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Medicare

How to spot Medicare fraud

Review your Medicare Summary Notices for errors and report anything suspicious to Medicare.

  • 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 from your plan if you’re in a Medicare Advantage Plan. They list the services you got or prescriptions you filled.
    • Check your claims early—the sooner you see and report errors, the sooner you can help stop fraud. Log into (or create) your secure Medicare account to view your Original Medicare claims as soon as they’re processed, or call us at 1-800-MEDICARE (1-800-633-4227).
  • Check the receipts and statements you get from providers for mistakes.

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 they may realize a billing error was made.

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.

What is Medicare and what does it cover?

Medicare pays for health care for:

  • People age 65 years and older
  • People under age 65 with receiving Social Security Disability benefits
  • People of all ages diagnosed with Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease) or end-stage renal disease (permanent kidney failure that requires dialysis or a kidney transplant).

Medicare covers medically necessary care for acute care, such as doctor visits, drugs, and hospital stays.

Except for the specific circumstances described below, Medicare does not pay for most long-term care services or personal care— such as help with bathing or for supervision (often referred to as custodial care).

When Does Medicare Pay for Long-term Care Services?

Following Hospitalization

Medicare will help pay for a short stay in a skilled nursing facility if you meet all of the following conditions:

  • You have had a hospital admission with an inpatient stay of at least three days
  • You are admitted to a Medicare-certified nursing facility within 30 daysof that inpatient hospital stay
  • You need skilled care, such as skilled nursing services, physical therapy, or other types of therapy

If you meet all these conditions, Original Medicare will pay a portion of the costs for up to 100 days for each benefit period as follows:

  • For the first 20 days, Medicare pays 100 percent of the cost.
  • For days 21 through 100, you pay a daily copayment, which was $164.50 as of November 2017), and Medicare pays any balance.
  • Medicare does not pay costs for days you stay in a skilled nursing facility after day 100.

(Medicare Advantage plans must cover the same services, but the cost sharing may vary.)

To treat medical conditions

Medicare pays for the following services when your doctor prescribes them as medically necessary to treat an illness or injury:

  • Part-time or intermittent skilled nursing care
  • Physical therapy, occupational therapy, and speech-language pathology provided by a Medicare-certified home health agency.
  • Medical social services to help cope with the social, psychological, cultural, and medical issues that result from an illness. This may include help accessing services and follow-up care, explaining how to use health care and other resources, and help understanding your disease
  • Medical supplies and durable medical equipment such as wheelchairs, hospital beds, oxygen, and walkers. For durable medical equipment, Medicare pays 80 percent of approved amount and you pay 20 percent.

There is no limit on how long you can receive any of these services as long as they remain medically necessary and a doctor reorders them every 60 days. There also is no requirement for your condition to improve, or for improvement to be expected.

To prevent further decline due to medical conditions

In some cases, Medicare also covers ongoing long-term care services to prevent further decline for people with medical conditions that may not improve. This can include conditions like stroke, Parkinson’s disease, ALS, Multiple Sclerosis, or Alzheimer’s disease.

Hospice care

Medicare covers hospice care if you have a terminal illness, are no longer seeking a cure, and you are not expected to live more than six months. With hospice care, Medicare covers drugs to control symptoms of the illness and pain relief, medical and support services from a Medicare-approved hospice provider, limited respite care, and other services that Medicare does not otherwise cover, such as grief counseling. You may receive hospice care in your home, in a nursing home, or in a hospice care facility. Medicare also pays for some short-term hospital stays and inpatient care for caregiver respite.

Resources for additional Medicare information or help:

Last modified on 02/18/2020
For more information – www.longtermcare.gov or www.acl.gov

Ask Your Legislators to Put an End to the Observation-Status Loophole

Currently, Medicare beneficiaries who are not officially admitted to a hospital may be classified under “observation status,” which is treated as an outpatient procedure for billing purposes. Unfortunately, the common practice of placing a beneficiary on observation status can have significant financial consequences for Medicare beneficiaries since Medicare Part A and its related coverage rules only apply to actual inpatient care admissions. This may lead patients, many who are extremely sick and may need skilled nursing care, to spend many days in the hospital and be charged for services that Medicare would have otherwise paid had they been admitted. Furthermore, hospitals have up to one year to retroactively change admission status to observation, leading unsuspecting beneficiaries with thousands of dollars in bills for SNF care they believed would be covered by Medicare.

Click Here to View The Complete Article

How do Medicare Advantage Plans work?

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare.  If you join a Medicare Advantage Plan, you still have Medicare.  These “bundled” plans include  Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare drug coverage (Part D).

Find Medicare Advantage Plans in your area.

Covered services in Medicare Advantage Plans

Most Medicare Advantage Plans offer coverage for things Original Medicare doesn’t cover, like some vision, hearing, dental, and fitness programs (like gym memberships or discounts). Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.  Learn more about what Medicare Advantage Plans cover.

Rules for Medicare Advantage Plans

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:

  • Whether you need a referral to see a specialist
  • If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

These rules can change each year.

Costs for Medicare Advantage Plans

What you pay in a Medicare Advantage Plan depends on several factors. In many cases, you’ll need to use doctors and other providers who are in the plan’s network and service area for the lowest costs. Some plans won’t cover services from providers outside the plan’s network and service area. 

Learn about these factors and how to get cost details.

Drug coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that:

  • Can’t offer drug coverage (like Medicare Medical Savings Account plans)
  • Choose not to offer drug coverage (like some Private Fee-for-Service plans)

You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:

  • You’re in a Medicare Advantage HMO or PPO.
  • You join a separate Medicare Prescription Drug Plan.

How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans

Medigap policies can’t work with Medicare Advantage Plans. Learn about your options related to Medigap policies and Medicare Advantage Plans.
Click here for statistics – Click Here
For More Medicare information go to – Medicare.gov

Center for Medicare & Medicaid – CMS Fraud Prevention Initiative

The federal government has made important strides in reducing fraud, waste and improper payments across the government. The Affordable Care Act provided additional resources and tools to enable the Centers for Medicare & Medicaid Services (CMS) to expand its efforts to prevent fraud, waste and improper payments. The same innovative tools are being used to further enhance collaboration with our State and law enforcement partners in detecting and preventing fraud.

Using tools provided under the ACA, CMS has used a multifaceted approach, ranging from provider screening to the use of predictive modeling technology similar to that used by credit card companies that has saved nearly $60 billion during 2013-15. This equates to an average savings of $12.40 for each dollar spent on these program integrity efforts.

Guard Your Card Campaign

The CMS “Guard Your Card” campaign tells people how they can protect themselves against fraud by:

  • Never giving out their Medicare or Social Security Number to anyone except those you know should have it.
  • Reporting any suspicious activities like being asked over the phone for their Medicare/Social Security number or banking information. Medicare will NEVER call you uninvited for this information.
  • By checking their billing statements and reporting suspicious charges. Using a calendar to track doctor’s appointments and services helps quickly spot possible fraud and billing mistakes. Check claims early by logging into mymedicare.gov.

Please report suspicious activities by calling 1-800-MEDICARE (1-800-633-4227).

Help Prevent Fraud – Click Here
The 4Rs on Fighting Fraud – Click Here

Extra Help with Part D

What is Extra Help with Medicare prescription drug plan costs? Anyone who has Medicare can get Medicare prescription drug coverage. Some people with limited resources and income also may be able to get Extra Help with the costs — monthly premiums, annual deductibles, and prescription co-payments — related to a Medicare prescription drug plan.

Click here for more details.

Are COVID-19 vaccines covered by Medicare?

Vaccines are getting increasingly more available. Are you wondering how it will be coverage if you have Medicare?  Administration and vaccine cost are covered by Part B of Medicare.

For more information CLICK HERE

Note
Medicare Advantage Plans can’t charge copayments, deductibles, or coinsurance for clinical lab tests to detect or diagnose COVID-19.

Stay up to date & more information on COVID-19 & Medicare. CLICK HERE

What Is A Serious Illness?

It is never easy for a patient to receive a diagnosis with a serious illness. Patients and their loved ones must navigate treatments, planning, setbacks, and numerous challenges while dealing with complicated emotions and fears. Recognizing the difficulties of serious illness, health insurance providers have set out to help, support, and ease the journey for patients, caregivers and loved ones. Ensuring access to tools, education, and services for patients and their loved ones during a difficult time can provide the opportunity to plan, allow patients to maintain their dignity and choice, and support loved ones to know their role and how best they can help.  

Click Here For More Information

Trends of enrollment and demographics of Medicare Supplements plans.

What Is Medicare Supplement? Medicare Supplement (also known as Medigap) is a key source of additional coverage for Medicare enrollees to further protect their health and financial security. Seniors purchase Medigap coverage to protect themselves from high out-of-pocket costs not covered by traditional Medicare, to budget for medical expenses, and to avoid the confusion and inconvenience of handling complex bills from health care providers. 

Click Here For More Information

Premiums for Part B & Part D for 2021

Part B – Premium and IRMAA* (*Income-related monthly adjustment amount)

Part B covers 2 types of services

Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.

Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

Some people automatically get Medicare Part B (Medical Insurance), and some people need to sign up for Part B. Learn how and when you can sign up for Part B.

If you don’t sign up for Part B when you’re first eligible, you may have to pay a late enrollment penalty.

Click here for cost of Part B – https://www.medicare.gov/your-medicare-costs/part-b-costs

Part D – IRMAA
All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDs. Information about a plan’s list of covered drugs (called a “formulary”) isn’t included in this handbook because each plan has its own formulary. Many Medicare drug plans and Medicare health plans with drug coverage place drugs into different levels called “tiers” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.

https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans

Deloitte: Medicare Advantage plans that don’t embrace telehealth ‘will get left behind’

COVID-19 has dramatically accelerated the adoption of digital health, and a new analysis from Deloitte finds that trend extends similarly to Medicare Advantage (MA) beneficiaries.

Deloitte researchers surveyed executives at MA plans, as well as digital health companies, and found that through April 2020 more MA members used telehealth than did so in all of 2019.

Through April, 26% of beneficiaries said they used telehealth or had a virtual visit for any reason, compared to 13% saying the same across all of 2019.

As open enrollment for Medicare continues, insurers that are embracing digital are getting a leg up on the competition, the analysis found.

“COVID has been a game changer. None of this was table stakes six months ago,” the Medicare sales lead at one MA plan said. “As we go into the next open enrollment, if you don’t have telemedicine, you’re going to hurt.”

Sarah Thomas, managing director of Deloitte’s Center for Health Solutions, told Fierce Healthcare that members are taking notice of plans that operate with an “old-school approach” to technology.

The interest among beneficiaries extends to digital ways to enroll in new plans in lieu of meeting a broker in person, Thomas said.

“There’s a significant and growing portion of people who are beginning to expect to get enrolled virtually,” she said.

The researchers also found that providers, who are critical partners in growing the use of these benefits, are also “surprised” by how effective these tools are.

Deloitte analysts surveyed physicians prior to the pandemic and found that these tools were making their work more efficient and a bit easier. They’re also finding it an effective way to deliver care in many circumstances, Thomas said.

“We have a primary care provider-centric view of technology. That’s our tech strategy,” the chief technology officer at one plan told Deloitte. “We arm our PCPs with as much tech as possible. The best product or tool to engage the seniors are the PCPs.”

The pandemic’s impact on digital health has included insurers’ supplemental benefits that target MA members’ social determinants of health. The Centers for Medicare & Medicaid Services allowed MA plans to make midyear adjustments to their supplemental benefits, which provided the opportunity to offer members a smartphone for virtual visits and other options that harness the virtual space.

RELATED: Why Papa, Humana think it’s crucial to ‘make noise’ about the impacts of loneliness amid COVID-19 

Insurers pointed to several key areas where they’ve focused amid the pandemic: transportation, home drug delivery, food and nutrition and social isolation. All of these get at one of the main challenges under COVID-19: the push for people, especially populations at high risk like seniors, to stay home to avoid exposure.

MA plans are offering transportation benefits to assist members in getting to their doctor’s office or to buy groceries and are also partnering with local food banks and other services to provide food delivery.

In addition, they’re offering programs to provide companionship and help members secure medications from their homes, according to the report.

The demands of the pandemic have taken these concerns from “the back seat to the passenger seat,” according to the report.

“The direction and the emphasis on digital—there is no turning back,” Thomas said. “Health plans that are sort of waiting on the sidelines and hoping to be a fad follower will get left behind.”

Full article – https://www.fiercehealthcare.com/payer/deloitte-medicare-advantage-plans-don-t-embrace-telehealth-will-get-left-behind