Episode Transcript
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Speaker 1 (00:01):
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And now Medicare three sixty.
Speaker 2 (00:44):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee, and we are diving in in the Medicare
New Handbook on page one hundred. So let us just
go back to how do I get help filing an appeal?
(01:06):
And how do I ask for coverage determination or exception? Okay,
so you or your prescriber must contact your plan to
ask for a coverage determination or an exception. If your
network pharmacy can't fill a prescription, the pharmacist will give
you notice that explains how to contact your Medicare drug plan,
(01:30):
so you can make your requests. If the pharmacy doesn't
give you this notice, ask for a copy. Really, I
haven't seen any pharmacists do this because every time the client,
if it's not covered, they call us and they never
say anything about the pharmacists giving them anything. So, if
(01:51):
you're asking for a prescription you haven't gotten yet, you
or your prescriber may make a standard request or an
expY gited fast request by.
Speaker 3 (02:02):
Phone or in writing.
Speaker 2 (02:04):
If you're asking get paid back for prescription drugs you
already bought, your plan can require you or your prescriber
to make the standard request in writing, You or your
prescriber can call or write your plan for an expedited
fast request. Your request will be expedited if you haven't
gone the gods in the prescription and your plan determines
(02:28):
or your prescriber tells your plan that your life or
health may be at risk by waiting.
Speaker 3 (02:34):
So important.
Speaker 2 (02:35):
If you're requesting an exception, your prescriber must provide a
statement explaining the medical reason why your plan should approve
the exception. Okay, so there was one time where I
had a client that really needed the prescription drug, but
there was time for getting that exception or approved, and
(03:00):
he just needed it right away, so he was willing
to pay for it out of his pocket and then
definitely see if you could just get reimbursed by it
by an insurance company. So every insurance company has different
ways of getting that approval or that exception. Maybe most
(03:21):
of the time you could just call in, but if needed,
there might be like a form that you need to complete,
So contact your insurance company for the different options on that. Okay,
So what are my rights if I think my services
are ending too soon? So that definitely does happen.
Speaker 3 (03:44):
Okay.
Speaker 2 (03:45):
So if you're getting Medicare services from a hospital, skilled
nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or
hospice and you think your Medicare covered service are ending
too soon or you're being discharged too soon, you get
asked for appeal also known as an immediate appeal or
(04:07):
an expedited appeal. Your provider will give you a notice
before your services end telling you how to ask for
a fast appeal. Read this notice carefully. If you don't
get this notice, as for it with a fast appeal
and an independent reviewer called a Beneficiary and Family Centered
Care Quality Improvement Organization b FCC dash q I zero
(04:29):
IO will decide if your covered services to continue. You
can contact your BFCC dash QIO for help with filing
an appeal, Go to page one twelve. Generally, a fast
appeal only covers the decision to end services or discharge
you from the hospital. You may start a separate appeal
(04:51):
for any items or services you may have gotten after
the decision to end services. Visit Medicare dot gov slash
Appeals or Medicare doc go slash Publications to review the
booklet Medicare Appeals. There are some exceptions detail in the
box below. Starting on February fourteenth, twenty twenty five, you'll
have the right to ask very fast appeal while you're
(05:13):
still in the hospital if you're admitted to the hospital
as an inpatient and hospital change your status to outpatient
getting observation services. For more information, visit Medicare dot gov
slash Providers, Dash Service Slash Claims, Dash Appeals, Dash Complaints,
slash appeal slash fast ash Appeals. I mean, I know,
(05:33):
hospitals seem to want to discharge you right away, maybe
because of the costs.
Speaker 3 (05:39):
Or so forth. So please, if you do have.
Speaker 2 (05:44):
And know when your end of service is and you
really definitely want to stay at.
Speaker 3 (05:49):
The hospital and so forth, you need to filew.
Speaker 2 (05:52):
This asap, right and it's the immediate or expited appeal,
because by the time if it's just a right appeal,
you know you're going to be out, So definitely keep
that in mind. I've had clients in this type of situation,
so you definitely want to make sure that you could
(06:15):
stay at the hospital if needed. Okay, so let's go over.
Speaker 3 (06:24):
What else should we do? Okay?
Speaker 2 (06:27):
What's an advanced beneficiary Notice of non coverage ABN? If
you have original Medicare, your doctor or healthcare provider or
supplier may give you written notice if they think Medicare
won't pay for the items or services.
Speaker 3 (06:44):
You'll get.
Speaker 2 (06:45):
This notice is called an advanced Beneficiary Notice of non
coverage or ABN. The ABN lists the items or services
that your provider expects Medicare won't pay for, along with
an estimate of the cost for the items and services
and reasons why Medicare may not pay. What happens if
I get this notice? You'll be asked to choose whether
(07:08):
to get the items or services listed on the notice.
You choose to get the items or services listed on
the notice, you're agreeing to pay. If Medicare doesn't, you'll
be asked to sign the notice to say that you've
read and understood it. Doctors, other healthcare providers and suppliers
don't have to, but still may give you a notice
for services that Medicare never covers.
Speaker 3 (07:30):
Go to page fifty five.
Speaker 2 (07:32):
At ABN isn't an official denial of coverage by Medicare.
If Medicare denies payment, you could sell file on appeal.
Once you get the Medicare Summary Notice MSN showing the
item or servicing question. However, you have to pay for
the items or services of Medicare, decide that the items
or services aren't covered, and know other insurance responsible for payment.
(07:56):
Can I get a notice like this for other reasons?
You may get a skilled nursing facility ABN when the
facility believes Medicare will no longer cover your day or
any other items and services.
Speaker 3 (08:10):
What if I.
Speaker 2 (08:10):
Didn't get this notice? If your provider was required to
give you this notice but didn't, in most cases, your
provider must give you a refund for what you paid
for the item or service. Okay, yeah, keep that in mind.
Where can I get more information? Visit Medicare dot gov,
slash Basic Slasher, Medicare Dash, Medicare Dash Rights Slasher dash
(08:33):
Protections to learn more about the different types of abns
and what to do if you get one.
Speaker 3 (08:38):
Note.
Speaker 2 (08:38):
If you're in a Medicare advantage plan, you have the
right to ask the plan in advance if it covers
a search and service, drug or supply. Contact your plan
to request and submit a pre service request from an
organization determination. The plan denies your requests, the response will
include instructions to file a timely appeal. You may all
(09:00):
so get plan directed care. This is when a plan
provider refers you for a service or per to a
provider outside the network without getting an organization determination in advance.
To go to page sixty six. Okay, Your right to
access your personal health information. By law, you or your
(09:21):
legal representative generally have the right to review and or
get copies of your personal health information from healthcare providers
who treat you and bil Medicare for your care. If
you want Medicare to give your personal information to someone else,
like a caregiver, Go to page one oh seven to
learn more about completing an authorization to disclose personal health
(09:43):
information for You also generally have the right to get
this information from health plans that pay for your care,
including Medicare. These type of personal health information include claims
and billing records, information related to your enrollment and health plans,
including Medicare, medical and case management records, other records that
(10:07):
doctors or healthcare plans use to make decisions about you. Generally,
you could get your information on paper electronically. If your
providers or plans store your information electronically.
Speaker 3 (10:20):
Excuse me.
Speaker 2 (10:22):
They generally must give you electronic copies if you ask
for them. You have the right to get informationally in
a timely manner, but it may take up to thirty
days to get a response if your information is electronic.
Speaker 3 (10:35):
You may also request the habits.
Speaker 2 (10:36):
In to a third party of your choosing, like a
healthcare provider who treats you, a family member, or a researcher.
Speaker 1 (10:45):
Okay.
Speaker 2 (10:47):
You may have to fill out a form to request
copies of information and pay a fee.
Speaker 3 (10:53):
This fee typically.
Speaker 2 (10:54):
Can be more than the total cost of labor for
copying the information or requested supplies for creating the copy postage.
If you ask your healthcare provider to mail your copy.
In most cases, you won't be charged for reviewing, searching, downloading,
or sending your information through an electronic portal. For information
(11:16):
visit HSS dot gov slash HIPPA for DASH, Individual SaaS
guidance DASH materials for consumers. You need help getting and
use your health records. Office of the National Coordinator for
Health Information, Technology and c in the US Department of
Health and Human Services HS has created the Guide to
(11:37):
Getting and Using your Health Records shows you how you
get your health records and make sure they're accurate and
complete so you get the most out of your healthcare.
Visit health it dot gov slash how DASH to get
oh my Gosh to Dash, get dash your Dash Health
(11:57):
Dash Record to review the guide. How does Medicare use
my personal information? Medicare protects the privacy of your health information.
The next three pages describe describe how Medicare may be
used and give out your information. Explain how you could
get this information. Notice a Privacy Practices Virginal Medicare. This
(12:19):
notice describes how medical information about how you may be
used and disclose how you can get access to this information.
Please review it carefully. The law requires Medicare to protect
the privacy of your personal medical information. It also requires
us to give you this notice so you know how
we may use and share disclosed in medical information we
(12:40):
have about you. We must provide your information too, you
to someone you name, designate designate, or someone who has
a legal right to act for you, your personal representative,
the Secretary of the Apartment of Health in Human Services
if necessary, anyone else that's the law requires to have it.
(13:01):
We have the right to use and provide your information
to pay for your healthcare and to operate Medicare. For example,
Medicare administrative contracts. Use your personal information to pay for
or deny your claims, lect your opinions, share your benefit
payment with your other insurers, or prepare your Medicare summary notice.
May use your information to provide you with customer service,
(13:23):
resolve complaints you have, contact you about research studies, and
make sure you get quality care. We may use or
share your information under these limited circumstances. Hey, let's read
this to state in other federal agencies that have the
legal rights to get Medicare data, like to make sure
(13:46):
Medicare is making proper payments, and to help federal slash
state medicaid programs. For public health activities like reporting disease outbreaks.
For government health care oversight activities like investigating fraud and abuse.
For judicial and administrating proceedings like responding to order. For
(14:06):
law enforcement purposes like providing limited information to find a
missing person. For research studies that meet all privacy law
requirements like research provided disease or disability, to avoid a
serious and imminent threat to health or safety. To contact
you about newer changed Medicare benefits. To create a collection
(14:28):
of information that no one can trace to you. To
healthcare providers and their business associates. For care coordination and
callity improvement purposes like participation in accountable care organization. We
don't sell or use and share your information. To tell
you about health products or services marketing. We must have
(14:50):
your written permission and authorization to use or share your
information for any purpose that isn't described in this notice.
You may take take back, or evoke your written permission
at any time unless you already shared an information. Because
you gave us a permission, You have the right to
(15:10):
or view and get a copy of information. We have
about you have us change your information if you think
it's wronger and concluded we agree. If we disagree, you
may have your statement of your disagreement added to your information.
Get a list of people who get your information from us.
The listing won't law. Won't cover information that we gave
(15:31):
to you your personal representative or law enforcement, or information
that we used to pay for your care or our operations.
Speaker 3 (15:38):
Ask us to.
Speaker 2 (15:39):
Communicate with you in different manner or at a different place,
for example by sending materials to a pea box instead
of your home address. Ask us limit how we use
your information and how we give it out to pay
claims and run medicare. You may not be able to
agree to your requests. Get a letter that tells you
(15:59):
about the life clerisk to privacy of your information. Reach
c notification. Get a separate paper copy of this notice.
Speak to a customer service representative about our privacy Notice
one eight hundred Medicare which is eight hundred six four
three for two seven.
Speaker 3 (16:17):
If you believe your.
Speaker 2 (16:18):
Privacy rights have been violated, you may file a privacy
complaint with the Centers for Medicare and Medicaid CMS. Visit
Medicare dot gov. Or call one one hundred Medicare the
US Department of Health and Human Services HS Office for
Civil Rights OCRHS dot gov, slash, ship off, file filing,
(16:43):
dashy complaint. Filing a complaint won't affect your coverage under Medicare.
The law requires us to follow the terms in this notice.
We have the right to change the way we use
or share your information.
Speaker 3 (16:54):
If we make a.
Speaker 2 (16:55):
Change, will mail you notice within sixty days of the change.
The notice of private see practices for original Medicare became
effective September twenty third, twenty thirteen. How can I protect
myself from brought and medical identity theft? Okay, medical identity
theft is someone when someone steals or uses your personal
(17:17):
information like your name, social Security number, or Medicare number,
to submit fraudulent claims to Medicare and other health insurance
companies without your permission. When you get healthcare services, record
the date, record the dates on the calendar, and save
the receipts and statements you get from providers to check.
Speaker 3 (17:43):
For mistakes. If you think there's an air or a
provider bill.
Speaker 2 (17:48):
You or your services you didn't get, take steps to
find out that was built. Check your Medicare Summary Notice
MSN if you have original Medicare to find out if the.
Speaker 3 (18:01):
Service was built to Medicare.
Speaker 2 (18:03):
If you're a Medicare health plan, check the statements you
get from your plan. Log into or create a secure
Medicare account at medicare dot gov to reveal your Medicare claims.
If you have original Medicare, your claims are generally available
online within twenty four hours after processing. You could also
download your claims data from your medicare dot gov account
(18:24):
by going to download my claims and personal data under
my account. You could also call one one hundred Medicare
eight hundred and six thirty three for two seven. If
you know the healthcare provider supplier, call and ask for
itemized statement.
Speaker 3 (18:40):
They should give this to you within thirty days. Okay,
that was a lot.
Speaker 2 (18:47):
And so this is one of the reasons for broader
medical identity THEFT. I actually the reason why I got
into Medicare was because.
Speaker 3 (19:06):
Started seeing that my father in law.
Speaker 2 (19:08):
Was receiving bills, was showing five thousand dollars that someone
was claiming a doctor was claiming on his Medicare, and
I had no idea, no clue on how medicare worked,
(19:28):
and I'm like, I'm licensed in life and health, why
don't I know these things? So I went down that
rabbit hole and come to find out that he was
put on hospice. And the only reason why I found
out about.
Speaker 3 (19:45):
It was.
Speaker 2 (19:48):
One day he couldn't get up from bed. And I'm
not a nurse. Yes, I offer healthcare insurance, but I
had no idea. But he did have a mild stroke
and when that happened, I was reviewing his files come
to find out that he was on hospice because on
(20:13):
these on this folder was like, don't resuscitate him, don't
call nine one one, don't go to the hospital, and
like seriously, like, of course we want to resuscitate him
or take him to the hospital if need be. So
(20:33):
finding that out that's so clueless, and so forth. But
I did talk to people in the industry on how
all this works, and unfortunately my in laws are just
not the type to call for fraud and so forth,
(20:55):
and they didn't want to press charges or anything else.
Speaker 3 (21:02):
With this because.
Speaker 2 (21:06):
It was their trusted friend that was I guess helping
them with.
Speaker 3 (21:11):
All this, And as a daughter in law, as a daughter.
Speaker 2 (21:19):
Or son, definitely I would say, if your parents, you know,
your elderly start making you friends, like why are.
Speaker 3 (21:29):
These people helping them? What's the reason for it?
Speaker 2 (21:35):
Right, because you never know the alternate altern to your
motives of these people, and come to find out I
think that was the demise of my father in law's health.
Speaker 3 (21:52):
And so forth.
Speaker 2 (21:53):
But that definitely is a topic that I'd probably want
to talk to in the future, but just really want
to make people aware that broad does go on and for.
Speaker 3 (22:13):
People that may not.
Speaker 2 (22:16):
Know the rules and the laws, or.
Speaker 3 (22:22):
Are just not born here.
Speaker 2 (22:26):
Or minorities, they definitely are targeted more heavily, I would believe,
and just not really educated on the healthcare systems and
so forth. So that was a little bit of a
downer this my father in law, but that's definitely a story.
(22:49):
But he definitely has got me the passion to learn
about how Medicare works and the bet and fraud that
goes into it. Okay, So I mean, if you've contacted
the provider and you suspect them that Medicare is being
(23:09):
charged or for a service or supply you didn't get
or you don't know the provider of the claim, call
one a hundred Medicare could also call on Medicare if
you believe your Medicare number has been used fraudulently and
that could happen too. Definitely, some people don't know that
(23:30):
they have services.
Speaker 3 (23:33):
They just don't.
Speaker 2 (23:35):
Only give information like your Medicare number to doctors. Insurance
companies and their licensed agents are brokers or plans acting
on your behalf or trusted people in the community who
work with Medicare like your state health insurance assystem program.
Don't share your Medicare number or their personal information with
any insilidous person contacts you by phone, email. Medicare or
(23:56):
your medical representative will only call you a limited situation,
so definitely do not give your Medicare information to just
anyone on the phone. They typically will change your plan,
bill you up some services or products that you don't
even need or know about. Medicare plan can call you
(24:20):
if you're already a member of planned. The agent who
have helped you join also could call you. Customer service
represented from eight hundred Medicare can call you if you
left their message, or representative that someone called you would
call back. Find yourself if you fold a report of
suspective fraud you get a call from someone representing Medicare
to fallo up on the status of your suspected fraud reportort.
(24:43):
For more information about Medicare fraud, visit medicare dot go,
slash fraud, or contact your local Senior Medical Patrol. Learn
more about the Senior Medicare Patrol and help bind your
state by going to SMP resource dot org or call
eight seven seven eight zero eight two four six eight.
So thank you for for listening today. My name is
(25:06):
Jennifer Lee, your Medicare three sixty host. I look forward
to talking to you guys next week. Have a wonderful day.
Speaker 1 (25:17):
Thank you for joining the program Medicare at three sixty.
Hope you found today's episode insightful and empowering. Remember understanding
your Medicare options is key to making the right choices
for your health and financial well being. If you have
questions or topics you would like covered in future episodes
of Medicare three sixty, don't hesitate to reach out and
(25:39):
speak with our licensed insurance agent. Until next time, stay
informed and take charge of your healthcare journey. This has
been Medicare three sixty, your trusted source for all things Medicare.
Take care,
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And now Medicare three sixty.
Speaker 2 (00:44):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee, and we are diving in in the Medicare
New Handbook on page one hundred. So let us just
go back to how do I get help filing an appeal?
(01:06):
And how do I ask for coverage determination or exception? Okay,
so you or your prescriber must contact your plan to
ask for a coverage determination or an exception. If your
network pharmacy can't fill a prescription, the pharmacist will give
you notice that explains how to contact your Medicare drug plan,
(01:30):
so you can make your requests. If the pharmacy doesn't
give you this notice, ask for a copy. Really, I
haven't seen any pharmacists do this because every time the client,
if it's not covered, they call us and they never
say anything about the pharmacists giving them anything. So, if
(01:51):
you're asking for a prescription you haven't gotten yet, you
or your prescriber may make a standard request or an
expY gited fast request by.
Speaker 3 (02:02):
Phone or in writing.
Speaker 2 (02:04):
If you're asking get paid back for prescription drugs you
already bought, your plan can require you or your prescriber
to make the standard request in writing, You or your
prescriber can call or write your plan for an expedited
fast request. Your request will be expedited if you haven't
gone the gods in the prescription and your plan determines
(02:28):
or your prescriber tells your plan that your life or
health may be at risk by waiting.
Speaker 3 (02:34):
So important.
Speaker 2 (02:35):
If you're requesting an exception, your prescriber must provide a
statement explaining the medical reason why your plan should approve
the exception. Okay, so there was one time where I
had a client that really needed the prescription drug, but
there was time for getting that exception or approved, and
(03:00):
he just needed it right away, so he was willing
to pay for it out of his pocket and then
definitely see if you could just get reimbursed by it
by an insurance company. So every insurance company has different
ways of getting that approval or that exception. Maybe most
(03:21):
of the time you could just call in, but if needed,
there might be like a form that you need to complete,
So contact your insurance company for the different options on that. Okay,
So what are my rights if I think my services
are ending too soon? So that definitely does happen.
Speaker 3 (03:44):
Okay.
Speaker 2 (03:45):
So if you're getting Medicare services from a hospital, skilled
nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or
hospice and you think your Medicare covered service are ending
too soon or you're being discharged too soon, you get
asked for appeal also known as an immediate appeal or
(04:07):
an expedited appeal. Your provider will give you a notice
before your services end telling you how to ask for
a fast appeal. Read this notice carefully. If you don't
get this notice, as for it with a fast appeal
and an independent reviewer called a Beneficiary and Family Centered
Care Quality Improvement Organization b FCC dash q I zero
(04:29):
IO will decide if your covered services to continue. You
can contact your BFCC dash QIO for help with filing
an appeal, Go to page one twelve. Generally, a fast
appeal only covers the decision to end services or discharge
you from the hospital. You may start a separate appeal
(04:51):
for any items or services you may have gotten after
the decision to end services. Visit Medicare dot gov slash
Appeals or Medicare doc go slash Publications to review the
booklet Medicare Appeals. There are some exceptions detail in the
box below. Starting on February fourteenth, twenty twenty five, you'll
have the right to ask very fast appeal while you're
(05:13):
still in the hospital if you're admitted to the hospital
as an inpatient and hospital change your status to outpatient
getting observation services. For more information, visit Medicare dot gov
slash Providers, Dash Service Slash Claims, Dash Appeals, Dash Complaints,
slash appeal slash fast ash Appeals. I mean, I know,
(05:33):
hospitals seem to want to discharge you right away, maybe
because of the costs.
Speaker 3 (05:39):
Or so forth. So please, if you do have.
Speaker 2 (05:44):
And know when your end of service is and you
really definitely want to stay at.
Speaker 3 (05:49):
The hospital and so forth, you need to filew.
Speaker 2 (05:52):
This asap, right and it's the immediate or expited appeal,
because by the time if it's just a right appeal,
you know you're going to be out, So definitely keep
that in mind. I've had clients in this type of situation,
so you definitely want to make sure that you could
(06:15):
stay at the hospital if needed. Okay, so let's go over.
Speaker 3 (06:24):
What else should we do? Okay?
Speaker 2 (06:27):
What's an advanced beneficiary Notice of non coverage ABN? If
you have original Medicare, your doctor or healthcare provider or
supplier may give you written notice if they think Medicare
won't pay for the items or services.
Speaker 3 (06:44):
You'll get.
Speaker 2 (06:45):
This notice is called an advanced Beneficiary Notice of non
coverage or ABN. The ABN lists the items or services
that your provider expects Medicare won't pay for, along with
an estimate of the cost for the items and services
and reasons why Medicare may not pay. What happens if
I get this notice? You'll be asked to choose whether
(07:08):
to get the items or services listed on the notice.
You choose to get the items or services listed on
the notice, you're agreeing to pay. If Medicare doesn't, you'll
be asked to sign the notice to say that you've
read and understood it. Doctors, other healthcare providers and suppliers
don't have to, but still may give you a notice
for services that Medicare never covers.
Speaker 3 (07:30):
Go to page fifty five.
Speaker 2 (07:32):
At ABN isn't an official denial of coverage by Medicare.
If Medicare denies payment, you could sell file on appeal.
Once you get the Medicare Summary Notice MSN showing the
item or servicing question. However, you have to pay for
the items or services of Medicare, decide that the items
or services aren't covered, and know other insurance responsible for payment.
(07:56):
Can I get a notice like this for other reasons?
You may get a skilled nursing facility ABN when the
facility believes Medicare will no longer cover your day or
any other items and services.
Speaker 3 (08:10):
What if I.
Speaker 2 (08:10):
Didn't get this notice? If your provider was required to
give you this notice but didn't, in most cases, your
provider must give you a refund for what you paid
for the item or service. Okay, yeah, keep that in mind.
Where can I get more information? Visit Medicare dot gov,
slash Basic Slasher, Medicare Dash, Medicare Dash Rights Slasher dash
(08:33):
Protections to learn more about the different types of abns
and what to do if you get one.
Speaker 3 (08:38):
Note.
Speaker 2 (08:38):
If you're in a Medicare advantage plan, you have the
right to ask the plan in advance if it covers
a search and service, drug or supply. Contact your plan
to request and submit a pre service request from an
organization determination. The plan denies your requests, the response will
include instructions to file a timely appeal. You may all
(09:00):
so get plan directed care. This is when a plan
provider refers you for a service or per to a
provider outside the network without getting an organization determination in advance.
To go to page sixty six. Okay, Your right to
access your personal health information. By law, you or your
(09:21):
legal representative generally have the right to review and or
get copies of your personal health information from healthcare providers
who treat you and bil Medicare for your care. If
you want Medicare to give your personal information to someone else,
like a caregiver, Go to page one oh seven to
learn more about completing an authorization to disclose personal health
(09:43):
information for You also generally have the right to get
this information from health plans that pay for your care,
including Medicare. These type of personal health information include claims
and billing records, information related to your enrollment and health plans,
including Medicare, medical and case management records, other records that
(10:07):
doctors or healthcare plans use to make decisions about you. Generally,
you could get your information on paper electronically. If your
providers or plans store your information electronically.
Speaker 3 (10:20):
Excuse me.
Speaker 2 (10:22):
They generally must give you electronic copies if you ask
for them. You have the right to get informationally in
a timely manner, but it may take up to thirty
days to get a response if your information is electronic.
Speaker 3 (10:35):
You may also request the habits.
Speaker 2 (10:36):
In to a third party of your choosing, like a
healthcare provider who treats you, a family member, or a researcher.
Speaker 1 (10:45):
Okay.
Speaker 2 (10:47):
You may have to fill out a form to request
copies of information and pay a fee.
Speaker 3 (10:53):
This fee typically.
Speaker 2 (10:54):
Can be more than the total cost of labor for
copying the information or requested supplies for creating the copy postage.
If you ask your healthcare provider to mail your copy.
In most cases, you won't be charged for reviewing, searching, downloading,
or sending your information through an electronic portal. For information
(11:16):
visit HSS dot gov slash HIPPA for DASH, Individual SaaS
guidance DASH materials for consumers. You need help getting and
use your health records. Office of the National Coordinator for
Health Information, Technology and c in the US Department of
Health and Human Services HS has created the Guide to
(11:37):
Getting and Using your Health Records shows you how you
get your health records and make sure they're accurate and
complete so you get the most out of your healthcare.
Visit health it dot gov slash how DASH to get
oh my Gosh to Dash, get dash your Dash Health
(11:57):
Dash Record to review the guide. How does Medicare use
my personal information? Medicare protects the privacy of your health information.
The next three pages describe describe how Medicare may be
used and give out your information. Explain how you could
get this information. Notice a Privacy Practices Virginal Medicare. This
(12:19):
notice describes how medical information about how you may be
used and disclose how you can get access to this information.
Please review it carefully. The law requires Medicare to protect
the privacy of your personal medical information. It also requires
us to give you this notice so you know how
we may use and share disclosed in medical information we
(12:40):
have about you. We must provide your information too, you
to someone you name, designate designate, or someone who has
a legal right to act for you, your personal representative,
the Secretary of the Apartment of Health in Human Services
if necessary, anyone else that's the law requires to have it.
(13:01):
We have the right to use and provide your information
to pay for your healthcare and to operate Medicare. For example,
Medicare administrative contracts. Use your personal information to pay for
or deny your claims, lect your opinions, share your benefit
payment with your other insurers, or prepare your Medicare summary notice.
May use your information to provide you with customer service,
(13:23):
resolve complaints you have, contact you about research studies, and
make sure you get quality care. We may use or
share your information under these limited circumstances. Hey, let's read
this to state in other federal agencies that have the
legal rights to get Medicare data, like to make sure
(13:46):
Medicare is making proper payments, and to help federal slash
state medicaid programs. For public health activities like reporting disease outbreaks.
For government health care oversight activities like investigating fraud and abuse.
For judicial and administrating proceedings like responding to order. For
(14:06):
law enforcement purposes like providing limited information to find a
missing person. For research studies that meet all privacy law
requirements like research provided disease or disability, to avoid a
serious and imminent threat to health or safety. To contact
you about newer changed Medicare benefits. To create a collection
(14:28):
of information that no one can trace to you. To
healthcare providers and their business associates. For care coordination and
callity improvement purposes like participation in accountable care organization. We
don't sell or use and share your information. To tell
you about health products or services marketing. We must have
(14:50):
your written permission and authorization to use or share your
information for any purpose that isn't described in this notice.
You may take take back, or evoke your written permission
at any time unless you already shared an information. Because
you gave us a permission, You have the right to
(15:10):
or view and get a copy of information. We have
about you have us change your information if you think
it's wronger and concluded we agree. If we disagree, you
may have your statement of your disagreement added to your information.
Get a list of people who get your information from us.
The listing won't law. Won't cover information that we gave
(15:31):
to you your personal representative or law enforcement, or information
that we used to pay for your care or our operations.
Speaker 3 (15:38):
Ask us to.
Speaker 2 (15:39):
Communicate with you in different manner or at a different place,
for example by sending materials to a pea box instead
of your home address. Ask us limit how we use
your information and how we give it out to pay
claims and run medicare. You may not be able to
agree to your requests. Get a letter that tells you
(15:59):
about the life clerisk to privacy of your information. Reach
c notification. Get a separate paper copy of this notice.
Speak to a customer service representative about our privacy Notice
one eight hundred Medicare which is eight hundred six four
three for two seven.
Speaker 3 (16:17):
If you believe your.
Speaker 2 (16:18):
Privacy rights have been violated, you may file a privacy
complaint with the Centers for Medicare and Medicaid CMS. Visit
Medicare dot gov. Or call one one hundred Medicare the
US Department of Health and Human Services HS Office for
Civil Rights OCRHS dot gov, slash, ship off, file filing,
(16:43):
dashy complaint. Filing a complaint won't affect your coverage under Medicare.
The law requires us to follow the terms in this notice.
We have the right to change the way we use
or share your information.
Speaker 3 (16:54):
If we make a.
Speaker 2 (16:55):
Change, will mail you notice within sixty days of the change.
The notice of private see practices for original Medicare became
effective September twenty third, twenty thirteen. How can I protect
myself from brought and medical identity theft? Okay, medical identity
theft is someone when someone steals or uses your personal
(17:17):
information like your name, social Security number, or Medicare number,
to submit fraudulent claims to Medicare and other health insurance
companies without your permission. When you get healthcare services, record
the date, record the dates on the calendar, and save
the receipts and statements you get from providers to check.
Speaker 3 (17:43):
For mistakes. If you think there's an air or a
provider bill.
Speaker 2 (17:48):
You or your services you didn't get, take steps to
find out that was built. Check your Medicare Summary Notice
MSN if you have original Medicare to find out if the.
Speaker 3 (18:01):
Service was built to Medicare.
Speaker 2 (18:03):
If you're a Medicare health plan, check the statements you
get from your plan. Log into or create a secure
Medicare account at medicare dot gov to reveal your Medicare claims.
If you have original Medicare, your claims are generally available
online within twenty four hours after processing. You could also
download your claims data from your medicare dot gov account
(18:24):
by going to download my claims and personal data under
my account. You could also call one one hundred Medicare
eight hundred and six thirty three for two seven. If
you know the healthcare provider supplier, call and ask for
itemized statement.
Speaker 3 (18:40):
They should give this to you within thirty days. Okay,
that was a lot.
Speaker 2 (18:47):
And so this is one of the reasons for broader
medical identity THEFT. I actually the reason why I got
into Medicare was because.
Speaker 3 (19:06):
Started seeing that my father in law.
Speaker 2 (19:08):
Was receiving bills, was showing five thousand dollars that someone
was claiming a doctor was claiming on his Medicare, and
I had no idea, no clue on how medicare worked,
(19:28):
and I'm like, I'm licensed in life and health, why
don't I know these things? So I went down that
rabbit hole and come to find out that he was
put on hospice. And the only reason why I found
out about.
Speaker 3 (19:45):
It was.
Speaker 2 (19:48):
One day he couldn't get up from bed. And I'm
not a nurse. Yes, I offer healthcare insurance, but I
had no idea. But he did have a mild stroke
and when that happened, I was reviewing his files come
to find out that he was on hospice because on
(20:13):
these on this folder was like, don't resuscitate him, don't
call nine one one, don't go to the hospital, and
like seriously, like, of course we want to resuscitate him
or take him to the hospital if need be. So
(20:33):
finding that out that's so clueless, and so forth. But
I did talk to people in the industry on how
all this works, and unfortunately my in laws are just
not the type to call for fraud and so forth,
(20:55):
and they didn't want to press charges or anything else.
Speaker 3 (21:02):
With this because.
Speaker 2 (21:06):
It was their trusted friend that was I guess helping
them with.
Speaker 3 (21:11):
All this, And as a daughter in law, as a daughter.
Speaker 2 (21:19):
Or son, definitely I would say, if your parents, you know,
your elderly start making you friends, like why are.
Speaker 3 (21:29):
These people helping them? What's the reason for it?
Speaker 2 (21:35):
Right, because you never know the alternate altern to your
motives of these people, and come to find out I
think that was the demise of my father in law's health.
Speaker 3 (21:52):
And so forth.
Speaker 2 (21:53):
But that definitely is a topic that I'd probably want
to talk to in the future, but just really want
to make people aware that broad does go on and for.
Speaker 3 (22:13):
People that may not.
Speaker 2 (22:16):
Know the rules and the laws, or.
Speaker 3 (22:22):
Are just not born here.
Speaker 2 (22:26):
Or minorities, they definitely are targeted more heavily, I would believe,
and just not really educated on the healthcare systems and
so forth. So that was a little bit of a
downer this my father in law, but that's definitely a story.
(22:49):
But he definitely has got me the passion to learn
about how Medicare works and the bet and fraud that
goes into it. Okay, So I mean, if you've contacted
the provider and you suspect them that Medicare is being
(23:09):
charged or for a service or supply you didn't get
or you don't know the provider of the claim, call
one a hundred Medicare could also call on Medicare if
you believe your Medicare number has been used fraudulently and
that could happen too. Definitely, some people don't know that
(23:30):
they have services.
Speaker 3 (23:33):
They just don't.
Speaker 2 (23:35):
Only give information like your Medicare number to doctors. Insurance
companies and their licensed agents are brokers or plans acting
on your behalf or trusted people in the community who
work with Medicare like your state health insurance assystem program.
Don't share your Medicare number or their personal information with
any insilidous person contacts you by phone, email. Medicare or
(23:56):
your medical representative will only call you a limited situation,
so definitely do not give your Medicare information to just
anyone on the phone. They typically will change your plan,
bill you up some services or products that you don't
even need or know about. Medicare plan can call you
(24:20):
if you're already a member of planned. The agent who
have helped you join also could call you. Customer service
represented from eight hundred Medicare can call you if you
left their message, or representative that someone called you would
call back. Find yourself if you fold a report of
suspective fraud you get a call from someone representing Medicare
to fallo up on the status of your suspected fraud reportort.
(24:43):
For more information about Medicare fraud, visit medicare dot go,
slash fraud, or contact your local Senior Medical Patrol. Learn
more about the Senior Medicare Patrol and help bind your
state by going to SMP resource dot org or call
eight seven seven eight zero eight two four six eight.
So thank you for for listening today. My name is
(25:06):
Jennifer Lee, your Medicare three sixty host. I look forward
to talking to you guys next week. Have a wonderful day.
Speaker 1 (25:17):
Thank you for joining the program Medicare at three sixty.
Hope you found today's episode insightful and empowering. Remember understanding
your Medicare options is key to making the right choices
for your health and financial well being. If you have
questions or topics you would like covered in future episodes
of Medicare three sixty, don't hesitate to reach out and
(25:39):
speak with our licensed insurance agent. Until next time, stay
informed and take charge of your healthcare journey. This has
been Medicare three sixty, your trusted source for all things Medicare.
Take care,
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