Category Archives: Medicare Benefits

Detroit Patient Recruiter Sentenced to 30 Months

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Last week, Santiago Villa-Restrepo, who plead guilty to conspiracy to commit health care fraud in November 2011, was sentenced to 30 months in Prison and has been ordered to repay nearly $3 million, with the assistance of his co-defendants.

Villa-Restrepo plead guilty to providing kickbacks to Medicare recipients who took part in medical tests at several Detroit based medical clinics. Medicare recipients allegedly signed forms stating they had undertaken treatment from these clinics and, in return, received case from Villa-Restrepo and his co-defendants.

The owners of these clinics are also charged, were allegedly complicit in this crime, which resulted in around five and a half million dollars in Medicare fraud. While Villa-Restrepo was not convicted until November 2011, the Medicare fraud dated back to 2007.

Villa-Restrepo faced up to 10 years in prison when he was originally convicted.

12 New Yorkers Charged in Almost $100 Million Medicare Fraud Scheme

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This week, twelve New Yorker’s were charged with Medicare fraud, which investigators contend was responsible for almost $100 million worth of false Medicare claims. Of those, eleven have been arrested as of last week. Those involved were not all related and were made up of three different groups.

Of those arrested, six were part of a group that operated in Flushing, Queens, who were alleged to be responsible for $12 million worth of fraudulent Medicare claims. These individuals, who included one person who was 85 years old, offered a number of treatments to clients, like massages and other spa like treatments. However, they were billed to Medicare as physical therapy sessions. It was also alleged that in exchange for Medicare account numbers, the defendants would provide free lunches and dance classes. They would then use the Medicare numbers when making fraudulent claims.

In Staten Island, one of the defendants, a fifty-six year old osteopathy doctor named Emma Poroger, allegedly billed Medicare for services like sleep studies, vitamin infusion treatment, and other tests, which were never performed. She is accused of around $13 million in Medicare Fraud.

However, the bulk of the Medicare Fraud allegedly came from a group of five individuals from Brooklyn, who attempted to launder around $70 million generated from Fraudulent Medicare claims. They allegedly used Medicare recipient names to bill for services that were never actually performed, offering money to those whose names were used. This same Medical group, Bay Medical Care, had previously been charged with defrauding Medicare to the tune of $72 million back in 2010.

Medicare Part B Benefits

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Part B Medicare Benefits cover a variety of procedures that are not covered under Part A Benefits. Like other Medicare Benefits, those who are working are able to put off enrolling for Part B Benefits, which are optional, however those who are not working and do not enroll will face a 10% increase in premiums each year.

To Enroll in Medicare, including Part B Benefits, you can visit their site here.

While Part C is used to cover prescription medicine, Part B will cover medication that is given by a doctor. It also covers some doctors visits, x-rays, blood tests, chemotherapy, ambulance transportation, and a number of other outpatient treatments, such as vaccination for the flu.


Durable Medical Equipment

One of the most important parts of Part B Benefits, however, is the coverage of Durable Medical Equipment. Durable Medical Equipment refers to a number of different types of home medical equipment, such as hospital beds and wheelchairs, as well as things like eye glasses, oxygen equipment, and prosthetics.

In most cases, Medicare will cover 80% of the cost of the equipment, with the insured being responsible for the remaining 20%. It is almost always necessary to have a doctors prescription and certain types of equipment will also require a Certificate of Medical Necessity, which is simply a much more detailed prescription that outlines the specific conditions the patient has. Certain equipment will have some extra requirements that the patient must meet, such as someone who wants to have their mobility scooter covered would need to use it all of the time, both at home and away, and not merely when away from home.

While the majority of medical equipment covered under Part B Benefits is covered up to 80%, this is not the case with all types. Lift Chairs, which are basically recliners that act as a standing aid, are one example, as they are only partially covered. They also require a Certificate of Medical Necessity, which among other things, requires that the patient can not stand from any chair in their home. Usually Medicare will be reimbursed for about $300, which covers the cost of the lifting mechanism, but the entire chair is not covered. Getting reimbursement is not always easy either.

Other items, specifically those that involve home modification are not usually covered under Medicare Part B. For example, widening the doorways for a wheelchair user or installing an elevator would not be covered.

Cost of Part B Benefits

A monthly premium is required for those wishing to use Part B Benefits, which is usually around $100. However, since 2007, the premium is also based off of income and whether the insured is married, with a higher income meaning a higher premium and can be as high as $300.

In addition to a monthly premium, the patient must also pay a yearly deductible if they use these benefits, which was around $130 in 2009. There is also a copay required for most items, which is usually 20% of the cost of the item, with Medicare paying the other 80%. However, as stated above, some items, like lift chairs Medicare, are only partially covered under Medicare. However, blood work and other laboratory services are often covered completely. A 15% surcharge is added if the physician is not certified by Medicare.

Medicare Part C Benefits: Medicare Advantage Plans

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Medicare is a socialized insurance program that is funded by the Federal Government and was first established during the 1960’s. Originally, Medicare included two Parts, Part A and Part B, and was both funded and administered over solely by the Government. However, beginning in 1997, a new part of Medicare was added that allowed those on Medicare to opt to use a private insurance plan, instead of the traditional federally run plans. These plans are called Medicare Advantage Plans and are under Part C of Medicare Benefits.

What Are Medicare Advantage Plans?

The idea behind Medicare Advantage Plans is that the actual plan itself is run by private insurance companies. The plans are still funded by the Federal Government, but are actually administered over by the private health industry. Medicare Advantage(MA) Plans, were added onto Medicare as part of the Balanced Budget Act of 1997 and in 2003, Prescription Drug Coverage was added as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Like traditional Medicare Plans, such as Part A Benefits, the insured usually has to pay a premium when using an MA plan. MA plans are also required to cover anything that regular Medicare would, but are given a good deal of leeway in how they implement their insurance program. So, for example, an MMA plan is required to help cover the cost of a doctors visit, but they may require a higher co-pay than traditional Medicare.

Many Medicare Advantage Plans will also cover some things that traditional Medicare does not, in an effort for the Private Insurance Companies to get people to use their programs.

Dangers of Using Medicare Advantage Plans

Since the private insurance companies run MA plans and are allowed to make some changes to what they charge or how they cover certain things, it is important to be very careful when choosing a plan. It is important to compare the benefits and costs of the plans to traditional Medicare, taking into account the needs of the insured. It is also important to compare the different Medicare Advantage Plans available, as they can differ too.

Again, because MA Plans are run by Private Insurance instead of the Government, many patients find that they have difficulty getting items covered and must fight the insurance companies, who are, after-all, out to make a profit. Each year, a great deal of those who signed up for MA plans, wooed by the extra perks, like dental coverage, decide to switch to the Federally run programs, with about a third of these people citing problems getting coverage through the private insurance companies.

Cost to the Taxpayers

In addition to many finding that the for-profit Medicare Advantage Plans do not provide adequate coverage and making claims is often met with resistance from the private insurance industry, these plans are also much more expensive to the taxpayers.

On average during 2005, these plans cost the taxpayers about 12.5% more than traditional Medicare, with the private insurance companies usually earning at least 6% profit.

When you take into account the fact that so many people are dissatisfied with MA plans and the added cost to tax payers, it makes it very hard to support allowing Private Insurance to become involved with Medicare. However, as can be seen from the current health care debate, Private Insurance Lobbyists have a very deep hold on the Senate and the President.

Medicare Part D Benefits-Prescription Medicine

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Medicare went into effect during the mid-sixties and for about forty years, did not provide any real coverage for prescription medicine. This changed on 01 January, 2006, when coverage of prescription medicine was added as a result of the Medicare Prescription Drug improvement and Modernization Act that was passed in 2003, but did not go into effect right away.

Today, Prescription Drugs and Medications are offered as Part D Medicare Benefits, which helps cover the cost of some medications.

Who is Eligible for Part D Benefits?

Enrollment in Part D Benefits is not required and instead is offered as a voluntary plan for those who are eligible to receive Medicare. However, those that do not enroll in it right away when they first become eligible, may face an increase of premiums if they decide to enroll later. Usually, a 1% increase in Part D premiums is added for each month that a patient does not enroll in Part D.

Who Runs Part D Prescription Plans?

While Medicare is, of course, funded federally, Part D is actually run by private insurance companies that are reimbursed through Medicare. There are two basic options, which allow a patient to either enroll in a Medicare Advantage Plan, which will mean that their entire Medicare Benefits will be administered by private insurance companies, or they can opt for a stand-alone Prescription Drug Plan, leaving their other benefits, like Part A and Part B, to be administered by the Government.

It is important to note that Medicare Advantage Plans are given some leniency in how they offer Medicare Benefits. They are still required to cover everything that Medicare Covers, but the private insurance companies are given flexibility in how they offer this coverage. In the end, this means some plans might offer lower co-pays for hospital stays, while offering higher rates on other things like durable medical equipment. As a result, before signing up for a Medicare Advantage Plan, it is imperative to compare its coverage and premiums both to traditional Medicare, as well as other Medicare Advantage Plans.

How Much Does Medicare Part D Cost?

In terms to the cost of premiums and out of pocket expenses, there is a deductible of around $275 that must be met, as well as a limit of about $2,500 that is the ceiling of how much medication will be covered each year. Of this $2,500, the patient must pay 25% or about $625.

After the initial ceiling of $2,500 is reached, the patient then must cover the next $2000 out of their own pocket, but once their total prescription costs is over $4300, Medicare will offer the patient a discount on their generic and brand name medications. Of course, this coverage gap, which is often called the Donut Hole, sneaks up on many patients, who are not completely aware that of the initial $2500 limit.

As a result of the coverage gap, many people find that it is very important to budget their medications throughout the year, paying for less expensive generics out of pocket and only using Medicare for their more expensive medications. This makes a lot of sense when you consider that Target and a few other larger companies often offer $4 generics, which would end up costing a lot more with Medicare.

Are All Drugs Covered by Part D Benefits?

No, only drugs that have been approved by the Federal Drug Administration(FDA) will be covered. There are also a number of medications that have been approved by the FDA, but are not covered by Medicare. This includes barbiturates, drugs like Viagra or those used to induce female fertility, drugs for hair growth, drugs to help with weight loss or weight gain, and prescription strength vitamins.

Problems with Part D Benefits

One of the biggest problems with Part D is that the government is literally not allowed to negotiate the cost of medications with the Prescription Drug Makers. Instead, in what is surely an indication of how important corporate lobbying is, Medicare must pay what ever the prescription drug makers require, even though other organizations, like the Veterans Administration(VA), pay a great deal less for the same drugs.

Also, when you take into account the Donut Hole, which means that Medicare will only cover the first $2500 and then offer assistance for anything over $4500, it ends up leaving the average citizen holding the bag as it were. It also means that if someone spends $4500 a year on medication, the true discount by using Medicare is only 50% of the cost.

There have also been studies that those who use Medicare Advantage Plans are 40% more likely to die than those who use similar plans offered by the VA, in what could be a strong argument against using a for profit health-care system. Source.