Premera Medicare Advantage

Posted by:  :  Category: Medicare

Premera offers Medicare Advantage plans in several Washington counties with coverage effective Jan. 1, 2014. The plans are available in Snohomish, King, Pierce, Thurston, and Spokane counties for Medicare-eligible individuals who have Medicare Parts A and B and are:
Source: onehealthport.com

Sequestration Does Not Mandate 2% Medicare Advantage Plan Reduction to be Forwarded to Contracted Providers

Physical therapists and other health care providers that contract with Medicare Advantage plans should check their agreements to make sure their payments aren’t erroneously being cut by 2% as part of sequestration. CMS clarified in a May 1 memo to Medicare Advantage organizations and others that sequestration does not mandate a 2% reduction of reimbursement to Medicare Advantage plan contracted providers. Medicare Advantage plans themselves are subject to the 2% reductions; however, Medicare Advantage plans cannot pass along sequestration cuts to providers unless their contracts with specific providers permit the pass-through. If providers determine that their contracts don’t permit these cuts, they should consider challenging the reductions as contrary to their participation and network agreements.
Source: apta.org

Medicare Supplement Plan F

Posted by:  :  Category: Medicare

* A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
Source: bcbsil.com

Medicare Supplement Insurance Quote Engine

In addition to Medicare supplement insurance, we are pleased to be participating in the Medicare Advantage market. The Medicare Advantage policy is a low cost alternative to a Medicare supplement policy and is especially advantageous for those less than 65 years old. The Private Fee For Service (PFFS) is a type of Advantage plan that allows Medicare recipient to visit any doctor, any hospital, anywhere. Therefore, many Medicare recipients are well served by the lower cost Private Fee For Service plan.
Source: bestmedicaresupplement.com

Compare Medicare Advantage & Supplemental Plans

Medicare Advantage insurance is offered by private insurance companies with a Medicare contract, and replaces Original Medicare Part A and Part B. You must continue to pay your Part B premiums. Medicare Advantage plans typically offer additional benefit options and have less cost-sharing than Original Medicare, and you may have to pay a monthly premium in return for the extra benefits. Medicare Advantage plans come in a variety of formats, such as HMO, PPO and PFFS plans, as well as special needs plans. Medicare beneficiaries can enroll in Medicare Advantage plans if they have Medicare Part A and Part B, but only during designated enrollment periods. These enrollment periods change from time-to-time, so please call us to get the most-up-to-date information.
Source: medicaresolutions.com

Boomer Benefits Medicare Supplements

Our caring agents provide lifetime claims service for your policy. This means when claims occur, you are not alone. You will have our experts on hand to help you sort through your statements, and even assist with appeals if necessary.
Source: boomerbenefits.com

Best Medicare Supplement Insurance Quotes

Every Medicare supplemental insurance plan must follow federal and state laws designed to protect you. Medicare supplement plan insurance companies can only sell you a “modernized” Medicare supplemental insurance plan identified by letters A through N. Each modernized Medicare supplemental insurance plan must offer the same basic benefits, no matter which insurance company sells it.
Source: medicaresupplementplans.com

Congresswoman Chellie Pingree

Posted by:  :  Category: Medicare

A bill backed by Congresswoman Chellie Pingree that would begin to develop a national strategy for addressing the problem of babies who sufferdrug withdrawal symptoms as soon as they are born passed the U.S. House tonight.  The number of infants who start life with drugs in their system is rising quickly in Maine, increasing by 500% between 2005 and 2012.
Source: house.gov

Medicare Beneficiaries as a Percent of Total Population

Data indicators about private plans participating in the Medicare Advantage program and the Medicare prescription drug program. The Medicare Health and Prescription Drug Plan Tracker enables users to monitor trends in enrollment, market penetration and other topics for Medicare Advantage plans since 1999 and stand-alone Medicare drug plans since 2006 by state, county and other sub-state geographies.
Source: kff.org

Medicare & Medicaid Cost Report l Owner Administrator Forum Seminar

Posted by:  :  Category: Medicare

Medicare Training & Consulting, Inc., was founded by Jim Plonsey in the Chicago area. After training Medicare auditors for Blue Cross Association, Jim established a business training Medicare auditors. This lead to doing cost reimbursement seminars for providers, most notably, home health agencies. Medicare Training & Consulting, Inc. has become a leader in providing Owners and Administrators with the reimbursement strategies.
Source: medicareconsulting.net

Getting Paid: Billing Medicare for Diabetes Self

Copyright © 2001 by the American Academy of Family Physicians. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.
Source: aafp.org

Medicare Billing: Wheelchairs, Scooters, Lift Chairs

We understand that the process of submitting claims to Medicare can be difficult and time consuming. To help make the process easier, SpinLife offers what is known as “courtesy billing”. This means that after you purchase an eligible product from SpinLife and request at checkout that we courtesy bill Medicare, we send you all of the documentation required by Medicare for you to complete with your physician. Once medically qualifying documentation is submitted into SpinLife, we can submit a claim to Medicare on your behalf. If your claim is approved by Medicare, they will reimburse you directly for their portion of your claim via mail.
Source: spinlife.com

Medicare Billing of Audiology Services

For treatment of auditory processing disorders or auditory rehabilitation/auditory training (including speech-reading or lip-reading), 92507, and 92508 are used to report a single encounter with “1” as the unit of service, regardless of the duration of the service on a given day. These codes always represent SLP services. See Pub. 100-02, chapter 15, sections 220 and 230 [PDF, 1.6MB] for SLP policies. These SLP evaluation and treatment services are not covered when performed or billed by audiologists, even if they are supervised by physicians or qualified NPPs. For evaluation of auditory rehabilitation to instruct the use of residual hearing provided by an implant or hearing aid related to hearing loss, the timed codes 92626 and 92627 are used. These are not “always therapy” codes. Evaluation of auditory rehabilitation shall be appropriately provided and billed by an audiologist or speech-language pathologist. Also, these services may be provided incident to a physician’s or qualified NPP’s service by a speech-language pathologist, or personally by a physician or qualified NPP within their scope of practice. Evaluation of auditory rehabilitation is a covered diagnostic test when performed and billed by an audiologist and is an SLP evaluation service covered under the SLP benefit when performed by a speech-language pathologist.
Source: asha.org

Medical billing CPT modifiers and list of medicare modifier.

Code 80163 (Digoxin; free). Industry Recommendation: Crosswalk to Code 80162 (Digoxin). CMS Recommendation: Crosswalk to Code 80162 (Digoxin). Rationale: CMS agrees with the commenters recommending the crosswalk to Code 80162,based on similarities in function. Code 80165 (Valproic acid (dipropylacetic acid); free). Industry Recommendation: Crosswalk to Code 80164 (Dipropylacetic acid (valproic acid)). CMS Recommendation: Crosswalk to Code 80164 (Dipropylacetic acid (valproic acid)). Rationale: CMS agrees with the commenters recommending the crosswalk to Code 80164, based on similarities in function. Code 81246 (FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836)). Code 81288 (MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis). Code 81313 (PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer)). Industry Recommendations: Various crosswalks to other Tier 1 codes. CMS Recommendation: Gapfill. Rationale: As we have done with past molecular codes, our final recommendation is that this series of new Tier 1 molecular pathology codes be gapfilled for 2015. This will allow CMS and its contractors the opportunity to gather current information about the manner in which the tests are performed and the resources necessary to provide them, so that ultimately CMS can set an appropriate payment rate for these tests. Codes 81410 through 81471 (21 codes) Industry Recommendation: Various crosswalks to other codes or gapfill. CMS Recommendation: Gapfill. Rationale: As we have done with past molecular codes, our final recommendation is that this series of new Tier 2 molecular pathology codes be gapfilled for 2015. This will allow CMS and its contractors the opportunity to gather current information about the manner in which the tests are performed and the resources necessary to provide them, so that ultimately CMS can set an appropriate payment rate for these tests. Code 0006M (Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier). Code 0007M (Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a namogram of tumor disease index). Code 0008M (Oncology (breast), mRNA analysis of 58 genes using hybrid capture, on formalinfixed paraffin-embedded (FFPE) tissue, prognostic algorithm reported as a risk score). Code 81519 (Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score). Industry Recommendations: Gapfill. CMS Recommendation: Gapfill if the Medicare contractor determines the code is payable. Rationale: The above codes have been classified beginning in 2015 as Multianalyte Assays with Algorithmic Analysis (MAAA). However, we do not believe there is a single consistent definition for a MAAA that allows us to make a categorical determination of whether these codes constitute diagnostic laboratory tests. The Medicare Administrator Contractor will continue to consider each individual test that is classified by the CPT as a MAAA for coverage and payment. Code 83006 (Growth stimulation expressed gene 2 (ST2, Interleukin 1 receptor like-1)). Industry Recommendation: Crosswalk to Code 82777 (Galectin-3). CMS Recommendation: Crosswalk to Code 82777. Rationale: CMS agrees with the commenters recommending the crosswalk to Code 82777, based on similarities in function. Code 87505 (Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets). Industry Recommendation: Crosswalk to code 87631 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 3-5 targets). CMS Recommendation: Crosswalk to code 87631. Rationale: CMS agrees with the commenters recommending the crosswalk to Code 87631, based on similarities in function. Code 87506 (Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets). Industry Recommendation: Crosswalk to Code 87632 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 6-11 targets). CMS Recommendation: Crosswalk to Code 87632. Rationale: CMS agrees with the commenters recommending the crosswalk to Code 87632,based on similarities in function.
Source: medicalbillingcptmodifiers.com

Medicare Billing for Well Woman Exam

1. Cervical High Risk Factors a. Early onset of sexual activity (under 16 years of age) b. Multiple sexual partners (five or more in a lifetime) c. History of a sexually transmitted disease (including HIV infection) d. Fewer than three negative pap smears within the previous 7 years 2. Vaginal Cancer High Risk Factors: DES (diethylstilbestrol) exposed daughters of women who took DES during pregnancy 3. Personal History of Health Hazards: If a patient has a specified personal history presenting hazards to health then apply the V15.89 diagnosis and the appropriate health history hazard (example: V10.3 History of Breast Malignancy).  Any V15.89 diagnosis is considered high risk and makes the patient eligible for the yearly G0101 and Q0091.
Source: capturebilling.com

Compare Medicare Advantage & Supplemental Plans

Posted by:  :  Category: Medicare

Medicare Advantage insurance is offered by private insurance companies with a Medicare contract, and replaces Original Medicare Part A and Part B. You must continue to pay your Part B premiums. Medicare Advantage plans typically offer additional benefit options and have less cost-sharing than Original Medicare, and you may have to pay a monthly premium in return for the extra benefits. Medicare Advantage plans come in a variety of formats, such as HMO, PPO and PFFS plans, as well as special needs plans. Medicare beneficiaries can enroll in Medicare Advantage plans if they have Medicare Part A and Part B, but only during designated enrollment periods. These enrollment periods change from time-to-time, so please call us to get the most-up-to-date information.
Source: medicaresolutions.com

Compare Medicare Supplement (Medigap) Plans and Rates in Your Area

Posted by:  :  Category: Medicare

"Times have changed since my mother had an AARP J plan and I was totally confused by the options available. Stan walked me through the process in a very educational, methodical, friendly way, and I feel secure now that we’re making the correct decision to provide the best possible coverage for my husband." – Pat K.
Source: medigap360.com

Medicare Supplement Plans & Quotes

Turning 65 is stressful, and the amount of information people receive leading up to their birthday is astounding. From the stacks of mail piling up on your desk, to the seemingly endless phone calls and quotes from insurance companies and agents, the task of gathering honest, unbiased information can feel impossible. Our goal is to offer what nobody else will, which is why we provide medicare supplement quotes, financial ratings, benefit information, application fee data, price history, and pricing methodology for all supplemental insurance companies in one clean, concise report. Our free, no obligation service is designed to give you the information you need regarding Part D and Medicare Supplement Plans in order to make an educated purchasing decision. In addition, we offer continued support for all of our customers to ensure they have no claims or billing issues. On an annual basis we review all medicare supplement insurance quotes and plan options in an effort to notify our customers of any new or better plans that may be available.
Source: medicaresupplementshop.com

Your Medicare Supplemental Insurance Information

Every Medicare Supplemental insurance policy, in order to be designated a “Medicare supplemental” or “Medigap” insurance plan, plan has to follow federal and state laws designed to make the buying process easier for the consumer. Medigap insurance companies can only sell you a “standardized” Medigap policy identified by letters A, B, C, D, F, High-Deductible F, G, K, L, M and N. Each standardized Medigap policy must offer the same basic benefits, no matter what insurance company sells it. Cost is usually the only difference between Medigap policies sold by different insurance companies. (You should, however, compare insurance companies on other measures such as customer service and reputation.)
Source: medicaresupplemental.com

Medicare Supplement Plans

To be eligible to enroll in a Medicare Supplement plan, you must be enrolled in both Medicare Part A and Part B. The best time to enroll in a plan is during the Medigap Open Enrollment Period, which begins on the first day of the month that you are both age 65 or older and enrolled in Part B, and lasts for six months. During this period, you have the guaranteed issue right to join any plan of your choice, meaning that you may not be denied coverage based on any pre-existing conditions. If you miss this enrollment period and attempt to enroll in the future, you may be denied coverage based on your medical history.
Source: ehealthinsurance.com

Compare Medicare Advantage & Supplemental Plans

Medicare Advantage insurance is offered by private insurance companies with a Medicare contract, and replaces Original Medicare Part A and Part B. You must continue to pay your Part B premiums. Medicare Advantage plans typically offer additional benefit options and have less cost-sharing than Original Medicare, and you may have to pay a monthly premium in return for the extra benefits. Medicare Advantage plans come in a variety of formats, such as HMO, PPO and PFFS plans, as well as special needs plans. Medicare beneficiaries can enroll in Medicare Advantage plans if they have Medicare Part A and Part B, but only during designated enrollment periods. These enrollment periods change from time-to-time, so please call us to get the most-up-to-date information.
Source: medicaresolutions.com

Compare Medicare Supplement Plans 2015Compare Medicare Supplement Plans 2015

With ever increasing numbers of people turning 65 and needing Medicare health care benefits, the choices are numerous. Is a Medicare Supplement plan the best option, or perhaps a Medicare advantage plan? Several people have turned to supplemental insurance for Medicare Part A and Part B and have been extremely happy with their coverage. We’ll help you to compare Medicare Supplement Plans in 2015 so you can choose the best coverage to fit your needs, as well as not overpay for it.
Source: comparemedicaresupplementplans2015.com

Medicare Supplement Insurance Quote Engine

In addition to Medicare supplement insurance, we are pleased to be participating in the Medicare Advantage market. The Medicare Advantage policy is a low cost alternative to a Medicare supplement policy and is especially advantageous for those less than 65 years old. The Private Fee For Service (PFFS) is a type of Advantage plan that allows Medicare recipient to visit any doctor, any hospital, anywhere. Therefore, many Medicare recipients are well served by the lower cost Private Fee For Service plan.
Source: bestmedicaresupplement.com

Medicare Supplemental Insurance

Finding the best Medicare Supplemental insurance, Medicare Advantage, and Medicare Part D has gotten more complicated nearly every year. In 2010 Medicare Supplement Insurance added 2 new plans Medigap plan N and Medigap Plan M. At the same time they eliminated several other Medicare Supplement options. Medicare Advantage insurance plans redefine benefits and premiums every year. And, with future Medicare subsidies uncertain due to changing regulation from healthcare reform who can keep up. For many individuals Medicare Supplement Insurance is becoming the best option. Unfortunately, comparing Medicare Supplemental Insurance Plan premiums (Medigap) and Medicare Advantage plans can be a time consuming endeavor. Our highly trained insurance advisors can explain all of your supplemental Insurance options, and assist in finding the best Medicare supplement and Medicare Part D combination that best fits your specific needs. With all the options affecting Supplement insurance and Part D it makes sense to have an expert assist you through the maze.
Source: mysenioradvisorsgroup.com

Medicare.gov – the Official Government Site for Medicare – Complaint Form

Posted by:  :  Category: Medicare

Please note that this tool is for non-critical complaints. If your issue needs to be addressed within 10 days, you should call 1-800-MEDICARE (1-800-633-4227). 1-800-MEDICARE is available 24 hours, 7 days a week, including some federal holidays. TTY/TTD users can call 1-877-486-2048. Selecting the ‘Continue Form’ button will change your answer from “Yes” to “No” for the question “Does your complaint or concern need to be addressed within 10 days?”. Selecting the ‘Exit Form’ button will navigate you to a page instructing you to contact Medicare over the phone.
Source: medicare.gov

Compare Medicare Advantage & Supplemental Plans

Posted by:  :  Category: Medicare

Medicare Advantage insurance is offered by private insurance companies with a Medicare contract, and replaces Original Medicare Part A and Part B. You must continue to pay your Part B premiums. Medicare Advantage plans typically offer additional benefit options and have less cost-sharing than Original Medicare, and you may have to pay a monthly premium in return for the extra benefits. Medicare Advantage plans come in a variety of formats, such as HMO, PPO and PFFS plans, as well as special needs plans. Medicare beneficiaries can enroll in Medicare Advantage plans if they have Medicare Part A and Part B, but only during designated enrollment periods. These enrollment periods change from time-to-time, so please call us to get the most-up-to-date information.
Source: medicaresolutions.com

Medicare Advantage, Medicare Advantage Plans

Aetna Medicare is an HMO/PPO/PDP plan with a Medicare contract. Enrollment in Aetna Medicare depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.
Source: aetnamedicare.com

Medicare Advantage Plans By State, Plan Comparison

Coventry Health Care* is a Coordinated Care plan with a Medicare contract. Enrollment in our plans depends on contract renewal. Coventry Health Plan of Florida, Inc. also has a contract with the Florida state Medicaid program. Coventry Health Care of Missouri has contracts with the Missouri state Medicaid program. HealthAmerica also has a contract with the Pennsylvania state Medicaid program. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. Our dual-eligible Special Needs Plans (DSNPs) are available in Florida, Missouri and Pennsylvania to anyone who has both Medical Assistance from the state and Medicare. Premiums, copays, coinsurance and deductibles may vary based on the level of Extra Help that you receive. Please contact the plan for further details. Our dual-eligible Special Needs Plans (DSNPs) are available to anyone who has both Medical Assistance from the State and Medicare. You must continue to pay your Medicare Part B premium. The Part B premium is covered for full-dual members where DSNP plans are available. This information is available for free in other languages. Please call Coventry Health Care at 1-877-988-3589, 8 a.m. to 8 p.m., seven days, from October 1 – February 14; 8 a.m. to 8 p.m. Monday – Friday, from February 15 – September 30. Medicare beneficiaries may also enroll in Coventry plans through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. *Coventry Medicare Advantage plans are offered by Coventry Health Care, Inc.’s licensed affiliated companies, which include Altius Health Plans, Inc.; Coventry Health Plan of Florida, Inc.; Coventry Health Care of Georgia, Inc.; Coventry Health Care of Illinois Inc.; Coventry Health Care of Iowa, Inc.; Coventry Health Care of Louisiana, Inc.; Coventry Health Care of Missouri, Inc.; Coventry Health Care of Nebraska, Inc.; Coventry Health and Life Insurance Company; Coventry Health Care of Kansas, Inc.; Coventry Health Care of Texas, Inc.; Coventry Health Care of West Virginia, Inc.; First Health Life & Health Insurance Company; HealthAmerica Pennsylvania, Inc.; and HealthAssurance Pennsylvania, Inc.
Source: coventryhealthcare.com

Medicare Plan Finder for Health, Prescription Drug and Medigap plans

The page could not be loaded. The Medicare.gov Home page currently does not fully support browsers with "JavaScript" disabled. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available.
Source: medicare.gov

Extra Help with Medicare Prescription Drug Plan Costs

Posted by:  :  Category: Medicare

Medicare beneficiaries can qualify for Extra Help with their Medicare prescription drug plan costs. The Extra Help is estimated to be worth about $4,000 per year. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia.
Source: socialsecurity.gov

Medicare Advantage Insurance Costs

Medicare Advantage plans, also known as Part C plans, are provided by private insurance companies that are contracted by Medicare. Each of these companies has the option to price its plans differently, though each Medicare Advantage plan must offer at least the same amount of coverage as Original Medicare (Part A and Part B). Plans that offer additional coverage such as vision, dental, and prescription drug coverage are more likely to charge higher out-of-pocket costs. Certain types of Medicare Advantage plans may require that beneficiaries use in-network providers or they will not share in the costs of services. In general, Medicare Advantage plans require more cost-sharing than Original Medicare.
Source: ehealthinsurance.com

Medicare Cost Savings Programs

The SLMB program provides payment of Medicare Part B premiums only for individuals who would be eligible for the QMB program except for excess income. Income for this program must be more than 100% of the FPL, but not exceed 120% or 135% of the FPL.
Source: mo.gov

Healthcare Whistleblower Cases, Tycko & Zavareei, Healthcare Fraud

Posted by:  :  Category: Medicare

A number of laws, including the so-called Stark laws and Anti-Kickback laws, generally prohibit the giving of money or other financial incentives (such as gifts) to doctors or hospitals in exchange for referrals or for the prescription of particular pharmaceuticals or supplies. These rules are intended to assure that doctors and other healthcare providers make decisions for their patients based solely upon medical necessity, and not because of some unlawful financial gain. Violations of the Stark and Anti-Kickback laws can result in false claims because, when a provider submits a claim to Medicare or Medicaid, the provider certifies that it has not violated these laws. Thus, if a healthcare provider is receiving kickbacks or is involved in an unlawful financial arrangement, the provider is also violating the False Claims Act, and could be subject to a qui tam lawsuit.
Source: fraudfighters.net

Another whistleblower suit alleges Medicare Advantage fraud

Whether her claims hold up in court or not, Silingo’s lawsuit is likely to draw further attention to government oversight of Medicare Advantage plans. The health plans, an alternative to standard Medicare, are mostly run by private insurance companies. They serve more than 15 million Americans, or about one in three elderly and disabled people on Medicare, at a cost to taxpayers that could reach $160 billion this year. The plans are paid based on a “risk score,” which estimates how sick patients are.  Medicare pays higher rates for sicker patients.
Source: publicintegrity.org

LabCorp Cheats Medicare, Costs Billions, Whistleblower Suit Alleges

This summer, the California state attorney general announced a $49.5 million settlement with LabCorp after allegations that it, and other labs, had overcharged the state’s Medicare program while providing kickbacks to doctors, hospitals and clinics that referred MediCal patients. In May, the attorney general settled with Quest Diagnostics for $241 million in what a press release describes as the same alleged practice.
Source: huffingtonpost.com

Whistleblower Says Medicare Advantage Plans Padded Charges In Home Visits : Shots

A 2014 Center for Public Integrity investigation found that home visits skyrocketed, even as federal officials struggled to prevent health plans from overcharging Medicare by tens of billions of dollars every year. Federal officials as early as 2013 were concerned the home visits could be a factor in jacking up risk scores improperly and wasting tax dollars. But when the industry objected, the officials backed off a proposal to limit the use of home visits, the investigation found.
Source: npr.org

How to report Durable Medical Equipment fraud (DME fraud) against Medicare and obtain a whistleblower reward

There are many fraudulent schemes by durable medical equipment (DME) companies. One durable medical equipment fraud (DME fraud) schemes consists of providing unnecessary equipment. Another Medicare DME fraud scheme is not supplying the medical equipment at all or providing it to a person not eligible for Medicare or Medicaid. Other durable medical equipment fraud (DME fraud) schemes include paying kickbacks or referral fees for patients. Still, other durable medical equipment fraud (DME fraud) schemes include upcoding or billing for a different and/or more expensive equipment than provided. Each of these fraudulent schemes will be briefly described followed by how to report durable medical equipment fraud (DME fraud) and how to apply for a reward for reporting DME fraud.
Source: howtoreportfraud.com

Whistleblower: Medicare Advantage Padded TX Charges

The private insurance plans offer seniors an alternative to standard Medicare, which pays doctors for each service they render. Medicare Advantage plans receive a set fee monthly for each patient based on a risk score that pays higher rates for sicker people and less for those in good health. Medicare essentially trusts health plans to report these risk scores accurately. The Medicare Advantage plans have grown rapidly in recent years, and now cover almost 17 million people.
Source: texastribune.org

Medicare Advantage plans padded charges on home visits, whistleblower says

The private insurance plans offer seniors an alternative to standard Medicare, which pays doctors for each service they render. Medicare Advantage plans receive a set fee monthly for each patient based on a risk score that pays higher rates for sicker people and less for those in good health. Medicare essentially trusts health plans to report these risk scores accurately. The Medicare Advantage plans have grown rapidly in recent years, and now cover almost 17 million people.
Source: publicintegrity.org