Project for Help Spot Medicare Fraud

The Basic Steps

Step 1: Review the Medicare Summary Notice (MSN)

Every quarter, Medicare sends enrollees a Medicare Summary Notice (MSN) summarizing claims for health care services that Medicare processed for that enrollee during the previous three months. The MSN includes details on health services received, how much Medicare paid on behalf of the enrollee and any additional amount the doctor or other health care providers are allowed to bill.

Medicare Summary Notices are not the easiest documents to understand. AARP has a “decoder” that explains each entry, code, figure, and column so you know what it means and what you should do if you spot something that doesn’t look right. Check out the Part A and Part B explanations at www.aarp.org/healthtools (under Medicare Summary Notice Decoders). You’ll also find helpful the Tip Sheet in this guide for “What to Look for in an MSN.”

You don’t have to wait for the mailed statement. MSNs are also online at www.myMedicare.gov. It is easy to help someone set up an account for any time access to claim information. Just follow the instructions. New claims information is typically reported within 24 hours of processing.

Step 2: Recognize Errors or Possible Fraud

Now it’s time to check your loved one’s calendar to make sure he or she saw the doctor on the dates listed on the MSN. Ask for any statements, bills, or other papers he or she got when leaving the doctor’s office. Check to make sure the dates, services and billing codes match. If they don’t have any paperwork, help them contact the doctor to ask for a statement that includes the billing codes. If they didn’t see that doctor, didn’t receive the specified medical service or equipment, or didn’t get the listed treatment in a hospital, clinic or other facility, they may be the victim of identity theft or fraud.

Your friend or loved one will need to be comfortable sharing personal information about his or her health with you. Determine if you are the right person to help here. Also, you should not copy, keep, or share with others any of medical information you learn. Important laws are in place to protect everyone’s right to privacy about their medical issues and they need to agree to the release of their medical information to others.

If the discrepancy doesn’t appear to be a mistake, it’s not up to you to determine if it is or isn’t fraud. Just take the next step.

Step 3: Investigate Discrepancies

To resolve discrepancies between the MSN and your loved one’s records, start by helping them contact the doctor, hospital or other health care provider who filed the claim. It could be a simple mistake or a clerical error. If this is the case, the provider who filed the claim with the mistake should report the error to Medicare. The correction will appear on a later statement. You could also follow up by checking your friend’s account at www.myMedicare.gov.

If the discrepancy doesn’t appear to be a mistake, it’s not up to you to determine if it is or isn’t fraud. Just take the next step.

Step 4: Report to Authorities

Call Medicare at 1-800-MEDICARE (1-800-633-4227). In fact, any time you have questions about something that doesn’t seem right about an MSN and which the doctor doesn’t resolve, call Medicare. If you’d rather write a letter on your friend’s behalf, send it and a copy of the MSN to the address in the box on the front of the MSN, explaining what you think is wrong.

You can also call your local Senior Medicare Patrol (SMP). SMP volunteers can answer your questions, help work out solutions to problems, or assist you in filing your report. You can find the SMP in your area at www.smpresource.org.

If you speak to someone at either office, ask for clear instructions on:

  • When you or your loved one can expect to hear back
  • What to do if you don’t hear back

Senior Medicare Patrol (SMP) volunteers can answer your questions, help work out solutions to problems, or assist you in filing your report.

If it appears that your friend or loved one's Medicare number may have been stolen, ask:

  • Whether he or she should continue to use the current Medicare number for health care services. If not, ask how he or she should obtain or pay for services while the investigation is ongoing.
  • Whether you or your loved one should contact any of his or her healthcare providers regarding the suspected fraud or theft.

Step 5: Commit to Follow Up

Make a note on your calendar and your loved one's calendar reminding you both of the follow-up date promised by Medicare (or the date you were told to check back). This will help ensure the issue ultimately gets resolved.

Step 6: INSPIRE OTHERS ON CREATETHEGOOD.ORG

KEEP UP THE GOOD!

Visit www.CreateTheGood.org for a range of opportunities to use your life experience, skills and passions to benefit your community.