Norma Kop, Director of Hawaii’s Senior Medicare Patrol (SMP) joins producer/host Coralie Chun Matayoshi to discuss how to protect yourself from Medicare fraud, errors and abuse, what to look for on your bills, and benefits of volunteering for SMP.
Q. Medicare is a broad and complicated health insurance program that serves almost 19% of the U.S. population (or 67.5 million people). Bills are paid electronically through a network of contracted intermediaries that handle millions of claims from various regions of the country, so mistakes do happen, and unfortunately, so does abuse. What is the Senior Medicare Program or SMP and how severe is the problem of Medicare fraud, errors and abuse?
SMP is a federal funded, volunteer program nationwide with the District of Columbia, Guam, Puerto Rico, the Virgin Islands to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education. Keep in mind:
• 10,000+ Americans turn 65 each day and become eligible for Medicare.
• 12.2 million Medicare-Medicaid enrollees in the U.S.
• Medicare has a solvency issue, much like a checkbook with limited funds to keep it going.
Here at home:
• Hawaii continues to lead the U.S. in average life expectancy – 80.7 years.
• Since 2020, 1 in 4 Hawaii residents is 65 or older. This population is growing at a rate of 17% and by 2030, will represent 1/3 of Hawaii’s total population.
• In 2017, Hawaii had 246,000 people eligible for Medicare. In 2037, this group will grow to over 500,000.
• We value ‘ohana here. On the flip side, there may be a lot of guilt and blame that comes when our older adult loved ones are victims to scams. SMP Hawaii wants everyone to know, “please, don’t shame and blame grandma or Dad…” We are all at risk of becoming the next victim. Contact SMP Hawaii for help.
The severity of the problem is that the Medicare program loses an estimated $60 billion every year to false claims submitted by medical professionals who bill for office visits, procedures, supplies, or equipment that: was never provided or received; not medically necessary; not ordered by your personal physician; or uses a higher billing code to get a larger reimbursement. Prevention education is the best defense in the fight against healthcare fraud and abuse. Mistakes can happen, but when there is malicious intent to commit fraud, SMP gets involved and works with state and federal partners such as the U.S. Office of Inspector General, Federal Trade Commission, and State Attorney General’s Office to investigate suspected cases of fraud. Typically, people pay their medical bills upon receipt to avoid late payment fees. SMP Hawaii encourages older adults to first check their medical statement for accuracy. The billing statement details may be difficult to understand. That’s when trained SMP Hawaii counselors can help by working with clients and doctor’s offices to resolve issues, saving everyone time and money.
Q. How can you detect billing errors?
To ensure integrity in the billing process, Medicare issues a Medicare Summary Notice (MSN) every three months if you have received care or services under traditional (original) Medicare during that period. Original Medicare also publishes a document online at https://www.cms.gov/ that allows you to research various services to determine if you are being charged appropriately, as many charges are bundled in the fee paid for the visit itself.
If you are enrolled in Medicare Advantage an Explanation of Benefits (EOB) is sent every month you have received care. Both show services rendered, what Medicare paid, other payments that may have been already paid such as deductibles and copays, and the amount you now owe. Advantage Plans also publish an Evidence of Coverage document to research the appropriateness of the charges. Recognize that services provided outside the physician’s office may be billed with additional costs. Also, physicians who oversee patients in a hospital setting will likely bill separately. Many such billings may appear in MSN notices months after the actual date of services as these providers frequently use outside billing departments that run months behind! This can also be an issue with Advantage Plans, especially out of network charges. It pays to know your plan and what is included and what is not. Look for this when reviewing these statements:
- Beneficiary – is the name of the beneficiary, correct? It could be someone else’s bill.
- Service or product – did you actually receive the service (e.g. doctor or hospital visit) or product (e.g. durable medical equipment like a wheelchair, prescription drugs). Keeping records of your visits and items received makes it easier to detect a possible billing error.
- Dates - are the dates accurate?
- Multiple billings - were you billed more than once for the same date of service?
- Appropriate care - was it part of the care your physician spoke to you about?
Q. A big problem, not just for seniors, is unexpected medical bills from out-of-network providers for example, in an emergency situation like when you have to go to the closest ER.
Fortunately, Medicare has some protections in place. See https://www.medicareresources.org/glossary/balance-billing/. For everyone else, there’s a federal law called the No Surprises Act that went into effect in 2022 and although it doesn’t apply to Medicare or Medicaid because there are already protections in place to prevent “balance billing,” the law does protect people who have most types of health insurance from unexpected out-of-network medical bills. See: https://www.cms.gov/medical-bill-rights/know-your-rights/using-insurance#notice-and-consent-may-cause-surprise-bills.
Q. What kinds of problems has your program helped with?
A Hilo man received a bill from a medical clinic in Oahu for a COVID-19 screening test and two outpatient visits. Fortunately, the Hawaii County Office on Aging helped him sort through the bill and found that he shouldn’t have been billed for the free COVID test.
A senior was charged over $10,000 for a dental procedure under a new plan that she did not clearly understand. Because this was more of a case about being misled, Senior Medical Patrol referred the case to the State Department of Commerce and Consumer Affairs Regulated Industries Complaint Office (RICO) which opened an investigation and ultimately helped her get back the $10,000.
When in doubt, please do some research. If you still believe there is an error, contact the provider first as there may well be justification for the charge. If you need more help or aren’t satisfied with what you discover, please contact our sister program, Hawaii SHIP, which stands for the State Health Insurance Assistance Program. Like SMP, there is a SHIP in each of the 50 states, the District of Columbia and the U.S. territories of Guam, Puerto Rico and the Virgin Islands. Go to http://www.hawaiiship.org or call: Oahu: 808-586-7299, Toll Free: 1-888-875-9229.
If there are still concerns or you suspect fraud, contact SMP Hawaii to help resolve the matter. We focus primarily on Medicare fraud, errors and abuse; and on occasion, will refer a non-healthcare case or alleged scam to the appropriate agency. Our website: smphawaii.org, Email: info@smphawaii.org. Oahu: 808-596-7281, Toll Free: 1-800-296-9422. [See SMP Facts and Stats]. Our sister program, Hawaii SHIP (State Health Insurance Assistance Program) is the go-to source for free, confidential, and objective counseling on Medicare. Visit Hawaii SHIP at: http://www.hawaiiship.org for reliable Medicare counseling.
Q. What are the benefits of volunteering for SMP Hawaii?
- Provides “local/on the ground” help for neighbor island residents and volunteers. Volunteers have a personal stake in helping their family, friends, and community.
- Keeps the mind active with continued learning. In-person trainings enhance learning, content retention, and peer learning, and dedication. You can stay informed of the latest Medicare updates, scam trends, and other topics.
- Volunteering can help you to Stay healthy and independent. Encourages stronger connections to avoid social isolation leading to depression. Build new friendships with people who have similar interests.
- Maintains physical health to stay independent, help others keeps the spirit fulfilled, stay independent while having friends to watch out for one another, learn to maximize your Medicare benefits, learn to advocate for change with issues that impact older adults, builds self confidence and trust in your judgment and abilities, improves skills (technical, computer, communications, time mgmt., problem solving), provides a sense of purpose to minimize stress and symptoms of depression and anxiety.
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Disclaimer: this material is intended for informational purposes only and does not constitute legal advice. The law varies by jurisdiction and is constantly changing. For legal advice, you should consult a lawyer that can apply the appropriate law to the facts in your case.