Possible Medicare fraud

[TexLaProgressive]

I am on an Aetna Medicare Advantage plan provided through my former employer as a retirement benefit. It has been quite good and reasonably priced. In July I had the mandated Medicare wellness check up with my PCP and got vaccinated flu and pneumonia.

A month ago I got a letter offering me a payment plan over 5 months for $347.84. Both Medicare and Aetna Medicare state that there is no co-payment, no co-insurance - well no charges to the patient for 4 vaccinations; flu, covid, pneumonia and hep B.

I called billing and they said I would need to speak to Aetna. I called Aetna and got John. He was great, he called billing with me conferenced on and informed them just what I had told them - no charge to the patient, period.

I got an email from them again offering a payment plan. I spent an hour on the phone ranting about how this was Medicare fraud. She said she would remew the claim to Aetna. I said what for, they are not paying anymore and I am not paying it because it is an illegal charge.

Should I report this to Medicare as fraud?

I think a lot of people would be taken in and pay the $350 never sure what it was for.

[bucolic_frolic]

1. Yes

I don't think improper coding is random. Making them aware means someone will take a look at it.

[1WorldHope]

2. I have uhc advantage and all my shots were free.

[vanlassie]

3. That PCP should be handled by Aetna's Provider Relations Dept.

You can report fraud if you want. But PR should have a chat with them STAT. They can get thrown off the roster if they are not in compliance with their contract with Aetna. Maybe John alerted them? Call again and say you want a supervisor and someone to phone the medical office on your behalf on a conference call to tell them to send you a zero balance bill now.

[Silent Type]

4. Although is wouldn't be $347, there is a charge for an office visit that might have been under a

deductible. Depending upon whether it's your first annual wellness visit or a subsequent one, Medicare's allowable for that office visit should be around $170 for first one and $115 for second. But by July, most of that should have been covered.

Get the EOB (Explanation of Benefits) from Aetna. That should help you figure it out if doctor's office won't budge. It is not unusual for insurance payments to be reflected in a doctor's office after a few months. Good luck. BTW, I doubt this is fraud.

[TexLaProgressive]

6. $10 co-pay for PCP visit

Here’s from the Aetna documents, page 14:

There is no coinsurance, copayment, or deductible for pneumonia, influenza, Hepatitis B and Covid-19 vaccines.

This is covered under Medicare part B. I think the doctor’s office charged it to Medicare part D - prescription drug benefit.

From the Medicare 2023 document:

Preventive Services
Flu shots
Medicare covers the seasonal flu shot (or vaccine). You pay nothing for the flu shot if the doctor or other qualified health care provider accepts assignment for giving the shot.

Preventive Service’Pneumococcal shots
Medicare covers pneumococcal shots (or vaccines) to help prevent pneumococcal infections (like certain types of pneumonia). Etc etc etc.

[DuaneT]

7. Whether it's Medicare or Medicare Advantage there is no deductible or co pay under the annual

wellness benefit. If after your wellness benefit you ask or the doc does anything else he can charge. Mistake was not going to pharmacy to get those vaccines, they would have been free.

Now, it is also possible those vaccines should have been filed under Medicare Part B instead of her advantage plan. Although if you have a Medicare Advantage plan some vaccines will be billed to Medicare Part B.

[sinkingfeeling]

5. I had a hospital bill me for a tentus shot, which under my Medicare Advantage plan was no charge.

Found that the hospital had billed the plan with incorrect code, but only after I had filed a complaint to the State AG's office (special form for medical complaints). They finally corrected their billing and everyone was satisfied.