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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. I know a couple who both go regularly to improve balance. Never heard them express a balance concern in fifty years.
Ears clogged with wax? You doctor will remove it and Medicare will pay. How do I know, Connie 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.
“I know a couple who both go regularly to improve balance”.
I don’t know the details, but as a retired orthopedic Physical Therapist I do know that if a patient is being seen for balance issues only, in most cases only a few visits are necessary then the exercises can be performed independently at home.
The way they describe it, it sounds like a regular social event for two bored seniors.
“I know a couple who both go regularly to improve balance. Never heard them express a balance concern in fifty years.”
Unnecessarily snarky.
First, people don’t have balance concerns at 30 or 50. They do at 70. Gee, maybe that’s why these folks are only expressing it now.
Second, many people don’t have balance concerns until their hip actually hits the stairs. Falls shorten lives. Dramatically. Wise of this couple to address the issue in advance. Preserving balance is a lot easier than recovering it once lost.
And third, physical therapy ain’t exactly Swedish massage. Most of the time it doesn’t “feel good” at all. I’ve had a fair amount due to my athletic background, and I’ve found it ranges from merely uncomfortable to downright painful.
But they wouldn’t be using it if they had to pay for it or even half of it. There are a lot of things medically necessary, that suddenly aren’t if there is a bill. Can’t afford it? Not the case.
if there are long term benefits and I agree there are, seems like a worthwhile investment of our own money, but that’s not how we think or the system works.
This is our own money.
This couple and their employers have paid Medicare taxes during their entire working lives. So they already paid for this benefit.
Making use of available benefits that keep us and society healthier isn’t fraud. It’s wisdom. And delivering “medically necessary” benefits that people otherwise would not (or could not) pay for is the reason Medicare exists.
Making use of available benefits when medically necessary is the purpose of Medicare or any insurance. Adhering to medically necessary is the key and there are strong incentives for both patients and providers to press the matter.
Medicare does not do pre-certification, medical necessity review or even a post care review. That’s why it takes so long for them to uncover actual fraud.
No, it’s not our money – unless you stop receiving coverage when what you paid is used up in claims. It’s all workers and retirees money.
FICA taxes don’t pay a penny toward Part B only Part A Medicare. Part B is all general revenue and Medicare premiums by participants, so no, it is not our own money.
“Medicare does not do pre-certification, medical necessity review or even a post care review.”
This statement is not true. The center for Medicare Services ie CMS has criteria for many tests, surgical procedures, and durable medical equipment (DME) such as c-paps, wheelchairs etc. I know as for several years I worked a contract for administration of NH Medicaid and I performed medical necessity reviews for DME.
I must also say that for the most part I agree with the criteria.
As an example my wife’s PCP recommended a bone density test purely based on her age. I googled the CMS criteria (it is available to anyone for review) and she did not meet any of the criteria.
But we did go through with the test knowing that we would most likely pay out of pocket via our HSA.
General revenue, by which presumably you mean taxes, and Medicare premiums are “our own money”.
If everyone used benefits to the extent of “their money” no insurance would be affordable.
There is no entitlement created by insurance beyond the intended protection outlined, which with medical always includes medical necessity.
However, nobody wants that questioned or challenged which is why people complain about insurance. On the other hand, they would complain even louder if premiums reflected a no medical necessity review policy.
And helping people stay healthy saves money. The “fee for service” model, based on fixing things that have gone wrong, is more expensive in the long run than “whole person” medicine that aims to keep people functioning.
Well, that’s the theory, but even if it’s true, where is the logic f someone else having to pay to keep me healthy. You would think that staying healthy would be a motivator itself.
Years ago the big thing in business was wellness program of various type. Even financial incentives. We were going to save money by keeping people healthy.
It was never substantiated by data this occurred.
Very true. Your balance starts to deteriorate as early as 40-50, although it may take a while to become apparent. In addition, the older you are, the more damage you are likely to do to yourself if you fall. Damage that is expensive to fix, and may leave you permanently compromised. I am now taking tai chi classes, partly to improve my balance. My retirement community offers both tai chi and balance classes.
Years ago I read an article that claimed your balance and indeed your overall general health could be evaluated by the ability to stand on one foot for at least 30 seconds. Try it with eyes closed too.
Is there a scientific basis? No idea.
There are multiple tests that show that how long you can stand on one leg can accurately predict your falls risk, I’m not sure about it’s predicting overall health. Also how fast someone walks is an excellent determinant as to fall risk. Generally the faster one’s walking pace the lower the risk, as generally someone who walks slower is more afraid of falls.
Those classes make sense. They have them in our 55+ condo community too, but it’s different than paying for PT under Medicare.
It’s actually “penny wise and pound foolish” for Medicare not to cover hearing aids and glasses. Falls are a major cause of injury and disability for seniors, and untreated vision and hearing loss contribute to the likelihood of falls. (For hearing loss and falls see here.)
Not to mention dementia which the government keeps saying is a huge problem due to the increasing number of seniors being diagnosed.
Medicare Part A trust is going bust. So new revenue needs to be found or payments cut. Medicare can cover anything we want as long as we are willing to pay for it. Problem is we aren’t we just want “government” to pay😎
The podiatrist comes every other month at a family member’s assisted living facility. She can’t clip her toenails anymore after her stroke. She has a MA plan that covers. It is a health issue for her, I think. Chris
Chris, Medicare part B also covers podiatry care for seniors who have certain conditions, like diabetes, arthritis and more. People in nursing homes are often wheel chair bound, have failed eyesight and trembling, rendering them helpless to do many things.
And contrary to what some people think, having toenails cut by a Podiatrist is a far cry from getting a pedicure.
MA can do pretty much as they like as long as they meet minimum Medicare requirement and sometimes state law.
Like with all health care, Medicare beneficiaries need to be involved every step of the way from first doctors visit forward.
Agreed but deciphering provider statements when they are as clear as mud confuses my little brain.
Like Connie, I have my ears cleaned at the ENT office and have never been charged.
My wife, a onetime physician in China, does mine. Has the kit and the headlamp and everything.
Medicare certainly does cover hearing tests, although not hearing aids, just as it covers eye exams but not glasses. See here. Removal of wax is necessary for an accurate hearing test. In fact, if you are having trouble hearing, it may be all that is necessary. Difficulty hearing is now recognized as a danger for seniors.
I have had several hearing tests paid for by Medicare, and I certainly was not gaming the system. I resent the inaccurate implication.
Kathy, I’m giving you an upvote which removes your downvote.
Thank you, Marjorie. I suspect there is someone who always downvotes my posts.
My quote above is from the Medicare.gov website. You need hearing loss for such exams. Isn’t that what your link says? It does not cover routine eye exams, there must be a medical condition.
From my link:
“You can also see an audiologist once every 12 months without an order from your health care provider, but only for:
You wrote: “In fact, Original Medicare benefits do not provide coverage for any hearing exams or hearing aids.” [Emphasis added.]
You were wrong about the exams. Also, you need the wax removed before you can have a hearing test, after which you may not need one.
Medicare covers diagnostic eye exams, but not refraction for prescribing eye glasses, except that it pays for one pair of glasses after cataract surgery.
Better take it up with Medicare. Those are their words not mine. The key is hearing loss.
The overriding concept is medical necessity, but more than that often gets paid simply by the coding applied.