Marci’s Medicare Answers: Preventing Medicare fraud

2013_zzsite_graphics_00_badges_dear_marci_logoDear Marci,

I have Original Medicare. What requirements do I have to meet in order for Medicare to cover home health care?


Dear Rachel,

Medicare will pay for home health care if you meet all of the following requirements:

• You must be homebound. Medicare considers you to be homebound if you need the help of another person or special equipment to leave your home or your doctor believes that leaving your home would be harmful to your health. In addition, it must be difficult for you to leave your home.

• You must need skilled nursing care on an intermittent basis or skilled therapy services. This means that you must need care as a little as once every 60 days to as much as once a day for three weeks. Note that skilled care is care that can only be safely administered by a licensed nurse or therapist. Also note that you will not qualify for Medicare coverage of home health care if you only need occupational therapy.

• You must have a face-to-face visit with a health care professional within 90 days of starting to receive home health care or 30 days after you have started to receive care. Your doctor must sign a home health certification, verifying that you have had this visit and that you qualify for home care because you are homebound and need skilled care.

• You must receive certified care from a Medicare-certified home health agency (HHA).

Keep in mind that your doctor will need to approve your plan of care every 60 days. As long as you continue to meet Medicare coverage rules, Medicare should continue to cover your home health care. If you have Original Medicare, the traditional Medicare program administered directly through the federal government, and you have questions about Medicare coverage of home health care, you can contact 800-MEDICARE or go online and visit


Dear Marci,

My local senior center recently provided some of us with a presentation on Medicare fraud and abuse. What can I do help prevent Medicare fraud and abuse?


Dear Bernice,

Medicare fraud occurs when health care providers bill Medicare for health care services you never received. Medicare abuse occurs when health care providers do not follow good medical practices, leading to unnecessary Medicare costs and improper payments made to providers. Medicare fraud, waste and abuse cost the federal government millions of dollars each year.

It is important for people with Medicare, caregivers and professionals to be on the lookout for Medicare fraud, waste and abuse. There are several things you can do to help prevent Medicare fraud:

• Protect your Medicare number and Social Security number. Only give this information out to health care providers and individuals you trust.

• Do not share your medical information with people who are not health care professionals and people you do not

• Know what health care services are covered by Medicare. If you get your Medicare benefits through Original Medicare, the traditional Medicare program administered directly through the federal government, you can contact 800-MEDICARE or go online and visit to learn more about what health care services Medicare will cover. If you get your Medicare benefits through a Medicare Advantage plan, also known as a Medicare private health plan, you should contact your plan directly to learn more about your plan benefits.

• Be wary of health care providers who promise you that Medicare will pay for treatments that are not medically necessary. In general, Medicare only covers care that is considered to be medically necessary.

• Don’t accept services you feel you don’t need. Be wary of health care providers who try to pressure or scare you into getting tests, exams or expensive procedures that you feel are not medically necessary.

The Affordable Care Act, also known as Obamacare, has empowered different organizations to combat Medicare fraud and abuse. One such organization is the Senior Medicare Patrol (SMP), a group of trained volunteers who show people with Medicare how to protect against, detect and report fraud. If you would like to learn more about Medicare fraud and abuse, contact the Senior Medicare Patrol by calling 877-808-2468.


Dear Marci,

I received a letter saying that I was awarded the Medicare Savings Program (MSP). The letter also told me that my MSP benefit would be effective a few months back. Will I be refunded the Part B premiums I had already paid for since my MSP effective date?


Dear William,

Yes. Medicare Savings Programs are assistance programs that can help pay Medicare health costs, such as Part B premiums, for those with limited finances. If you were awarded the Medicare Savings Program (MSP) and you were told that the MSP effective date began at some point in the past, you should be refunded any Part B premiums that you paid since your MSP effective date began. Note that the Part B premium is automatically deducted from your Social Security payments if you receive Social Security retirement or Social Security Disability Insurance.

For example, let’s say you received an MSP award letter in August 2014 saying that your MSP benefit became effective May 1, 2014. The Part B premiums you paid for since May 2014 should be refunded back to you by the Social Security Administration (SSA). In addition, you would not have to pay for future Part B premiums, since the MSP benefit pays for your Medicare Part B premiums.

Keep in mind that it may take a while for the refund to process. If you have any questions about getting your refund, you should contact the Social Security Administration directly by calling 800-772-1213 or by visiting your local Social Security office.