Fraud, waste and abuse cost the Medicare program $48 billion in 2010, affecting one in 10 claims, according to the Government Accountability Office (GAO). It comes in many forms, but has one thing in common: We all pay for it through higher costs. That's a powerful reason why everyone should help identify, report and prevent fraud.
Both the government, which administers Original Medicare, and private health plans, which contract with the government to administer Medicare Advantage and Prescription Drug Plans, are getting better at detecting and preventing fraud, waste and abuse, according to Edward Stubbers, vice president of compliance for Anthem Blue Cross's senior products. In the past, these organizations paid claims first and chased fraud later, but that's rapidly changing.
Stubbers said the industry has begun incorporating the latest technology from the banking industry to catch fraud, waste and abuse earlier. "Have you ever gone on a spending spree only to get a call from your credit card company that same day to make sure your card wasn't stolen?" Stubbers asked. "In the same way, health plans have begun detecting claims that might be out of the ordinary to stop fraud before it happens."
But even with these technologies, the frontline of defense against Medicare fraud is still the individual member. In addition to wasting taxpayer dollars, medical fraud can disrupt members' lives, damage their credit ratings and corrupt their health history. Stubbers offers the following tips for helping members recognize fraud quickly and prevent it:
Guard your insurance information. Safeguard your insurance and/or prescription drug card, just like you would your credit card. If someone calls or visits asking for your insurance information, don't give it to them, even if they claim to be with a health plan or Medicare. Report a lost or stolen card immediately.
Don't fall for illegitimate offers. Many health care thieves target their victims with offers of cash or other rewards. For example, someone may offer you cash for the use of your insurance or drug card or for switching to another plan. This is illegal. Don't do it. Additionally, be suspicious of anyone who offers you free medical equipment or services and asks for your card number. Remember the old adage: "If it sounds too good to be true, then it probably is."
Make sure you get all your medication. When you visit your pharmacy, make sure that you get all of your medicine. That means if your doctor ordered 30 pills, then you should get all 30 -- and not just 25. Also make sure you get the drug the doctor ordered, and not another, unless your physician allowed for generic substitutions.
Check your receipt. When you go to the grocery store, chances are you check your receipt to make sure you weren't overcharged. Medicare members get a receipt, too. It's called an Explanation of Benefits (EOB). Always check the services and drugs listed on your EOB to make sure you actually received them. Large criminal operations have been brought down thanks largely to alert individuals who caught fraudulent charges on their statements. Examples of fraud include being billed for services you did not receive, being charged by a provider you did not see or being billed for dates you were not there. Always call your provider first to make sure the error wasn't an honest mistake. In most cases, you also can go to your health plan's website to view your claims history.
Report suspect charges immediately. If you think you have been the victim of Medicare fraud, you should report it immediately by calling Medicare 24 hours a day, 7 days a week, at 1-800-633-4227 (1-800-MEDICARE) TTY: 1-877-486-2048, visiting Medicare's website at www.medicare.gov or contacting your health plan at the number on your ID card.
"Most people who work with Medicare program are honest," Stubbers said. "Unfortunately, a few are not. These outliers end up costing us all billions of dollars each year in fraud, waste and abuse so it pays to be vigilant."
This information is intended for educational purposes only and should not be interpreted as medical advice. Please consult your health care provider for advice about treatments that may affect your health.
A health plan with a Medicare contract.
A stand-alone prescription drug plan with a Medicare contract.
Darrel Ng is the PR Director for Anthem Blue Cross.