For Professionals: Medicare billing, claims and appeals

Still Got Complaints? Here’s Your Guide for Medicare Fraud, Billings and Claims and Part D

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Published: August 2007

Making a complaint and knowing where to file it is crucial for our advocacy efforts in monitoring and improving our Medicare system. Having public access to this information and an effective system to measure accountability and effective action taken by the entities collecting this information is also imperative. As a follow-up to last edition’s newsletter article covering the complaint process concerning physicians, hospitals, skilled nursing facilities, home health care providers, durable medical equipment, pharmacists, and insurance agents, this one reviews:

Again note that the appeals process (when Medicare does not pay for an item or service a beneficiary has been given, or if a beneficiary is not given an item or service they think they should get) is not discussed here. For more information on Medicare Part A, B, C and D appeals, visit our Medicare billing section.

Complaints about:

Medicare fraud

  • Call the beneficiary’s health care provider listed on their Medicare Summary Notice (MSN) and inquire about the item or service in question. In many cases, there's been a billing error, which the beneficiary’s health care provider can easily correct.
  • If a complaint is not resolved in speaking with the provider, contact California Health Advocates' Senior Medicare Patrol (SMP) project. They handle Medicare Part A, B, C, and/or D fraud complaints. They are the easiest and most efficient contact as they will send your complaint directly on to the appropriate Medicare Integrity Unit. They will also send you an electronic notice of acknowledgment on receipt of your complaint and provide follow-up communication as it is received on the progress of your complaint.

    You can mail in or fax complaint information with additional supportive documentation to:

    Anne Gray, SMP Project Coordinator
    California Health Advocates
    Council on Aging of Orange County
    1971 East 4th Street, Suite 200
    Santa Ana, CA 92705
    FAX: 714-560-0319

    To find an SMP project outside of California, use the SMP Locator tool on the national SMP website.
  • You can also contact U.S. Department of Health and Human Services, Office of the Inspector General (OIG) at (800) HHS-TIPS; (800) 447-8477; by fax at (800) 223-2164; or by email at . California Health Advocates' SMP staff can help determine whether this step is necessary.

    If you do submit a complaint to OIG, provide as much identifying information as possible regarding your concern. Such information should include subject's name, address and phone number etc. Details regarding the allegation should include the basics of who, what, when, where, why, and how.

Billings and claims

  • Call 1-800-Medicare. A customer service representative should record your complaint and forward it on to the appropriate contractor (i.e. NHIC for Part B, Noridian for DME, United Government Services or Palmetto for Part A), and the contractor will then follow up with you for more information and to report the results of the complaint.
  • Disputes regarding billing amounts and/or services billed are generally handled with an appeal. See information on Part A, B, C and D appeals.
  • Beneficiaries with complaints about billings and claims can also contact their local Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.

Medicare Part D

  • (Note that using this process for filing urgent complaints is requested by CMS.) To file an urgent complaint, when a beneficiary’s health or life is in serious jeopardy due to an inability to timely secure critical prescription drugs through Medicare Part D benefits, first contact the beneficiary’s specific Medicare Part D Plan customer service department or call center. The Centers for Medicare and Medicaid Services (CMS) has all Part D Plan telephone numbers on their website.

    When calling the plan call center, be sure to say that this beneficiary has “an immediate need that is life threatening.” Tell the plan customer service representative (CSR) that you are the beneficiary’s primary contact (if the beneficiary so authorizes). This will ensure that you receive a notification about actions taken. Otherwise you will need to ask your client about what steps were taken. Allow the Part D Plan 48 hours to take action and resolve the complaint. (Note: if this timeframe is too long for the beneficiary’s safety and securing a beneficiary’s needed medication through visiting another pharmacy, using the Wellpoint/Point-of-Service option, or getting medication samples from their doctor is unsuccessful, get the beneficiary to the nearest hospital emergency room.)

    If you have no resolution in 48 hours, call the plan back to check on the progress made to date.

    If the Plan did not resolve the complaint or take action within these 48 hours, call 1-800-Medicare. Again inform the Medicare CSR that this beneficiary has “an immediate need that is life threatening.” Ask the CSR to specifically enter the complaint into the CMS Complaint Tracking Module. Be sure to tell the Medicare CSR that you are the primary contact for the beneficiary (if beneficiary so authorizes). Provide your unique Medicare CSR number if necessary. Document the information, day, time, and CSR name or ID for future reference. Documentation is very important for future advocacy efforts.

    If the urgent complaint remains unresolved 48 hours after contacting 1-800-Medicare (meaning four days later), contact CMS Region IX by email at ; phone at 415-744-3605; and/or by fax at 415-744-3771.
  • For a complaint about a Part D plan call center providing inaccurate information, first file a grievance with the Part D plan. Information on how to file a grievance is available on each plan’s website. Note that grievances filed with a plan generally stay within that plan; CMS, the plan’s outside regulator, may not be notified of the grievance.

    You can also call 1-800-Medicare and ask the CSR to enter the complaint into the CMS Complaint Tracking Module.
  • For a complaint about a pharmacy that does not use the Point of Service (POS) system to submit a claim on behalf of a dual eligible beneficiary who is not enrolled in a Part D plan, if possible, it may be best to go to a different pharmacy. Find a pharmacy that does use the POS system and have the beneficiary fill their prescriptions there. Pharmacies are not legally required to use this system and therefore the California Board of Pharmacy has no regulatory authority over them regarding this issue.

    You can also provide the pharmacy with information on the POS system and how to use it with the following documents:
  • For complaints about a beneficiary showing enrollment in multiple plans:
    • Contact the beneficiary’s pharmacy to get the history of Part D billing for the beneficiary
    • Contact 1-800-Medicare for the beneficiary’s enrollment history and current enrollment status
    • Reconcile Part D billing with CMS’s record
    • Submit a written request to CMS Region 9, outlining the above attempts and request any required changes in Part D enrollment history, to reflect the history of reimbursements sought by the pharmacy.
    • File a complaint about these erroneous enrollments to 1-800-Medicare.
  • For complaints about a dual-eligible beneficiary who does not show her/his Part D Low Income Subsidy (LIS, also called “Extra Help”) eligibility, first confirm that the beneficiary does have both Medicare and full Medi-Cal.

    Contact the Department of Health Care Services to verify the beneficiary’s Medi-Cal status at 916-636-1980, or call the beneficiary’s social worker at their local county social services agency. Second, call 1-800-Medicare to see if the LIS eligibility is showing on the beneficiary’s record. Submit a complaint if the plan does not show LIS but Medicare does.

    Call the Part D plan government liaison to submit copies of the beneficiary’s Medi-Cal card for adjusting premium and copayment amounts to the LIS amount. Also contact the beneficiary’s pharmacist and have her/him call the plan’s pharmacy line to adjust the beneficiary’s LIS copayment amount.

Institute of Medicine’s findings regarding QIOs

A recent 2006 comprehensive study conducted by the national Institute of Medicine (IOM) on beneficiary complaint process in Medicare’s QIOs, found that private contractors hired by Medicare have often inadequately promoted patients' rights, and face conflicts of interest that may lead them to favor doctors and hospitals over beneficiaries. The IOM, which is the government's key consultant on health care policy, concluded that while QIOs play an important role in health care, responsibility for investigating patient complaints should be removed from them and shifted to other organizations.

Medicare pays 53 QIOs about $300 million a year to measure quality, work with hospitals and physicians to improve care, and to investigate patient complaints. Yet the numbers of complaints they receive is actually quite few. In 2004, for example, these QIOs nationwide only investigated a total of 3,100 complaints, and even then, complaints are not often upheld in favor of the Medicare beneficiary and sanctions are few. For 2006, Lumetra reviewed 301 complaints, and confirmed only 111 of these to be quality of care complaints. This is a small number given the 4.2 million beneficiaries in California. The 283-page IOM report included recommendations that would dramatically alter the work and operations of the quality contractors if adopted by Congress and Medicare officials. It called for increased oversight and more competition, less secrecy in the QIO operations and major revision of the governance of the physician-dominated groups, such as putting more consumers on their boards and making public the compensation paid to directors.

Center for Medicare Advocacy (CMA) convened a conference earlier this year to discuss these findings with the QIOs and came up with a series of recommendations for improvement. For more information, visit the CMA website for postings on the conference documents and extensive background information.

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