Tag Archives: aging

Medicare Fraud Report

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Medicare, which is Federally Run Insurance/Heath Care System, is one of the most controversial departments of the US Government. It is often ripe with fraud and many in the Health Care Industry feel that Medicare and Medicaid do not pay enough to cover the costs of their service. However, many others, including many of those who are on Medicare, feel that it offers a quality of service that would be unaffordable for many seniors.

Medicare Fraud is actually one of the biggest downsides of Medicare and is something that is constantly occurring. For example, just in the last day, there are about 1000 newspapers articles in the Google News Database that are about Medicare Fraud. Of course, many of these are likely about similar cases, but it serves to illustrate how prevalent this problem is in Medicare.

Medicare Fraud Watch

In Miami, the owner of a Medicare Clinic is facing prison time and will be sentenced today, after submitting $100 million of fraudulent HIV claims and $30 Million in Fraudulent Medicare Claims. This occurred not only in Florida, but also North Carolina, Georgia, South Carolina, and Louisiana. Michel De Jesus Huarte, the owner of the clinic, faces up to 20 years in prison, while six others are also facing prison time.

In California, the owners of a Medical Center that found homeless people and preformed unneeded services on them has been ordered to pay $10 Million. The owners paid people who worked at homeless shelters to act as recruiters, finding homeless people that were on Medicare or Medicaid and paying using them, albeit as employees, in defrauding the government.

In Houston Texas, several individuals who own a durable medical equipment company were just sentenced to repay $36 Million in fines, after they used their position in the home medical equipment industry to bill Medicare for different types of durable medical equipment, like adjustable beds and mobility scooters, which was never actually given to the patient.

Common Types of Medicare Fraud

There are a lot of different types of Medicare Fraud, but more often than not, it is the suppliers of durable medical equipment who are found to be committing these crimes.

Medicare Part B Benefits include the coverage of durable medical equipment, which includes a wide variety of home medical equipment, such as wheelchairs, scooters, and adjustable beds. It also covers glasses, prostheses, and oxygen equipment. In most cases, providing the patient is covered by Medicare and has a prescription for the equipment, Medicare will cover 80% of the cost. There are exceptions to this rule though, such as Medicare Lift Chairs, which are not completely covered. However, for the most part, as long as there is a medical need for the item, Medicare will provide 80% reimbursement for it.

Unfortunately, the home medical equipment industry has always been ripe with fraud, not just with Medicare. This is in part because medical equipment suppliers are not necessarily run by health care professionals or doctors. Instead, they are usually business people who are out to make a profit, which of course leads to abuse. Also, it is much easier to fraudulently sell Medical Equipment than it is to bill for services that are not preformed, so Durable Medical Equipment fraud remains one of the most common types of Medicare Fraud.

Of course, as the examples above illustrate, there are many other types of Medicare Fraud and fraudulent billing is also very common.

The prevalence of this type of dishonest medical billing is one factor that many are using to argue against a state run health care program. However, to be fair, Insurance Fraud occurs all the time in all private insurance as well. However, since most private insurance companies are in the business of denying claims, rather than approving them, Medicare makes an easier target.

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.

Part A Medicare Benefits

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Medicare is an insurance program that is offered and run by the Federal Government, primarily intended for those over 65, although people with certain medical conditions, like acute renal failure, are also covered. Medicare Benefits are divided into 4 Parts, with Part A covering hospital related costs.

Part A Medicare Benefits are primarily intended to cover the cost of overnight hospital stays. The amount of the cost that is covered varies, depending on the length of the hospital stay and will also sometimes cover the cost of temporary stays at a nursing home.

While I the hospital, Part A Benefits extend to all costs, including medical tests, doctors costs, and incidentals, like food and board.

Requirements for Coverage of Semi-Long Term Care
In order for an extended stay at a nursing home or assisted care facility to be covered, it is necessary for the patient to have had a previous hospital stay for the same problem, which lasted at least full days, not including the day the patient was released. Also, the treatment must be for rehabilitation or to help manage a disease in order to be covered. Further, it is imperative that the assisted living facility offers skilled care, meaning that the workers must be registered nurses.

Length of Stay Covered By Medicare

Medicare will usually cover stays of up to 100 days, providing the above requirements have been met. The first 20 days are paid for by Medicare, with the following 80 days requiring a copay of around $134 per day.

If the patient uses their Part A Benefits, even partially, they must wait 60 days before they ca receive another full 100 day hospital stay.

Premiums and Deductibles

Providing the Medicare Recipient has paid payroll taxes for more than 13 years, there is monthly premium to receive Part A Benefits. However, those who have only paid in between 10 and 13 years will need to pay a deductible of $233 and those with less than 10 years paid into Medicare must pay $423 a month to receive Part A Benefits.

The required deductible, however, is the same for both and depends on how long the senior is in the hospital. For example, hospital stays between 1 and 60 days require a deductible of around $1000. After that, it drops down to about $260 per-day for the next 30 days. Then, stays between 91 and 150 days require a $534 deductible per-day. After 150 days, the patient will no longer be able to receive benefits.

If a stay at a skilled nursing facility is required, the patient’s first 20 days are covered by Medicare and there is a $133 deductible after that. Stays must be no longer than 100 days at a skilled-nursing home.

Determine Eligibility for Part A Benefits

To determine if you are eligible for Part A Benefits, you can visit Medicare Site and use their Part A Benefits Eligibility Tool

Falls Disseases and Medicares Role in Treating these Conditions

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In seniors who experience diseases such as arthritis and osteoporosis, it is very important to prevent falls from occurring. This is because a fall, even a very small one, can end up being very serious and result in a fracture. If this happens, it can be very difficult for the senior to recover from the accident and in many cases, it will mean a move to an assisted living situation or nursing home. Often, these stays will be covered by Medicare, but this depends on the patients Medicare Eligibility ad what types of benefits they receive.

With such serious ramifications from even a very small fall, protecting against these types of accidents is very serious.

Why Osteoporosis Can Be Dangerous

Osteoporosis is a disease that is most common among the elderly, but can affect those of all ages. However, usually in younger people, it is caused after some sort of injury. Osteoporosis causes the bones to loose some of their density, which makes them very brittle and prone to fracture. It is caused by a lack of calcium and vitamin D and is much more common in post-menopausal women, although it can also affect males.

Osteoporosis is not itself does not cause injuries, but because the bones begin to become more brittle and loose their density, it is more likely for them to break or fracture, even after a very small fall.

Why Arthritis Can Be Dangerous

Arthritis can cause a number of problems and is not actually just one disease, but rather more than 100 different disorders that primarily affect the bodies joints. While, depending on the kind of arthritis, the effects can greatly vary, typically, arthritis causes the joints to become damaged, inflamed, and tender. This can mean that bending the joints becomes much more difficult and even painful.

Unlike osteoporosis, arthritis by itself can cause the affected person to experience dramatic losses to maneuverability and often results in disability. Arthritis can also greatly increase the risk of a fall and if the senior also has osteoporosis, this means that there will be a much bigger chance of injury.

Protecting Against Falls

To protect against falls, there are several options, but often it is important to first take measures to treat the arthritis and osteoporosis. For osteoporosis, maintaining a healthy diet of foods that contain calcium and vitamin D is important, with most seniors also taking vitamin supplements.

In the case of arthritis, treatment is not always as straightforward and depends on what type of arthritis the patient has. Many times, proper diet and exercise are as important as taking medication when it comes to treating arthritis. It is also very important to find ways to make life easier for the patient, as there is no way to work backwards and reverse the effects of arthritis.

In addition to assuring that there is proper treatment, there are also a number of helper aids that are used by seniors with arthritis and osteoporosis. This includes a number of different types of home medical equipment that is designed to either make life easier or safer for the senior. Having a proper pair of shoes with non-skid soles is very important, as is using a walker or rolling walker, and ensuring that all areas of the home can be easily accessed. Lift chairs are also often used, which are like recliners, but are designed to make it easier for the senior to stand.

Medicare’s Role in Treating Osteoporosis and Arthritis

In addition to actually being important for providing treatment, such as covering the cost of medicine and doctors visits, Medicare also covers the cost of a number of different types of home medical equipment. These items are covered under Medicare Part B Benefits and covers a wide variety of medical equipment, including wheelchairs, walkers, mobility scooters, eye glasses, and much more.

Usually, Medicare will provide 80% reimbursement for these items, but this is not always the case. For example, lift chairs Medicare do not qualify for full reimbursement and instead only part of the cost of the device is covered.

Usually for a device to be covered by Medicare, it must, of course, be on their approved list of items (PDF), but it will also require that the individual has a doctors prescription and sometimes also a Certificate of Medical Necessity. A Certificate of Medical Necessity is similar to traditional prescription, but is more detailed and must describe the reasons the senior needs the type of equipment. Usually, if a doctor feels there is a need to offer the patient a prescription for the device, it is not a problem for them to also fill out a certificate of medical necessity.

What is Medicare?

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Medicare is a health insurance program that was established by the federal government in 1965. It was part of the Social Security Act of 1965, which was signed by President Lyndon Johnson on 30 July, 1965. Arguably, Medicare is a type of socialized medicine, which is administered by the Government, but since the actual medicine and treatment is preformed by private doctors and the governments role is more of as a supervisor, Medicare would technically be a Social Insurance Program.

Those that qualify for Medicare are able to receive reimbursement for their medical costs, including doctors visits and medical equipment, but as of recently, also prescription medication.

How is Medicare Funded

Medicare is paid for by taxes, which are taken out of workers paychecks. Currently, 2.9 percent of a persons income is taken for Social Security taxes, with the employee paying half of this and the employer paying the other half.

Part of the requirements for participating in Medicare, or at least participating without paying extra fees, is that the person has paid enough money into Medicare throughout their life.

Requirements for Medicare Coverage

Medicare is designed primarily to help cover the medical costs of those who are over 65, legal residents of the United States, and have been paying taxes for at least 10 years. However, in certain cases, usually due to disability, Lou Gehrig’s Disease, or renal failure, it may be possible to receive Medicare Benefits before the age of 65.

Currently, congress is discussing allowing those who are over 55 to buy into Medicare Early, as part of the current health care reform that is taking place in Congress. This is, however, still under wraps, so it remains to be seen if this will make it into the final bill and what the buy in cost will actually be.

What is Covered By Medicare?

This is something that I will go into further in my later posts and will update this one as well, but Medicare covers doctors visits, certain hospital stays, many types of home medical equipment, as well as prescription medicine.

However, when you sign up for Medicare, you are given the opportunity to decide what type of coverage you would like to receive. The different types are decided into Parts, such as Part A Medicare and Part B Medicare, and you will usually be given the opportunity to enroll in whichever parts you qualify for.

Those who have insurance through an employer can usually wait on deciding without penalty, but otherwise, adding on coverage later, especially prescription medicine coverage, will have a few hurdles.

In addition to Government Run Plans, it is also possible to sign up for a Medicare Advantage Plan, which is actually run by a private insurance company, but because these are allowed to be slightly different from traditional Medicare, it is imperative to carefully read the plan and compare it to regular Medicare.

How can I Find Out More Information About Medicare?

I would encourage you to check back at this blog regularly, as we will be updating it with more information about how Medicare Works, what Medicare Covers, and current news events.

With that said, one of the best places to find out about Medicare is to visit the official Medicare site. They have a tremendous amount of information for those on Medicare or curious about how it works, including sections to find out Your Medicare Coverage.