Stories
Prescription Drug Phone Call
Mr. Lee has Medicare. One evening he received
a phone call from a woman who identified herself as a Medicare
representative. The woman on the phone told Mr. Lee she could
save him hundreds of dollars each month by signing him up for
the new Medicare Prescription Drug Coverage. Mr. Lee pays over
$300 in drug costs each month, so he was eager to join. When
the woman said she could sign him up over the phone and asked
for Mr. Lee’s Medicare and checking account numbers, he gave
them to her.
After sleeping on it, Mr. Lee realized he had made a mistake
by giving out his personal information and contacted his local
SMP. The SMP helped Mr. Lee contact his bank to close his
account and reported the crime to the police and Medicare.
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A 75-year-old Waterloo, Iowa woman asked a million-dollar
question. In the fall, like every year, she received her
annual flu shot. A short time later, she received a letter
informing her the shot contained defective serum. She was
asked to return to her doctor’s office for a new dose and that
Medicare would pay for it. Medicare was billed for both shots.
The Iowa woman thought about Medicare paying twice for the
shots and asked the question, "why is Medicare paying for a
second round of shots, when the first batch was faulty serum?"
She recalled a program she had recently attended at her local
senior center. Similar to as SMP presentation,
she was offered tips on preventing Medicare waste and fraud.
She decided to write a letter to the Iowa senator that spoke
that day.
Her question was responded to and in the end, Medicare
reached a settlement with the pharmaceutical company for $9.19
per vaccination, the national average cost for one of the
shots. Medicare was reimbursed for 123,802 defective shots, a
savings of $1,137,740. Consumers can make a difference as
illustrated in this story of Medicare waste. As this Iowa
woman said "It felt so good. I don’t like to see my insurance
company getting bilked. It’s the taxpayers’ money – it’s
everybody’s money".
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Compared to other states, Medicare fraud is relatively low
in Minnesota but it does occur.
According to the U.S. Attorney’s office, a large Minnesota
health system paid the federal government $16 million to
settle allegations that it fraudulently over billed Medicare
and two other government health programs.
Initially, the health care system denied the allegations. A
settlement reached on December 31, 2001 ended a two-year
investigation that began when at least two whistleblowers came
forward. Medicare and Medicaid billing improprieties began at
the health care system’s hospitals and clinics in 1994.
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Help Control Medicare Waste
A 65-year-old Medicare beneficiary didn't pay attention to
her Medicare Summary Notice (MSN) until she received a bill
from her clinic. She received her Medicare statement, glanced
at it briefly, and did not pay attention to what the services
were. She only checked to see if Medicare had made a payment.
Satisfied that they had, she filed her MSN away.
Two weeks later, she received a letter from her Medicare
supplemental insurance company stating that they needed a copy
of the MSN in order to process the claim. Not wanting to
bother with it, she brought the letter into her clinic and
asked them to send the MSN to the insurance company. They said
they would. Several weeks later she received an Explanation of
Benefits from her insurance company indicating no payment
would be made on the submitted claim because they did not
receive the requested information. At the same time, she also
received a bill from the clinic indicating that she had a
balance. NOW she was paying attention!
She pulled the MSN from her file and compared it to her
clinic statement. Upon careful examination, she noticed the
charges were for a doctor's hospital visit and discharge from
a hospital in which she was never a patient!
A health insurance advocate from the State Health Insurance
and Assistance Program (SHIP) called the clinic on her behalf
to investigate and correct the mistake. At first, the clinic
indicated they had no record of her. Her advocate was
persistent, however, and eventually they did find there had
been a billing error. They said the charges would be removed
from her account.
Her SHIP advocate went one step further by asking the
clinic if they would be refunding the money to Medicare, not
only because Medicare paid for a service not provided, but
also because she wanted those services removed from the
beneficiary’s claims history. To be certain, the SHIP advocate
called Medicare. A short time later, the beneficiary did
receive a letter from Medicare informing her they were in the
process of being reimbursed by the clinic.
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Disclaimer
This website was supported, in part, by a grant from the Administration on Aging,
Department of Health and Human Services. Grantees
undertaking projects under government sponsorship
are encouraged to express freely their findings
and conclusions. Points of view or opinions do
not, therefore, necessarily represent official
Administration on Aging policy. |
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