December 1999 Bulletin

How to respond to HHS, AARP fraud campaign

By Laura Nuechterlein

Earlier this year, the Department of Health and Human Services (HHS), along with the American Association of Retired Persons (AARP), launched a publicity campaign targeting Medicare fraud and abuse. AARP is the nation's largest senior citizen's advocacy organization.

The campaign, entitled "Who Pays? You Pay," encourages Medicare beneficiaries to be alert to possible fraud and abuse by physicians and other health care providers. Beneficiaries are asked to examine their Medicare statements for billing of services that were not provided, billing for services or supplies more than once (double billing), or billing for services that are not relevant to the patient's diagnosis and/or treatment plan.

If a charge appears questionable and the patient is uncomfortable speaking with the provider or unsatisfied with the answers the provider gives, he or she is encouraged to contact a Medicare fraud hotline. The Health Care Financing Administration (HCFA) also is offering monetary incentives if an individual reports fraud and consequently, an action is taken against a provider because of that information.

Physicians across the country, led by the American Medical Association and specialty society organizations, are greatly concerned that this campaign will weaken the physician-patient relationship and that it is not based on any real evidence of fraudulent billing practices among physicians. Government estimates of fraud and abuse in the Medicare system have declined almost 50 percent between 1996 and 1998, and HCFA officials acknowledge their statistics cannot distinguish between actual fraud and billing errors.

In addition, physicians believe that monetary rewards for Medicare recipients who report fraud and abuse may encourage frivolous inquiries and investigations.

These concerns notwithstanding, orthopaedic surgeons should expect an increase in billing inquiries from their Medicare patients. In fact, HCFA now requires that notices be sent with Medicare statements advising beneficiaries that they have the right to an itemized statement if they request it. If requested, physicians have 30 days to supply the statement or face civil penalties of $100 per day thereafter for non-compliance.

Nevertheless, physicians can protect themselves from potential investigations and audits by answering inquiries from Medicare beneficiaries, keeping accurate Medicare billing records and providing itemized statements for all services billed to Medicare if requested. The Academy also recommends that orthopaedic surgeons supply Medicare patients with a letter asking the patient to call his or her office with any billing questions (see the accompanying example). Lastly, physicians should educate themselves about government efforts to eliminate fraud and abuse in the Medicare program, such as the False Claims Act, the Stark self-referral statutes, and the Health Insurance Portability and Accountability Act (HIPAA). Information about these statutes can be found in the Federal Health Policy section of the Academy's home page

(Following is a suggested letter to Medicare patients about fraud and abuse. Fellows are encouraged to modify this letter to suit their purposes.)

Dear Patient:

If you are a Medicare recipient and have questions or problems regarding fees and/or services on your Medicare statement, please contact me at (physician's phone number) at your earliest convenience. I would be happy to discuss any concerns you may have about your Medicare fees or services provided to you. If you prefer, I can provide you with an itemized statement of fees and services. If you request an itemized statement, please provide my office with your name, address, and the date(s) services were provided.

If, after you receive your itemized statement, you have additional questions or concerns about your bill, please call my office at the above phone number. I would be happy to talk with you personally about fees and services billed to your Medicare account.

As you know, Medicare is extremely complicated. Today, physicians must comply with more than 100,000 pages of Medicare rules and regulations. Physicians are asking the federal government to simplify these regulations and to educate physicians on what we need to do to comply with the requirements. We are concerned about government policies and programs that lump honest billing mistakes together with intentional fraud.

As a result of the complexity of the Medicare program, inadvertent billing errors can occur. If you believe you have found an error, please bring it to my attention. I want to be helpful and answer your questions and concerns.


Laura Nuechterlein is a senior policy analyst in the AAOS health policy department

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