Jane Dotson
Medicare and Medicaid are both health insurance programs, but they cater to different groups. Medicare is a federal health insurance program for people aged 65 and above, or those with disabilities. Medicaid, on the other hand, is a health insurance program for people with limited income and resources. While Medicare beneficiaries must notify Medicare when a claim is made against an alleged tortfeasor with liability insurance, Medicare fraud and abuse can occur, and there are steps in place to help prevent, identify, and report such issues. This includes contacting the Statewide Health Insurance Benefits Advisor (SHIBA) or the Senior Medicare Patrol (SMP), or filling out a fraud report form.
| Characteristics | Values |
|---|---|
| What is it used for? | Reporting a case involving Medicare and other insurance |
| Who should use it? | Medicare beneficiaries, through their attorney or otherwise |
| When should it be used? | When a claim is made against an alleged tortfeasor with liability insurance (including self-insurance), no-fault insurance, or against Workers' Compensation (WC) |
| How to report? | Via the Medicare Secondary Payor Recovery Portal (MSPRP) or by contacting the Benefits Coordination & Recovery Center (BCRC) |
| What information is needed? | Details of the case, including the name of the alleged tortfeasor, the date of the incident, and the type of insurance involved |
| What is the process after reporting? | The BCRC will apply the information to the Medicare record and determine the recovery process if Medicare has already made payments |
| Are there any exceptions? | Medicare does not claim a MSP liability insurance-based recovery claim for incidents that occurred before 12/5/1980 |
| What about fraud or abuse? | Beneficiaries can report suspected fraud online or by calling SHIBA at 800-562-6900; they can also take preventive measures, such as keeping receipts and bills and protecting their personal information |
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What You'll Learn
Report Medicare fraud, waste, or abuse
If you believe you have experienced Medicare fraud, errors, or abuse, you can speak to a Statewide Health Insurance Benefits Advisor (SHIBA) volunteer or fill out a fraud report form. SHIBA volunteers can help you understand the different parts of Medicare, assess your needs, and help you enroll in Medicare and assistance programs. They can also provide everyone involved in your care with the information and tools to find and prevent fraud before it happens. If you suspect fraud has already occurred, SHIBA volunteers will help answer your questions and report your concerns to investigators. You can call SHIBA at 800-562-6900 or report suspected fraud online.
To help spot and prevent Medicare fraud and abuse, you can take several precautions. Keep copies of all your receipts and bills. Check your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) regularly to ensure you received all the care listed. Compare the dates and services on your calendar with your Medicare statements to make sure you got each service listed and that all the details are correct. Protect your personal information and become familiar with how Medicare uses it. Know what a Medicare health or drug plan can and can't do before you join. If you join a Medicare health or drug plan, the plan will let you know how it will use your personal information.
If you suspect fraud, you can call 1-800-MEDICARE (1-800-633-4227) or report Medicare fraud online. If you have a Medicare Advantage Plan or Medicare drug plan, you can also call the Investigations Medicare Drug Integrity Contractor (I-MEDIC) at 1-877-7SAFERX (1-877-772-3379). Medicare beneficiaries, through their attorney or otherwise, must notify Medicare when a claim is made against an alleged tortfeasor with liability insurance (including self-insurance), no-fault insurance, or Workers' Compensation (WC). This obligation can be fulfilled by reporting the case in the Medicare Secondary Payor Recovery Portal (MSPRP) or by contacting the Benefits Coordination & Recovery Center (BCRC).
Remember that Medicare will never call you to sell you anything or visit you at your home. Medicare, or someone representing Medicare, will only call and ask for personal information in limited situations (such as an agent or representative returning your call after you've joined a plan, reported fraud, or left a message for Medicare). Do not give your Medicare card, Medicare Number, Social Security card, or Social Security Number to anyone except your doctor or people you know should have it (like insurers acting on your behalf or people who work with Medicare, like your State Health Insurance Assistance Program (SHIP) representatives).
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Notify Medicare of a claim against an alleged tortfeasor
If you are a Medicare beneficiary, you must notify Medicare when a claim is made against an alleged tortfeasor with liability insurance (including self-insurance), no-fault insurance, or Workers' Compensation (WC). This obligation can be fulfilled by either reporting the case through the Medicare Secondary Payor Recovery Portal (MSPRP) or by contacting the Benefits Coordination & Recovery Center (BCRC).
When reporting a case in the MSPRP or contacting the BCRC, you will need to provide the following information:
- Your name, address, and Medicare number
- The name and address of the alleged tortfeasor
- The date of the incident
- A description of the incident
- The type of insurance involved (e.g., liability, no-fault, etc.)
- The policy number and name of the insurance company
- The claim number and date of the claim
- The name and address of the insurance adjuster
- The amount of the claim
Once all the necessary information has been obtained, the BCRC will update Medicare's records. If Medicare is pursuing recovery directly from the beneficiary, the BCRC will issue a Rights and Responsibilities letter and brochure, which will be mailed to all parties associated with the case.
It is important to note that you can fulfil this obligation through your attorney if you prefer. Additionally, contact information for the BCRC can be found by clicking the "Contacts" link on the relevant website.
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File a claim, appeal, or complaint
If you have an issue with a plan's refusal to cover a service, supply, or prescription, you can file a claim, appeal, or complaint. Here's what you need to know about the process:
Filing a Claim
If you have Medicare and need to file an insurance or workers' compensation claim, you must notify Medicare. This can be done through the Medicare Secondary Payor Recovery Portal (MSPRP) or by contacting the Benefits Coordination & Recovery Center (BCRC). Keep in mind that if Medicare pursues recovery directly from the insurer, the Commercial Repayment Center (CRC) will send correspondence to both the insurer and the beneficiary.
Filing an Appeal
If your claim or service is denied, you will receive a "Notice of Adverse Action" letter explaining the denial. You or your authorized representative can file an appeal, either orally or in writing, within 60 calendar days of the denial letter. If you want to continue receiving previously approved services during the appeal process, you must file within 10 calendar days. The appeal will be reviewed by a healthcare professional with appropriate expertise who was not involved in the original decision.
Expedited Appeals
In cases where a delay in resolution could seriously impact the member's life, health, or ability to function, an expedited appeal can be requested. Decisions for expedited appeals are made within 3 calendar days, and verbal notice of any unfavourable decisions is provided promptly, followed by written notice within 2 calendar days.
Administrative Hearing
If you disagree with the appeal outcome, you or your representative can request an Administrative Hearing within 120 calendar days of the appeal decision letter. You may request a quick decision if your health is at risk. After exhausting the appeal and hearing processes, you have the right to seek an independent review within 21 calendar days.
Filing a Complaint
If you have a complaint about Medicare, you can contact your local State Health Insurance Assistance Program (SHIP) to receive free, personalized health insurance counselling. You can also file a complaint anonymously, depending on the type of complaint. Additionally, Washington residents can seek assistance from the Statewide Health Insurance Benefits Advisor (SHIBA) or the Senior Medicare Patrol (SMP) to prevent, identify, and report Medicare fraud, errors, or abuse.
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Report suspected fraud online
If you suspect Medicaid fraud, errors, or abuse, you can report your concerns to investigators in several ways. Washington's Statewide Health Insurance Benefits Advisors (SHIBA) are volunteers who can help you understand the different parts of Medicare, assess your needs, and help you enroll in Medicare and assistance programs. You can call SHIBA at 800-562-6900 or report suspected fraud online. The Senior Medicare Patrol (SMP) is another resource that can help you report suspected fraud. You can call or locate your local SMP online.
The Office of Inspector General (OIG) also accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services' (HHS) programs, including Medicare and Medicaid. You can submit a complaint online or call the OIG Fraud Hotline at 1-800-436-6184. If you suspect a provider of wrongdoing, provide the name and address of the clinic, office, or business they work for, as well as any other information you think might be helpful to an investigator. Your identity and contact information will be kept confidential to the extent permitted by law.
Additionally, if you are aware of a fraudulent website targeting HHS recipients or related to HHS programs, you can report the concern as a cybercrime to the Federal Bureau of Investigations (FBI) or the Texas Office of Attorney General, in addition to the OIG.
It is important to keep in mind that not every submission results in an investigation due to the high volume of complaints received. However, all reports are important, and hotline tips are valuable in helping to identify and prevent fraud.
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Medicare Recovery Process
Medicare's Recovery Process involves several steps and can be quite complex. It is important to understand the various contractors and their roles in the process. The two main contractors are the Benefits Coordination & Recovery Contractor (BCRC) and the Commercial Repayment Center (CRC). The BCRC is responsible for pursuing recovery directly from the beneficiary, while the CRC pursues recovery from the entity providing medical coverage, usually an insurance carrier.
The first step in the recovery process is reporting the case. Once a pending liability, no-fault, or workers' compensation case is reported to the BCRC, they will collect information from various sources, including claims processors, Medicare, and Medicaid, to determine if another insurance is primary to Medicare. If the BCRC determines that another insurance is primary, they will create an MSP occurrence and post it to Medicare's records. The BCRC uses MMSEA Section 111 data to maintain files and manage coordination of benefits for Medicare beneficiaries.
After the BCRC has collected the necessary information, they will identify and recover Medicare payments that should have been paid by another entity as the primary payer. The BCRC will apply a termination date, typically the date of settlement, and will identify any new, related claims. The information sent to the BCRC must clearly include the settlement date, amount, and any attorney's fees or other costs borne by the beneficiary. Settlement information can be submitted electronically using the Medicare Secondary Payer Recovery Portal (MSPRP).
If you are settling a liability case, you may obtain Medicare's demand amount prior to settlement or pay a flat percentage of the total settlement. Interest accrues from the date of the demand letter, and if the debt is not repaid within the specified time frame, interest is assessed for each 30-day period. You may appeal or request a waiver, but interest will continue to accrue. Medicare's final demand amount will account for a share of attorney's fees and costs, and a check must be sent within 60 days to avoid interest.
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