Safety Article:

Watch out for Medicaid fraud, abuse, and waste

Health care fraud and abuse contribute significantly to rising health care costs, putting a burden not only on Medicare beneficiaries but on all consumers. Older adults can help contain costs by trusting their instincts and learning how to detect fraud.

"Although most health care providers are honest, there are some who intentionally deceive, misrepresent or bill Medicare or Medicaid for services that were never provided," says Marita Berg, King County coordinator of Statewide Health Insurance Benefits Advisors (SHIBA), a public agency that provides health insurance education, assistance and advocacy for Washington residents. "When fraud occurs, you are being used for someone's criminal scheme to steal our health care dollars."

The Healthy Aging Partnership, a coalition of 30 not-for-profit and public organizations dedicated to the health and well-being of seniors, joins with SHIBA to offer these suggestions to help older adults understand and help fight Medicaid fraud.

First, be alert for possible fraudulent situations such as when you are:

  • Offered free testing or screening in exchange for your Medicare number. Medicare does not offer free services.
  • Provided services that exceed what are medically necessary.
  • Billed for services or equipment that were not rendered or received.
  • Charged for filling out claim forms.
  • Given a waiver of the 20 percent coinsurance or deductible.
  • Told by your provider that he or she has been "endorsed" by the federal government or by Medicare or that he or she represents Medicare.
  • Pressured to purchase a high-priced medical service or diagnostic test that you feel you don't need.
  • Told by your provider that the item or service is not usually covered, but they know how to bill Medicare to get it paid.

It is also important to understand what does not constitute fraud. For example:

  • A billing or processing error can occur if someone enters the wrong Medicare number.
  • A service may be legitimately rendered by a provider you may not have seen, such as a laboratory, pathologist, anesthesiologist or radiologist.
  • You may have seen an employee of the physician (such as a nurse practitioner, physician assistant or physical therapist) even though the claim shows a physician provided the service.
  • Hospital inpatient claims are paid automatically by Medicare according to the type of service provided, not by how much the provider actually charges. Therefore, the amount paid may be more or less than what is actually billed. If you are still in doubt and wish to verify the amount with Medicare, you can call the Medicare carrier or intermediary, whose name, address and toll-free telephone number appear on the Medicare Summary Notice you receive.

To help prevent fraud, never give out the Medicare Health Insurance Claim Number on your Medicare card to anyone except your doctor or other Medicare provider. Do not allow anyone except appropriate medical professionals to review your medical records or recommend services. And do not accept medical supplies or equipment from a door-to-door salesperson.

If you suspect that a provider may be attempting to defraud Medicare, call the Medicare carrier or intermediary who sent the Medicare Summary Notice. You can also contact the SHIBA HelpLine at 1-800-397-4422 for confidential assistance. Reporting concerns or suspicions could lead to program savings and better care and service for everyone.

For answers to other questions about your health care - or for information and assistance about every aspect of life as an older adult - call 1-844-348-KING or visit the Healthy Aging Partnership's Web site at HAP is generously supported by its partner agencies, Puget Sound Energy and the Comprehensive Health Education Foundation