Tag Archives: medical

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.

Pork in the Health Care Reform Bill and Medicare

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With the passage of the new senate health care reform bill and its move from a private committee to the public light, now gives analysts some time to see what is in the bill and what pork was added to buy the votes it needed to pass. In terms of Medicare, many people are also concerned that even though there are higher tax rates for Medicare, there will also be cuts to service.

It looks like doctors and hospitals in a number of states will be getting paid more, as senators traded their vote on the health care reform issue in return for pork for their state.

Pork Report: Medicare and Medicaid Bribes

In return for the votes of the Senators from North Dakota, Byron Dorgan and Kent Conrad, an amendment was added to the bill, which requires higher payments from Medicare to hospitals in their state. This amendment, dubbed the Frontier Amendment, will funnel $650 million more into the hands of doctors and hospitals in North Dakota over the next 10 years.

In return for the votes of the senators from Hawaii and Michigan, doctors will also earn more for their Medicare Payments, while also reducing costs for Blue Cross and Blue Shield, a major insurance company, in Michigan.

The votes from Vermont and Massachusetts senators were also similarly won, with larger payments going towards Medicaid. Vermont is expected to take in a $250 million windfall.

There is also an Amendment that will funnel $100 million dollars into one of several prospective states, in order to build a new hospital/research center. While the winner of this bride is not known yet, it was promoted by Senator Dodd, in the hopes of funneling it into his home state of Connecticut.

In what is now being called the “New Louisiana Purchase,” senator Mary Landrieu in Louisiana was paid off with a $300 million expansion to Medicaid Funding.

While there is still much to review, it is clear that the Pork was effective, securing the necessary votes to pass what is being referred to as health care reform. Despite these big payouts to increase payments to doctors and hospitals, there are still a number of cuts to Medicare Funding, including some reductions in how Medicare Advantage Plans will be paid.

While there are certainly a number of good points to the Health Care Reform Bill passed by the Senate, it ultimately ends up forcing people to buy into private insurance companies, while providing few mechanisms to actually ensure that the private insurance companies do not simply raise their premiums.

All of the good in this bill could have been made without funneling money into the corporations, who indecently spent around $700 million bribing our political leaders for the last two years. However, they do not work for us, so we will get reform in the sense of raising bonuses for the health insurance CEO’s.

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 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