Nebraska Department of Insurance

Nebraska Department of Insurance

  Home     Consumer     Producer     Company     About NDOI     Quick Links     Outside Links  


THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

MARCH 2000 NICA NEWS

ISSUES

Ambulance Services

Medicare pays for medically necessary ambulance services only when other methods of transportation would endanger a beneficiary's health. To better achieve this goal, a new rule tightens requirements for determining medical necessity. This rule requires better documentation from ambulance companies, and requires physician certification for non-emergency ambulance services.

Non-emergency, scheduled ambulance services are covered if, before furnishing the service to the beneficiary, the ambulance supplier obtains a written order from the beneficiary's attending physician certifying that the medical necessity criteria has been met.

Other provisions include minimum vehicle and staffing requirements and a definition of "bed-confined." The term, as defined in the rule, applies to a beneficiary who is unable to get up from bed without assistance, unable to walk and unable to sit in a chair or wheelchair.

The new rule allows round-trip ambulance services if medically necessary for beneficiaries with end-stage renal disease from their home to the nearest appropriate freestanding or hospital-based dialysis facility. Prior to this, coverage was only allowed to hospital-based dialysis facilities.

In addition, Medicare, in certain circumstances, will now cover services provided by paramedics who operate separately from an ambulance supplier.

Don't Just Watch for the Ice

We all know to walk carefully on icy roads and sidewalks. But walking-related injuries also stem from sliding and skidding vehicles that may not be able to avoid hitting someone. Be sure to walk in bright or reflective clothing, and be careful when walking near snow piles and drifts that may obscure your view or the view of a vehicle.

FRAUD

Medicare Future More Stable After Fraud Battle

The most surprising surge of savings was generated by the high-profile government crackdown on fraud and abuse. Doctors, hospitals, home health-care agencies, testing laboratories and providers of medical equipment have been forced to pay nearly $500 million to the government for trying to defraud Medicare in 1998 alone. Hospital officials, doctors and other providers are less likely to bend the rules now that their practices are being closely watched by FBI agents, Justice Department prosecutors, and Health & Human Services Department investigators.

The government's health-care fraud program has been in existence since the mid-1980s, but it was not until the 1996 Health Insurance Portability & Accountability Act that it got a steady stream of funding for investigators and attorneys trained in detecting white-collar crime and health-care fraud.

Auditors Cite Vast Medicare Fraud

Congressional auditors say organized criminal groups are increasingly behind Medicare fraud. In the past, the most common type of health care fraud involved medical professionals who rendered legitimate services but padded their bills. Typical of newer, more elaborate scams, are "rent-a-patient" schemes in which teams of recruiters are paid for each person they bring in to act as a sham patient. Those "patients" get a cut of the recruiters' fees. In exchange, some agree to have blood drawn unnecessarily, and Medicare is billed, supposedly for tests. In other cases, the patients simply sell their Medicare numbers to the groups. In another scheme, called a "drop box", front corporations are established using rented commercial mailboxes for an address. These companies obtain Medicare numbers by a variety of means. One, in Illinois, got old patient billing information by purchasing a legitimate medical laboratory, then submitting bills as though the lab was still operating.

Recouping Costs

Improper payments by Medicare - money lost to fraud or money spent for services that weren't medically justified - were reduced to $12.6 billion annually, down nearly half from $23 billion in 1996, according to Justice Department figures.

Some of the cases cited included:

  • An indictment in connection with a scheme in which the mastermind used a large network of bogus nursing groups to submit false Medicare Part A billings for persons not qualified to receive home health services under Medicare.

  • Inflating the mileage an ambulance company charged on claims submitted to the government.

  • Conviction of a psychiatrist who showed patients movies (Lethal Weapon, Ghostbusters, Batman) and then billed Medicare and Medicaid for group psychotherapy services.

  • Receiving kickbacks in exchange for referring Medicare patients to a physician.

  • Falsely billing for services never rendered, fraudulent claims, mail fraud, tax evasion.

  • Double-billing patients, insurance plans, and Medicare for the same procedure.

  • A conspiracy scheme billed Medicare $20 million for catheter-related items that actually were nonreimbursable "diaper kits" used by nursing homes for incontinent patients.

  • Hospital bills miscoded for a rare type of pneumonia diagnoses to receive higher Medicare reimbursement.

Follow these steps if you feel there has been any fraudulent billing.

  1. Call the provider and ask about the bill in question. There may be a simple explanation for an error. You may also find that you have forgotten that you had an extra procedure performed when you were at the physician's office or hospital.

  2. If you don't get the answer that you want or need, call the Medicare number that is listed on your Medicare Summary Notice or Explanation of Medicare Benefits. The Medicare Carrier or Intermediary can explain the charges.

  3. If you still think it is fraud call:
    800-HHS-TIPS

    They will take the information and send it out to the respective office. Keep in mind that every complaint is looked at and taken seriously.

Medicare Fraud costs Medicare lots of money and beneficiaries end up partly paying for these costs in higher taxes, coinsurance, premiums, and deductibles to cover these Medicare losses. Medicare beneficiaries are the best line of defense against fraud, and because of this, The Department of Health and Human Services, the Department of Justice, and the American Association of Retired Persons, have joined together to educate beneficiaries, through a national campaign "Who Pays, You Pay," on how to detect health care fraud. To help prevent Medicare fraud, you should report all suspected instances. Medicare will also give a reward for information that leads to the recovery of Medicare funds from health care providers who engage in unlawful activity.

WHAT CAN YOU DO TO HELP DETECT OR PREVENT FRAUD & ABUSE?

  • Review your Explanation of Medicare Benefits or Medicare Summary Notice.

  • These Medicare statements are not bills, but a summary of services provided and Medicare payments made on your behalf. As you review the summary of charges, consider three very important questions:
    *Did you receive the service or product for which Medicare is being billed?
    *Did your doctor/provider order the service or product for you?
    *To the best of your knowledge, is the service or product relevant to your diagnosis or treatment?

  • Do not give out your Social Security or Medicare number over the phone to anyone.

  • Do not let anyone convince you to see a doctor for services you don't need.

  • Be suspicious that a provider may be attempting to defraud Medicare if any of the following things happen:
    *You are offered free testing or screening in exchange for you Medicare number.
    *You are offered free medical equipment.
    *You are offered money or gifts for medical care.
    *Someone claims to be from Medicare or another branch of the Federal Government and tries to sell you something.

  • Always use your own Medicare card whenever you receive care and/or supplies.

  • Educate yourself about the Medicare program so that you know what benefits the program covers.

  • Ask questions. You have a RIGHT to know about your medical care.
REMEMBER: MOST HEALTH CARE PROVIDERS ARE HONEST. MANY QUESTIONS OR CONCERNS END UP BEING HONEST CLERICAL ERRORS.

Still, these simple errors should be reported.

If you can't resolve your questions with your provider, then contact your Medicare contractor whose phone number is on your Medicare statement.

If you feel further action is needed, call the Medicare fraud hotline: 1-800-HHS-TIPS (1-800-447-8477).

The Pizza Man

Here is some humor you might enjoy:

FBI agents conducted a raid of a psychiatric hospital in San Diego that was under investigation for medical insurance fraud. After hours of reviewing thousands of medical records, the dozens of agents had worked up quite an appetite. The agent in charge of the investigation called a nearby pizza parlor with delivery service to order a quick dinner for his colleagues.The following telephone conversation took place and was recorded by the FBI, because they were taping all conversations at the hospital.

Agent: "Hello. I would like to order 19 large pizzas and 67 cans of soda."

Pizza Man: "And where would you like them delivered?"

A: We're over at the psychiatric hospital."

P: "The psychiatric hospital?"

A: "That's right. I'm an FBI agent."

P: "You're an FBI agent?"

A: "That's correct. Just about everybody here is."

P: "And you're at the psychiatric hospital?'

A: "That's correct. And make sure you don't go through the front doors. We have them locked. You will have to go around to the back to the service entrance to deliver the pizzas."

P: "And you say you're all FBI agents?"

A: "That's right. How soon can you have them here?

P: "And everyone at the psychiatric hospital is an FBI agent?"

A: "That's right. We've been here all day and we're starving."

P: "How are you going to pay for all of this?"

A: "I have my checkbook right here."

P: "And you're all FBI agents?"

A: "That's right. Everyone here is an FBI agent. Can you remember to bring the pizzas and sodas to the service entrance in the rear? We have the front doors locked."

P: "I don't think so."

Click.

Medicine

When a client needs assistance purchasing prescription drugs, the companies listed here may help. These private firms offer discounts on prescriptions. However, neither the Nebraska Department of Insurance nor NICA endorses any of the companies shown.

Each company in this group can be contacted through its toll-free phone number.

  • AARP Mail Order Plan,
    1-800-456-7821

  • Medi-Mail,
    1-800-922-3444

  • Providian Prescription Plan,
    1-800-221-4800

  • Share Pharmacy Program,
    1-800-542-1110
    (Code 110)

  • Save Well Program,
    1-800-474-2583

  • American Preferred Prescription Plan,
    1-800-227-1195
The companies grouped below can be contacted on the internet as well as by phoning toll-free.

Special Prescription Option

Novartis, an Arizona pharmaceutical company, offers (almost) free prescriptions for folks who meet financial and "rare disease" qualifications, under their indigent patients program. Thirty (30) medications are offered through this program. All are life-sustaining, single-sourced medications with no generic forms. They specialize in rare disease medications. An advocate or the patient can apply directly and receive instant-over-the-phone approval. The patient then receives an application to fill out within 7-10 days, accompanied by an ID which can be used immediately at participating pharmacies (most major pharmacies).

The phone number is 1-800-257-3273,
FAX: 480-314-7170,
Address: Novartis Patient Assistance Program,
PO Box 52052
Phoenix, AZ 85072-9170.

Seventh Annual National Senior Health & Fitness Day Set for Wednesday, May 31, 2000

The event is always held on the last Wednesday in May as part of Older Americans Month activities. The event's purpose is to promote senior involvement in physical activity. Activities will be noncompetitive and may include walking events, low-impact exercises, health screenings and infor-mation workshops. If local organizations would like to host an event, they may call 1-800-828-8225 for help with event planning. Seniors should ask local hospitals, senior centers, retirement communities, health departments, Agencies on Aging, etc., if activities are planned in your area. For more information contact the website at www.fitnessday.com.

MEDSUPP CLOSURES

Effective 1/1/2000, Bankers United Life Assurance Company will no longer be issuing Individual Medicare Supplement Plans A, B, C, F, G or I.

Effective 1/1/2000, PFL Insurance Company will no longer be issuing Individual Medicare Supplement Plans A, B, C, F, G or I.

Effective 12/24/99, Principal Life Insurance Company will discontinue all Medicare supplement policy sales in all states.

Effective 12/31/99, Combined Insurance Company of America will no longer be issuing Individual Medicare Supplement Plans A, B, or E.

Effective 12/31/99, Union Fidelity Life Insurance Company, A GE Financial Assurance Company will no longer be issuing Individual Medicare Supplement Plans A, B, or E. Effective 6/1/99, Penn Treaty Network America Insurance Company stopped selling Individual Medicare Supplement Plans A, B, C, E and F.

Effective 12/31/99, Blue Cross Blue Shield of Nebraska has terminated their Blue Senior Select contracts and have offered members currently under these contracts one of the Standard Medicare Supplement contracts.

What happens when a block of business closes?

There will be no new policies sold; consequently, there will not be any new people added to the block of business. As the existing block members age, it is likely that the cost of claims per member will increase.

Therefore, the premium will also increase. Healthy members, seeing the increase in premiums, will be able to switch to a different policy. This decrease in the number of healthy members will also cause the premiums to increase. As those healthy persons move to other policies, the cost of claims per person in the closed block increases.

Theoretically, as policyholders die or switch to cheaper policies, those who remain do so because they cannot obtain coverage elsewhere. When those remaining persons file claims, it causes the premiums to increase further. Eventually, the premiums could exceed the "reasonable" cost of the benefits provided.

As a Seniors Insurance Volunteer, you may wish to let your clients with these policies know the above information. What a policyholder decides to do about changing or not changing should remain his or her own decision.



Contact Us   State of Nebraska   Privacy/Security Policy   Contact Webmaster