As part of its drive to deregulate business, the Trump Administration has asked the health care industry for recommendations to relax rules against kickbacks, fraud and other abuses which are intended to influence the quality and quantity of care for Medicare and Medicaid patients. The stated intent is to allow doctors and hospitals to work together to improve care and save money.
According to news reports, medical industry lobbyists are in a “frenzy” to deregulate insurers and allow things like giving bonuses to doctors for cutting insurance company payout costs. Present rules seek to limit improper influence over choice of hospital and prescriptions for more than 100 million Medicare and Medicaid patients.
One lawyer called the Administration’s proposals a “get out of jail free card” for the medical industry. Present regulations are aimed at having providers make medical decisions on the bass of patient need, and not on the provider’s financial interests. The U.S. Dept. of Justice currently files cases against providers for violations on an almost weekly basis.
Whether present regulations are left intact or weakened, seniors are used as cash cows by the medical industry on a regular and continuing basis. In researching for this article your reporter talked to a number of seniors and health care professionals about their experience. Most believe that Medicare is routinely billed for tests and procedures that never took place. Some complained that they were ordered to take tests that were unrelated to the conditions that took them to the doctor’s office.
Fearing reprisals, few were willing to let us use their real names or identifying information. The names of insurers and institutions, however, have not been changed. This story is not about Obamacare, or Medicare for all – it is about the way the system works, or doesn’t, and the cost to Americans.
Gwendolyn N. related an incident that happened several years ago when she went for a routine flu shot at the Marana Health Center. Unlike most people, Gwendolyn reads the Medicare summaries she receives in the mail, and was surprised to see that Medicare had been billed over $100 for a doctor’s visit along with the flu shot. That, she said, never happened. So she called MHC and got the runaround. She was persistent, especially with talk in the news about Medicare potentially going broke, until one MHC staff person told her, “Look, we’re just trying to make a buck where we can to stay afloat.” Gwendolyn, unwilling to be an accomplice to fraud, passed the information along to Medicare, but never heard anything from them.
Larry R. has a relative in California who goes to a hospital for dialysis three times each week. When visiting, he has observed staff regularly opening a vial, use a portion of the drug, and simply throwing the rest away, and then opening another vial and do the same thing. Big Pharma makes a bundle and the cost is simply passed on to Medicare.
On the other hand, a neighbor of mine, Jack K., has just been diagnosed with terminal cancer. He is marginally self-employed, has no insurance, and is too young for Medicare. No doctor will touch him because there is no money to made from his disease. When Obamacare was being debated in Congress, there was much negative talk about so-called “death panels” making decisions on who gets care and who doesn’t. The medical industry has used the “free market” as its own form of “death panel” and sentenced Jack to a miserable death.
There are things seniors can do to reduce the ripoffs. These “Do’s and Don’ts” are from the Medicare website: https://www.medicare.gov/forms-help-resources/help-fight-medicare-fraud.
- Do protect your Medicare Number (on your Medicare card) and your Social Security Number (on your Social Security card). Treat your Medicare card like it’s a credit card.
- Do remember that nothing is ever “free.” Don’t accept offers of money or gifts for free medical care.
- Do ask questions. You have a right to know everything about your medical care including the costs billed to Medicare.
- Do educate yourself about Medicare. Know your rights and know what a provider can and can’t bill to Medicare.
- Do use a calendar to record all of your doctor’s appointments and what tests or X-rays you get. Then check your Medicare statements carefully to make sure you got each service listed and that all the details are correct. If you spend time in a hospital, make sure the admission date, discharge date, and diagnosis on your bill are correct.
- Do be wary of providers who tell you that the item or service isn’t usually covered, but they “know how to bill Medicare” so Medicare will pay.
- Do make sure you understand how a plan works before you join.
- Do always check your pills before you leave the pharmacy to be sure you got the correct medication, including whether it’s a brand or generic and the full amount. If you don’t get your full prescription, report the problem to the pharmacist.
- Do report suspected instances of fraud.
- Don’t allow anyone, except your doctor or other Medicare providers, to review your medical records or recommend services.
- Don’t contact your doctor to request a service that you don’t need.
- Don’t let anyone persuade you to see a doctor for care or services you don’t need.
- Don’t accept medical supplies from a door-to-door salesman. If someone comes to your door claiming to be from Medicare or Medicaid, remember that Medicare and Medicaid don’t send representatives to your home to sell products or services.
- Don’t be influenced by certain media advertising about your health. Many television and radio ads don’t have your best interest at heart.
- Don’t give your Medicare card, Medicare Number, Social Security card, or Social Security Number to anyone except your doctor or people you know should have it.
PROTECT YOURSELF BY KEEPING RECORDS:
- When you get health care services, record the dates on a calendar and save the receipts and statements you get from providers to check for mistakes.
- Compare the dates and services on your calendar with the statements you get from Medicare to make sure you got each service listed and that all the details are correct.
- These include the “Medicare Summary Notice” (MSN)if you have Original Medicare , or similar statements that list the services you got or prescriptions you filled.
- Check your claims early—the sooner you see and report errors, the sooner we can stop fraud. To view your claims as soon as they’re processed, log into MyMedicare.gov, or call us at 1-800-MEDICARE (1-800-633-4227).
- If you find items listed in your claims that you don’t have a record of, it’s possible that you or Medicare may have been billed for services or items you didn’t get.
- If you think a charge is incorrect and you know the provider, you may want to call their office to ask about it. The person you speak to may help you better understand the services or supplies you got. Or, your provider may realize a billing error was made. Sometimes you’ll receive a bill because a secondary insurer was never billed.
- If you’ve contacted the provider and you suspect that Medicare is being charged for health care you didn’t get, or you don’t know the provider on the claim, find out how to report fraud.
YOU CAN REPORT SUSPECTED MEDICARE FRAUD IN ANY OF THESE WAYS:
- Call 1-800-MEDICARE (1-800-633-4227).
- Report it online to the Office of the Inspector General.
- Call the Office of the Inspector General at 1‑800‑HHS‑TIPS (1‑800‑447‑8477). TTY: 1‑800‑377‑4950.
HAVE THIS INFORMATION BEFORE YOU REPORT FRAUD:
- The provider’s name and any identifying number you may have.
- The service or item you’re questioning.
- The date the service or item was supposedly given or delivered.
- The payment amount approved and paid by Medicare.
- The date on your Medicare Summary Notice.
- Your name and Medicare Number.
- The reason you think Medicare shouldn’t have paid.
- Any other information you have showing why Medicare shouldn’t have paid for a service or item.
NEXT WEEK: HOW INSURERS SCAM SENIORS: THE ARIZONA BLUE CROSS BLUE SHIELD MODEL