Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
DECEMBER 2003 NICA NEWS
ISSUES
Operation Wheeler Dealer
The Centers for Medicare & Medicaid Services announced a 10-point initiative to substantially curb abuse of the Medicare program by unscrupulous providers of power wheelchairs and other power mobility products who prey on Medicare beneficiaries. The Department of Health and Human Services Office has also begun investigating the proliferation of durable medical equipment (DME) fraud cases involving inflated billings to Medicare, charges for equipment and supplies not delivered, and the falsification of documents to qualify beneficiaries for wheelchairs and other equipment that they often did not need."Spending on power wheelchairs has increased nearly 450 percent over the last 4 years, an unprecedented growth in this benefit," said CMS Administrator Tom Scully. "While many of these wheelchairs are provided by ethical suppliers and go to beneficiaries in need, we know that a great number of unscrupulous suppliers are promising free wheelchairs to beneficiaries who don't need them. We are taking immediate action to stop these scams." Acting Principal Deputy Inspector General Dara Corrigan warned Medicare beneficiaries to be suspicious of offers of "free" scooters and other enticements from unscrupulous suppliers.
Nationally, total Medicare payments for motorized wheelchairs increased from $289 million in 1999 to $538 million in 2001, with payments of over $845 million in 2002, and a projected $1.2 billion for 2003. By contrast, overall Medicare benefit payments rose only 11 percent during that same period. The number of Medicare beneficiaries with at least one claim for a motorized wheelchair rose from just over 55,000 in 1999 to almost 159,000 in 2002, an increase of 189 percent, while the overall Medicare population rose only 1 percent per year during that same time period.
Under the campaign, dubbed "Operation Wheeler Dealer," Medicare will be able to support honest providers and target those who are exploiting the program. CMS will aggressively review applications from companies that seek to provide power wheelchairs to ensure they meet reputable business standards of operation. Other initiatives will clarify rules and provide beneficiaries with information to protect themselves against unscrupulous suppliers.
Private Contracting Physicians
Private contracting physicians are providers who have chosen to enter into private contracts with beneficiaries to provide services normally covered under Medicare. A physician who has chosen to initiate a private contract has chosen to "opt out" of the Medicare program for a period of two years, for all patients and for all services. This means that the physician will not bill Medicare nor receive any payment from Medicare. There are four private contracting physicians in Nebraska: Dr. Eli Chesen, Psychiatry, Lincoln; Dr. Bruce Gutnik, Psychiatry, Omaha; Dr. Abraham Scheer, Neurology, Lincoln; and Dr. James Murphy Jr, General Practice, Omaha. (Manual Pg E17)Home Health Quality Initiative
CMS released new information in early November regarding the quality of care provided by home health agencies across the country. This information is part of an expanding initiative to improve the quality of care given to the millions of Americans who receive home health care. The Home Health Quality Initiative combines information for consumers and their families about the quality of care provided by individual home health agencies with important resources to assist home health agencies working to improve the quality of care in their facilities.The consumer quality data, along with other information about individual home health agencies, is available on www.medicare.gov, and by calling 1-800-MEDICARE. Similar to the Nursing Home Quality Initiative data that was released last fall, beneficiaries and family members should use these resources to help learn more about the quality of care provided by home health agencies they may be considering. Data shows that 12,635 beneficiaries in Nebraska receive home health or hospice care covered by Medicare each year. Beneficiaries and family members searching for a home health or hospice provider in their area can visit the website for the National Association for Home Care and Hospice (NAHC) at www.nahc.org/tango/hclocator/locator.html. This is not a comprehensive list, but it does list agencies that have contacted NAHC to be listed on the site. Other options for finding home health or hospice agencies would be to look in the yellow pages of the phone book, or to ask their provider for what agencies he/she has worked with before. It is important to make certain that the agency be "Medicare-certified" in order to be eligible for Medicare-covered services.
Tricare For Life & Denied Medicare Claims
If Medicare denies a claim under Tricare for Life, Tricare may initially deny it also. Even if the service is otherwise a Tricare benefit. The determining factor is what Medicare has to say about the patient's right to appeal. If Medicare reports on the Medicare Summary Notice that the service is not a Medicare benefit, and the patient has no appeal rights, Tricare will process the claim as if it were the patient's only coverage. Tricare program requirements will apply, as will the Tricare deductible and cost share as required by law. If Medicare advises that the patient has appeal rights, Tricare must deny the claim pending resolution of the Medicare denial.This denial occurs because federal law forces Tricare to be the last payer. All avenues of payment by the primary payer, in this situation Medicare, must be exhausted first. Thus the patient or the provider must file an appeal with Medicare. After Medicare completes the appeal and issues a report, the provider or patient must resubmit the claim to Tricare, including a copy of the Medicare report, because Medicare will not automatically resubmit the claim to Tricare. Tricare will reprocess the claim according to data in Medicare's report and its own program requirements.
Different laws and regulations govern Medicare and Tricare, which may have different program requirements for the same medical service. Depending on a patient's medical condition and the type of service and the information submitted with the claim, the same service could be covered for one patient and denied for another, even under the same program. The essential thing to remember is that any time Medicare or Tricare denies a claim or a portion of a claim, the patient or the provider should file an appeal. Instructions for filing an appeal are on the program's payment statement. (Manual Section K)