Medicare statement must be checked and double-checked

February 17, 1993|By Katherine Richards | Katherine Richards,Staff Writer

Fasten your seat belt, count your change, and always read your Medicare statement carefully.

The best way to fight Medicare fraud and abuse, according to Susan G. Cronin, coordinator of the Senior Health Insurance Counseling and Advocacy Program in Carroll County, is to check the Medicare Explanation of Benefits statement to make sure you've received all services the provider has billed for.

"Most providers are honest and responsible," she said, but even in Carroll County, Medicare fraud and abuse are a problem.

Mrs. Cronin said Medicare fraud occurs when a health care provider bills for a service that was not actually provided. Medicare abuse occurs when a provider bills for a service that was not necessary for the patient's medical condition, she said.

Ms. Cronin said if there is something on your benefit statement you don't understand, or if you think there might be a mistake, it is best to ask your doctor about it.

If a treatment or service is identified on the statement with only a code number, she said, the senior should ask for an explanation in English.

"Discuss these things with your doctor. Don't just assume they're OK," she said.

Nationally, fraud and abuse account for 10 percent to 25 percent of Medicare spending, she said. In 1990, fraud and abuse cost the program about $10 billion.

In addition to costing the program billions of dollars, some Medicare billing problems result in seniors being asked to pay bills they do not actually owe, Ms. Cronin said.

"I don't see an awful lot of fraud and abuse [in Carroll County]," she said. "But I see horrendous billing problems."

Whether a provider deliberately overcharges or just makes a mistake, she said, seniors can often catch the problem by checking all Medicare statements to make sure everything is in order.

Medicare records are confidential. But, with permission, Ms. Cronin used the story of her late sister, Janet, as an example.

Janet, 51, was disabled and on Medicare, and had issued written instructions that she did not want to be fed intravenously.

Later, Ms. Cronin said, Janet's Medicare statement showed that her health care provider had billed Medicare $750 for intravenous feeding.

So, either the provider charged for a service never provided or charged for a treatment provided against the patient's wishes, she said.

In a separate incident, Ms. Cronin said, one doctor billed Medicare for a consultation after introducing himself to Janet and handing her his business card.

She said older people can be upset when they discover billing problems.

"I've had patients who have said to me, 'This stuff is going to make me ill and put me back in the hospital.' "

She said many older people hesitate to press their doctors for explanations because they were brought up not to question the professional judgment of doctors and attorneys.

"We have a lot of problems with trust and Carroll County seniors," Ms. Cronin said.

Bob Jackson, a senior program specialist with the American Association of Retired Persons in Washington, said Medicare patients often don't want to confront their doctors.

"They're vulnerable," he said. "You don't want to mess up your relationship with your physician."

Ms. Cronin said another factor contributing to Medicare fraud and abuse is that Medicare regulations change often and can be vague. Sometimes health care providers don't know what is required.

And in the insurance industry, she said, overworked claims processors and investigators may fail to spot unusual billings.

"The claims process is fairly complicated," said Mr. Jackson. "Somewhere between the physician's scribble and the billing clerk," numbers can be transposed and other mistakes made.

However, Ms. Cronin said she has seen a "radical" drop in the number of problems related to the sale of Medicare supplementary insurance, known as Medigap insurance.

In the past, many seniors were sold duplicate Medigap insurance polices they did not need.

But last summer, a federal law took effect requiring Medigap salespeople to ask prospective clients if they already have Medigap insurance.

If a person already has a Medigap policy, the salesperson is supposed to outline why the new policy is better, Ms. Cronin said.

However, she said, there are still many people in their who have several Medigap policies, but need only one.

She said one Carroll senior came to her who had been paying $154 a month for extra Medigap insurance that provided no additional benefit. She helped that person cancel the policy.


If you see something you don't understand on your Medicare Explanation of Benefits statement:

1. Call your doctor or health care provider and ask about it.

2. If you still have a question, call or write the Medicare carrier. The carrier is identified on the Explanation of Benefits statement. (In Carroll County, the carrier is often, but not always, Blue Cross/Blue Shield of Maryland.)

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