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TrustSolutions,
LLC's most Frequently Asked Questions about Medicare fraud are listed
below. We hope they will help to answer some of your questions. |
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Question: What is
Medicare Fraud? |
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Answer: An intentional
deception or misrepresentation that the individual knows to
be false or
does not believe to be true, and makes knowing that the deception could
result in some unauthorized benefit to himself/herself or some other person. |
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Question: What is
Medicare Abuse? |
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Answer: Abuse
includes incidents or practices of providers, physicians or suppliers
of services that are inconsistent with accepted sound medical practices,
directly or indirectly resulting in unnecessary costs to the program,
improper payment or
program payment for services that fail to meet
professionally recognized standards of care or are not medically necessary. |
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Question: What is
TrustSolutions' role in fighting Medicare Fraud and Abuse? |
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Answer: TrustSolutions is
a Medicare Program Safeguard Contractor that is responsible for performing
a variety of data analysis, audit and investigative activities
for
the Centers of Medicare and Medicaid Services (CMS) to reduce fraud
and abuse
in the Medicare Program |
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Question: What types
of common situations should be referred to TrustSolutions? |
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Answer: Some
instances when TrustSolutions should be contacted are: when a person
on
Medicare is billed for covered services but Medicare has not been billed;
when a provider is billing for services that have not been rendered;
when
someone
other than the correct person on Medicare is using a Medicare
card; and, if the services in question were not processed by TrustSolutions'
affiliated contractors, National Government
Services, Wisconsin Physicians
Service, and CIGNA
Government Services, since
that situation would be out of TrustSolutions' jurisdiction to investigate. |
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Question: What are
common situations that should not be referred to TrustSolutions? |
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Answer: Some
common situations that should not be referred to TrustSolutions include:
the quality of care a person on Medicare receives since these are most
often addressed by the state survey agency; specific charge amounts
on hospital and or outpatient claims since actual reimbursement to
the provider for services is based
on a set fee schedule established
by CMS; and, if the services in question were not processed by TrustSolutions'
affiliated contractors, National Government
Services, Wisconsin Physicians Service, or CIGNA
Government Services since that situation would be out of TrustSolutions'
jurisdiction to investigate. |
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Question: As a person
receiving Medicare benefits, how can I help to identify ways to prevent
Medicare Fraud and Abuse? |
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Answer: First
of all, you should review your Medicare Summary Notice (MSN) and compare
it to the information you have kept for these service dates. Secondly,
if you disagree with the services, it is important to discuss them with
the provider of the services. If the provider billed the services in error,
you will receive a corrected MSN.
If you feel further investigation is
needed due to possible fraud or abuse, call
1-800-MEDICARE.
In the last decade,
the Medicare Home Health Benefit was one of the fastest growing benefits
in the Medicare Program. Visit
the CMS Web Site to learn more about this Medicare service and action
you can take to protect your benefit. |
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Question: What type
of evidence does TrustSolutions need to pursue a case? |
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Answer: A complaint
should clearly describe the potential fraudulent or abusive activity.
In addition, it should contain as much detail as possible in order
to help our investigators. Any letters from a provider, notes on conversations,
or documented
visits from a provider are always helpful. Any other
documentation that supports the complaint should be included. |
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Question: What happens
to a complaint once it is submitted to TrustSolutions? |
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Answer: TrustSolutions
will review the complaint and determine if further investigation is
needed or if the complaint would be more appropriately handled by another
agency. If the complaint has merit for TrustSolutions to investigate,
then the complainant will
be acknowledged and additional information
may be gathered. If TrustSolutions can substantiate that potential
Medicare fraud exists, then a referral to a law enforcement agency
may be initiated. TrustSolutions may also initiate administrative remedies
to effectively address the concern. The complainant will be notified
of the resolution of
the initial complaint. |
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Question: Why does
a complaint/investigation take so long? |
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Answer: A complaint
regarding potential Medicare fraud is a very serious situation. TrustSolutions
performs work in such a manner to ensure our investigation is
complete
and accurate in our findings. Likewise, our law enforcement partners who
investigate our referred complaints ensure their work is also complete
and accurate since the consequences to the accused could be significant.
Therefore, it is not uncommon for health care fraud investigations to
last several years. However, in
spite of the length of time these investigations
can take, when complainants inquire, TrustSolutions will provide the information
they can to keep complainants informed about the progress of their complaints. |
