MEDICARE FRAUDIdaho’s Benefits Counseling ToolkitSeptember 2012

Funded by the Idaho Commission on Aging through the Aging and Disability Resource Center/Medicare Improvements for Patients and Providers Act (MIPPA) Grant.

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Medicare Puzzle

MedicareBasics

Part A

Part B

Part C

Part D

MedicaidBasics

MSP/LIS

DualEligibles

SupplementalPlans

MedicareFraud

Glossary

ConsumerNeeds

September 2012

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Senior Medicare Patrol (SMP)• Goal of SMP is to empower seniors to prevent health care

fraud through outreach and education throughout Idaho• Develop a corps of senior volunteers and professionals

that can help their peers become better healthcare consumers.

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Senior Medicare Patrol (SMP)• Senior Medicare Patrol Program can help:

• Educate and empower people with Medicare to take an active role in detecting and preventing health care fraud and abuse.

• Preserve Medicare dollars.• Provide personalized counseling. • Attend community events and help educate groups.

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Senior Medicare Patrol (SMP) in Idaho

• In Idaho the SMP program is hosted by the Idaho Commission on Aging, which received funding for the program from the U.S. Administration on Community Living/Administration on Aging.

• The SMP program coordinates with the Senior Health Insurance Benefits Advisors (SHIBA) program at the Idaho Department of Insurance to offer Medicare fraud prevention and education events, presentations and one to one counseling to Medicare beneficiaries and their families.

• The SMP and SHIBA programs rely on skilled volunteers through out the state to provide outreach and education for the programs. To volunteer contact SHIBA at 1-800-247-4422 or via the internet at http://www.doi.idaho.gov/shiba/Vol/login.aspx

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Things to Watch For:• Services and supplies not provided on the Medicare

Summary Notice (MSN). Errors occur and could potentially cost Medicare money which affects everyone.• Most errors are not intentional. It is fraud when they are. • Ask health care providers or supplier for an itemized statement and

or to explain charges.• Providers should “never” say “It’s OK you’re not having to pay it,

because Medicare has to pay it”. This philosophy results in increases in costs for basic insurance coverage

• Up coding is coding a service at a higher level/rate for a higher reimbursement to the provider, even though you received a lower code service. This is a big issue to watch for and should be reported.

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Medicare Summary Notice

September 2012

Medicare sends out statements like this one quarterly. If you didn't use any medical services in a particular three-month period, a statement won't be sent. Your Medicare Summary Notice shows all services and supplies billed to your Medicare Part A account by hospitals, home health providers, and hospice and skilled nursing facilities.

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Medicare Summary Notice

September 2012

This is the date the notice was mailed. Medicare Summary Notices are sent out four times a year — once a quarter — but you don't have to wait for your notice to arrive in the mail. You can also check your account online at MyMedicare.gov. Claims typically appear on your electronic statement 24 hours after processing.

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Medicare Summary Notice

September 2012

If the name or address listed here is not correct, visit your local Social Security Administration office or call 800-772-1213 (TTY 800-325-0778 for the deaf or hard of hearing), weekdays from 7 a.m. to 7 p.m. You can also make the corrections online at SSA.gov. In addition, be sure to contact the company that processes your Medicare claims with any corrections or changes.

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Medicare Summary Notice

September 2012

Medicare contracts with private companies called "Medicare administrative contractors" to process your Medicare claims and pay your health care providers. That's why you may see the name and address of a private company in this part of the notice. If you have questions about your Medicare statement, contact this company.

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Medicare Summary Notice

September 2012

This is the number on your Medicare card. Protect it just as you would a credit card, Social Security or bank account number.

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Medicare Summary Notice

September 2012

This section gives tips on how to protect against Medicare fraud. 

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Medicare Summary Notice

September 2012

Your Medicare Summary Notice covers claims that were made between the two dates you see here. If you want to check a more recent claim, you can always review your account online at MyMedicare.gov. Claims typically appear on your electronic statement 24 hours after processing.

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Medicare Summary Notice

September 2012

Medicare uses this area to give you extra information about the claims listed in your Medicare Summary Notice. If a letter code appears in the column called "See Notes Section," you'll find an explanation of that code here.

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Medicare Part A Summary Notice

September 2012

Part A claims are made for medical services or supplies received while you are a patient in a hospital or skilled nursing or hospice facility. Some services or supplies you receive at home also are covered under Part A. You have the right to receive an itemized statement listing all services and supplies referred to in this section. For an itemized statement, contact the billing hospital or facility directly. Also, contact the billing office if you spot errors in this section of the statement.

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Medicare Part A Summary Notice

September 2012

Each inpatient claim made to your Medicare account is assigned a claim number. If, for instance, you were hospitalized for three days, all billed services and supplies relating to that visit would have the same claim number.

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Medicare Part A Summary Notice

September 2012

This is the hospital where you received treatment. If you did not receive services or supplies from this hospital, contact the hospital billing office directly. If the billing office cannot resolve your concerns, contact your customer service company. If you still have concerns, contact Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part A Summary Notice

September 2012

This is the name of the doctor who admitted you to the hospital or facility.

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Medicare Part A Summary Notice

September 2012

These are the dates you received treatment. If you did not receive services or supplies on these dates, contact the hospital or facility billing office. If the billing office cannot resolve your concerns, contact your customer service company. If you still have concerns, call Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part A Summary Notice

September 2012

This is the name and address of the skilled nursing or hospice facility where you received care. It may also be the name of the company that provided home health care. If you did not receive services or supplies from this facility or company, contact the facility or company billing office directly. If the billing office cannot resolve your concerns, contact your customer service company. If you still have concerns, call Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part A Summary Notice

September 2012

A "benefit period" begins on the day you are admitted to the hospital, hospice or skilled nursing facility and ends when you have been out for 60 days in a row. Benefit periods matter because you pay an out-of-pocket deductible ($1,132 in 2011) each time you enter a new benefit period.This column indicates the number of days you have been in your benefit period. If you are readmitted to a hospital or facility before you've been out for 60 days, you will continue in the "old" benefit period. If you are admitted again after you have been out for at least 60 days, you begin a new benefit period and will pay another out-of-pocket deductible.

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Medicare Part A Summary Notice

September 2012

Medicare doesn't cover all of your medical expenses. For example, Medicare does not pay for the first three units of blood used in a transfusion, nor does it cover copies of X-rays, or the charge for a television or telephone in your hospital room. The dollar amounts in this column are the part of the hospital's or facility's claim that Medicare did not pay.

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Medicare Part A Summary Notice

September 2012

Each of your hospital benefit periods has an out-of-pocket deductible. You must pay the deductible amount ($1,132 in 2011) to the hospital or facility before Medicare pays on the claim.

This section shows the amount that has been applied to your insurance deductible, and/or to your coinsurance. (Coinsurance is a percentage of a charge that you pay out-of-pocket. For instance, Medicare might cover 80 percent of a charge and require you to pay the remaining 20 percent.)

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Medicare Part A Summary Notice

September 2012

This is the maximum amount the hospital or facility can bill you. It may include your deductible, coinsurance charges or any other charges that Medicare does not cover. If you have a Medicare supplemental insurance policy (also called Medigap), Medicare will send this claim information to your insurance company. Your Medigap policy should cover at least some of the costs not paid by Medicare.

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Medicare Part A Summary Notice

September 2012

This column directs you to additional information about your claims. If there is a letter code in this column, refer to the Notes Section at the end of your statement.

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Medicare Part A Summary Notice

September 2012

Any services or supplies received on an outpatient basis — whether in a hospital or, say, a renal dialysis center — appear in this section. For other Part B claims, see your Part B Medicare Summary Notice

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Medicare Part A Summary Notice

September 2012

Each outpatient claim made to your Medicare account is assigned a claim number. For instance, a single doctor's visit has a claim number as would each dialysis treatment session.

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Medicare Part A Summary Notice

September 2012

This is the name and address of the facility that provided your outpatient treatment. If you did not receive treatment from this facility, contact the facility's billing office. If the billing office cannot resolve your concerns, contact your customer service company. If you still have concerns, call Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part A Summary Notice

September 2012

This is the name of the doctor who ordered the outpatient services.

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Medicare Part A Summary Notice

September 2012

These are the dates you received outpatient services at the hospital or facility. If you did not receive services or supplies on these dates, contact the hospital or facility billing office. If the billing office cannot resolve your concerns, contact your customer service company. If you still have concerns, call Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part A Summary Notice

September 2012

This is a brief description of the provided service. If you did not receive the service, contact the facility directly. It may be a simple mistake that the facility can easily correct. If the facility does not resolve your concerns, contact your customer service company. If you still have concerns, call Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part A Summary Notice

September 2012

Medical procedures and services are assigned billing codes. Compare this code with the code that appears on the billing statement you received from the facility. If the codes are different, contact the facility making the claim. It may be a simple mistake that the facility can easily correct. If the facility does not resolve your concerns, contact your customer service company. If you still have concerns, call Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part A Summary Notice

September 2012

This is the total amount the facility billed Medicare for the service or treatment.

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Medicare Part A Summary Notice

September 2012

Medicare doesn't cover all of your medical expenses. For example, Medicare does not pay for copies of X-rays or the first three units of blood used in a transfusion. 

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Medicare Part A Summary Notice

September 2012

Your outpatient services fall under your Medicare Part B deductible. This is the amount of money you pay out-of-pocket before Medicare helps with the costs. After you have met the annual deductible ($162 in 2011), you pay 20 percent of the Medicare-allowed fees for later charges.

Depending on the services you receive, you may also be charged a co-payment. For example, if you visit an emergency room and are not admitted to the hospital, you pay a co-payment directly to the hospital.

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Medicare Part A Summary Notice

September 2012

This is the maximum amount the hospital or facility can bill you. It can include your deductible and coinsurance or other charges Medicare does not cover. If you have Medicare supplemental insurance (also called Medigap), Medicare will send this claim information to your insurance company. Your Medigap policy should cover at least some of the costs not paid by Medicare.

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Medicare Part A Summary Notice

September 2012

This column directs you to additional information about your claims. If there's a letter in this column, refer to the Notes Section at the end of your Medicare Summary Notice.

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Medicare Part A Summary Notice

September 2012

Yes, that's right! Your Medicare Summary Notice is not a bill. However, it is a statement you should review for accuracy and keep for your personal records.

Very important: Never send a health care provider payment for charges listed on a Medicare Summary Notice until you've received a bill for the service directly from the provider. If you have already paid the provider, check to make sure what you paid matches the amounts on your Medicare Summary Notice. If you paid more than needed, contact the provider's billing office to request a refund.

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Medicare Part B Summary Notice

September 2012

Part B claims are made by the doctors and other health professionals who provide your medical care. Claims by providers who agree to accept a Medicare-approved rate for their services appear in this section. These bills are called "assigned claims." With an assigned claim, Medicare typically pays 80 percent of its approved cost for the service while you pay the remaining 20 percent directly to the provider.

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Medicare Part B Summary Notice

September 2012

Each claim made to your Medicare Part B account, such as for a doctor visit, is assigned a distinct number.

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Medicare Part B Summary Notice

September 2012

Be aware that the name listed on your MSN might differ from your doctor's name. For instance, the name that appears here could be that of the medical practice or its owner. Also, the listed address might be for the doctor's billing office rather than the medical office. If you have questions, contact the doctor who is filing the claim. If the doctor's office cannot resolve your concerns, contact your customer service company If you still have concerns, contact Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part B Summary Notice

September 2012

This column lists the date or dates you received medical care. To make sure the dates are correct, you can check your calendar or the statement you were given by the doctor's office at your visit. If you did not receive medical services on a date listed here, contact the doctor who is filing the claim. It could be a mistake that the doctor's office can easily correct. If the office cannot resolve your concerns, contact your customer service company. If you still have concerns, contact Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part B Summary Notice

September 2012

This is a brief description of the provided service(s). If you did not receive a service listed here, contact the doctor who is making the claim. It could be a mistake that the doctor's office can easily correct. If the office cannot resolve your concerns, contact your customer service company. If you still have concerns, contact Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part B Summary Notice

September 2012

Medical procedures and services are assigned billing codes. You have the right to receive an itemized billing statement that lists each medical service you received. If you need an itemized statement, contact your doctor. Compare the billing code on your MSN with the code that appears on the billing statement you received from your doctor or health care provider. If the codes are different, or if you didn't receive the medical service indicated, contact the doctor who is making the claim. It may be a simple mistake that the doctor's office can easily correct. If the office does not resolve your concerns, contact your customer service company. If you still have concerns, call Medicare at 800-MEDICARE (800-633-4227).

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Medicare Part B Summary Notice

September 2012

This is the amount the doctor or health care provider billed Medicare.

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Medicare Part B Summary Notice

September 2012

This is the amount Medicare approved as an acceptable charge for this service.

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Medicare Part B Summary Notice

September 2012

This is the amount Medicare paid to your doctor. In general, this amount is 80 percent of the Medicare-approved amount.

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Medicare Part B Summary Notice

September 2012

This is the maximum amount your doctor can bill you. It may include your deductible ($162 in 2011), your 20 percent coinsurance charges or any other charges that Medicare does not cover. Compare your Medicare Summary Notice with the doctor's billing statement to make sure you are paying the correct amount. Contact your doctor if you spot errors in this section of your MSN. If you have a Medicare supplemental insurance policy (also called Medigap), Medicare will send this claim information to your insurance company. Your supplemental insurance may cover some or all of the costs not paid by Medicare.

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Medicare Part B Summary Notice

September 2012

This column directs you to additional information about your claims. If there's a letter in this column, refer to the Notes Section at the end of your Medicare Summary Notice.

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Medicare Part B Summary Notice

September 2012

Part B claims are made by the doctors and other health professionals who provide your medical care. Claims by providers who have not agreed to accept Medicare's approved rates, known as "unassigned claims," appear in this section. The amount you have to pay — no more than 15 percent of the Medicare-approved rate — is shown under the heading "You May Be Billed."

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Medicare Part B Summary Notice

September 2012

This is the amount of the claim the doctor or provider filed with Medicare.

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Medicare Part B Summary Notice

September 2012

This is the amount Medicare approved as an acceptable charge for this service.

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Medicare Part B Summary Notice

September 2012

These funds reimburse you for the fee you paid a doctor or health care provider who did not accept the Medicare-approved rate as full payment.

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Medicare Part B Summary Notice

September 2012

Federal law limits how much you can be charged by a provider who does not accept a Medicare reimbursement as full payment. Medicare calculates this "unassigned claim" amount, the maximum of which is noted in this column.

Important: Compare your Medicare Summary Notice with the doctor's billing statement to make sure you did not pay more than the amount listed in this section. If you spot errors, contact the doctor. If you have a Medicare supplemental insurance policy (also called Medigap), Medicare will send this claim information to your insurance company. Your supplemental insurance may cover some of the costs not paid by Medicare.

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Medicare Part B Summary Notice

September 2012

Yes, that's right! Your Medicare Summary Notice is not a bill. It is a statement you should review for accuracy and keep for your personal records.

Very important: Never send a health care provider payment for charges listed on a Medicare Summary Notice until you've received a bill for the service directly from the provider. If you have already paid the provider, check to make sure what you paid matches the amounts on your Medicare Summary Notice. If you paid more than needed, contact the provider's billing office to request a refund.

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How to Report Medicare Fraud• Call 1-800-247-4422 or contact local SHIBA office

• Coeur d’Alene (208) 666-6847 or 1-800-488-5725• Boise (208) 334-4353, (208) 334-4278, or

1-800-247-4422• Twin Falls (208) 736-4713 or 1-800-488-5731• Pocatello (208) 236-6044 or 1-800-488-5764

• Complete this form and return it by fax (208-334-4398) or mail your complaint with any supporting documentation to:• Idaho Department of Insurance

Attention: SHIBA/SMPP. O. Box 83720Boise, ID 83720-0043

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Guard Against Identity Theft• Do not give out any personal information to someone you

do not know (includes your name, Social Security, Medicare, or credit card numbers).

• No one should call or come to your home uninvited to get you to join or change a Medicare plan.

• Generally it is safe to give out personal information to doctors, other health providers and trusted people in the community who work with Medicare. If you are unsure, call to verify those people are actually who they say they are.

• If you feel you are a victim call your local police department and the Federal Trade Commission’s ID Theft Hotline at 1-877-4338 to make a report. TTY users should call 1-866-653-4261.

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Additional Resources• Medicare Plan Finder – An online tool to find and compare

drug plans, Medicare Advantage plans and Medicare Supplemental/Medigap policies. www.medicare.gov

• Social Security Administration (SSA) - For questions about eligibility as well as enrolling in Medicare or Social Security retirement and disability benefits. www.ssa.gov

• Administration on Aging - Helps locate organizations in all states to help seniors and their caregivers. www.eldercare.gov

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Additional Resources• Veterans Administration – Go to www.va.gov/healthbenefits

or www.myhealth.va.gov. Be patient, this process can be slow. Know what your benefits are, based on your time and length of service before you need them.

• Contact your current health plan benefits customer services office to see if your plan can work with Medicare. You may also contact your employer’s benefits administrator to see if you are eligible for employer-sponsored retirement benefits. Information is usually on the back of your benefits card. • Be proactive• Don’t wait• Understand your options before you are ready to retire.

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Area Agencies on Aging• Area I

• North Idaho College• 1-208-667-3179• 1-800-786-5536• www.aaani.org/

• Area II• Community Action

Partnership• 1-208-798-4192• 1-800-877-3206• www.cap4action.org

• Area III• Idaho Council of

Governments• 1-208-908-4990• 1-800-859-0321• seniors.idahocog.com

September 2012

• Area IV• College of Southern Idaho• 1-208-736-2122• 1-800-574-8656• officeonaging.csi.edu/

• Area V• Southeast Idaho Council of

Governments• 1-208-233-4032• 1-800-526-8129• www.sicog.org/

• Area VI• Eastern Idaho Community

Action Partnership• 1-208-522-5391• 1-800-632-4813• www.eastidahoaging.com