Medicare Fraud: Protect Yourself by Reviewing Your Statements

By Kristin Griffith, Director, SHIIP/SMP

Reviewing your health care statements for accuracy is one of the best ways to detect suspected fraud or errors related to your health care. Your first question is likely what statements to review. The answer to this depends on how you receive your health care insurance.

Persons with Original Medicare should review what is called a “Medicare Summary Notice” or MSN. The MSN is a notice, not a bill, that people receive in the mail every three months for Medicare Part A and Part B covered services. The MSN shows all the services or supplies that providers and suppliers billed Medicare during the three-month period, and this notice also shows what Medicare paid and what you may owe the provider. You can also access your MSN online by setting up an account at medicare.gov.

If you have a Medicare Advantage plan or a Medicare prescription drug plan (also called a Part D plan), you will receive what is called an “Explanation of Benefits” or EOB. The EOB is a notice, not a bill, that shows what the insurance company paid and what you must pay. This comes from your Medicare Advantage plan provider or a Medicare prescription drug plan provider which delivers a summary of all claims filed.

Here are the important things to look for on either type of statement:

• Your name and correct contact information
• Your doctor and provider information
• Date of service
• Service description
• Charges for the service and overview of what Medicare/Medicare Advantage plan is covering and what payments you might be responsible for

We suggest that you keep records of visits, lab work, or any other treatments for comparison purposes when reviewing an MSN or EOB. If something doesn’t look right, your first step is to call your health care provider for clarification or further explanation. As a health care consumer, you have a right to request additional information to understand your health care. Please know it might take several tries to get to the right person, but don’t give up, be persistent!

Reviewing these statements on a regular basis for accuracy is important to make sure that what you and your insurers are paying for are the correct treatments/services that you received. How does this relate to suspected fraud? The scammers hope that you don’t review your statements because if you don’t, then the fraudulent claims that they filed on your behalf will be paid and never questioned. And that gives them encouragement to continue. As informed health care consumers, you can take control of this situation by reviewing the statements and asking questions when something doesn’t seem right.

Iowa Insurance Division’s SHIIP-SMP counselors are trained in fraud prevention. Through our Senior Medicare Patrol outreach, we work to educate Iowans on how to prevent, detect and report health care fraud, errors and abuse. Watch for Fraud Awareness presentations in your community, visit our website and follow us on Facebook to see how you can protect against healthcare scams. If you suspect you or a loved one may have been a victim of Medicare fraud, call us to report it at 1-800-351-4664. We can help you get the answers and support you need.

This project was supported, in part by grant numbers 90SAPG0070 and 90MPPG0046, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201