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Seniors may be susceptible to participating in grey area fraud – my term.
Many seniors routinely have their toenails trimmed under Medicare. It’s a covered expense but only under certain medical conditions like a diabetes complication, but it’s convenient, less costly than a pedicure and many podiatrists are willing to oblige.
Physical therapy is unlimited under Medicare as long as it is necessary for existing conditions and there is progress treating a condition. But hey it feels good. Providers have no incentive to deny a script for visits.
Ears clogged with wax? You doctor will remove it and Medicare will pay. How do I know, my wife has it done a couple of times a year when she can’t hear well. In the past by a ENT specialist, but now by a group PA. However, here is what Medicare.gov says:
“Medicare only covers procedures deemed to be medically necessary. Ear wax removal does not usually fall into that category. In fact, Original Medicare benefits do not provide coverage for any hearing exams or hearing aids. This means that all ear wax removal procedures will need to be paid for out of pocket.”
We have never paid OOP. How does that happen? The secret is in the procedure and diagnosis codes. And our Medigap picks up the 20%. The PA now says avoid her services and buy a kit in the pharmacy – of course.
Medicare covers non-emergency medical transportation (NEMT)
NEMT vehicles are usually vans that can accommodate patients in wheelchairs or who need extra help getting in and out. Medicare will only cover the cost of taking you to the closest appropriate facility. Medicare generally doesn’t cover routine trips from home to the doctor. But there is great temptation especially with a willing provider. One ambulance service was found allowing patients to ride up with the driver.
By far this kind of fraud is small potatoes.
Any claim filed on your behalf with or without your knowledge will generate a claim report and Explanation of Benefits (EOB). According to Medicare you will be able to see a claim in your account within 24 hours. Paper EOBs take a few months. Part D plans send a EOB monthly.
Reviewing your online account may spot fraud for services you didn’t receive, and will give you an accurate amount you may owe.
Never pay a health care provider- Medicare or not – until your claim has been fully adjudicated. If you see something questionable question it and report it.
Months after I had surgery a few years ago I noticed a $5,000 claim for assistant surgery denied by Medicare and indicating patient responsibility. I was getting ready to do battle because I wasn’t paying it. I was never billed, they were just rolling the dice against Medicare.
Using your online account is also a good way to keep track of your health visits and procedures.
Like with all health care, Medicare beneficiaries need to be involved every step of the way from first doctors visit forward.
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