been a victim of Medicare fraud or abuse you should contact your local Nebraska SHIIP office.
Nebraska SHIIP provides free, confidential, unbiased Medicare education and counseling. Nebraska SHIIP also serves as the state’s SMP (Senior Medicare Patrol) and will assist you with suspected Medicare fraud or abuse. Nebraska SHIIP can be reached at 1-800-234-7119.