Bamboozled March 16, 2017: Medicare patient suspects fraud. Here’s why she was wrong.

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Arleene Birenkrant sits with her Medicare benefits statements. She believed new charges from her oncologist – for visits she never had – were fraud.

Arleene Birenkrant of Morganville is a breast cancer survivor.

She had surgery in 2013 and radiation in 2014, and now, her health is good.

After radiation, her surgeon recommended an oncologist for her follow-ups.

“They take blood and write a prescription for a little pill daily for the cancer,” Birenkrant said of her visits, which she said are every six months.

All was well until July 2016, when Birenkrant, a Medicare beneficiary, noted something different on her benefits statements.

There was a charge for her regular office visit, but also a second charge for $160.

The statement read “Oncology Care Model (OCM) Monthly Enhanced Oncology Services (MEOS) payment for enhanced care manage (G9678).”

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Arleene Birenkrant questioned some charges that appeared on her Medicare beneficiary statements

She wasn’t sure what the charge was for, and at first, she didn’t question it.

But the next month, August, her benefits statement showed another $160 charge with the same description.

“I didn’t see the doctor,” Birenkrant said. “I only see him every six months.”

Unsure of what the charges were for, she said she and her husband contacted the billing office, which said, “It’s government-approved,” and said nothing further.

Monthly $160 charges continued through December, and the couple found the charges suspect.

In October, the couple called Medicare, which said it would look into it.

When it was time for Birenkrant’s next six month appointment, she said she asked the oncologist about the costs.

“He said, “It’s not coming out of your pocket so what’s the big deal?” Birenkrant said. “He said, ‘Think of it this way: It’s like the government paying the farmers not to plant a crop.'”

That response troubled Birenkrant and her husband, who was also in the room and witnessed the comments.

She tried Medicare again, but the agency said it was still checking.

Then she sent letters to President Donald Trump, Department of Health and Human Services Secretary Tom Price and House speaker Paul Ryan, but she hasn’t received any responses.

And she reached out to Bamboozled.

CHECKING IT OUT

We reached out to the oncologist, and while we waited for a response, we did some checking.

The $160 per month charges were for a new program meant to help cancer patients receive ongoing care.

The Oncology Care Model (OCM) works like this:

“The Center for Medicare & Medicaid Innovation (CMS Innovation Center) is developing new payment and delivery models designed to improve the effectiveness and efficiency of specialty care,” the Medicare website says.  “Among those specialty models is the Oncology Care Model, which aims to provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare.”

The site says 190 practices across the country participate in the program, which includes “financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.”

The idea behind the program is to give “enhanced services” leading to “higher quality, more coordinated oncology care.”

That sounds terrific, in theory, but Birenkrant said she was never told she was part of the program.

So we wanted to know if a provider needs a patient’s permission to put them in the program.

No permission is needed, a Medicare spokesman said.

“When practices choose to participate in the Oncology Care Model, all of their Medicare beneficiaries who meet the eligibility criteria of this initiative will receive care under the initiative, including access to patient-focused services,” the spokesman said. “If a beneficiary does not wish to receive care under OCM, he or she can choose a health care provider who does not participate in this initiative.”

The spokesman said patients must be provided with a beneficiary notification letter “prior to their first chemotherapy administration or second E&M visit, whichever is earlier.”

“If the patient does not receive one of the qualifying chemotherapies, he or she would not be in the model,” he said.

Uh-oh.

Birenkrant never had chemotherapy. She only had radiation.

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The Medicare fraud army you’ve never heard of

Learn how the Senior Medicare Patrol can stop scams and ensure your Medicare bills are accurate.

When we heard back from the doctor’s office, it shared an interesting explanation.

The medication Birenkrant is on — anastrozole — is considered a chemotherapy drug, the oncology practice said.

And that’s correct, our research found. It’s a hormonal treatment that helps fight breast cancer by lowering the amount of estrogen in the body, and it’s considered chemotherapy.

So Birenkrant, indeed, qualifies for the program.

Many patients have questioned the charges since the program started in July, the practice said.

Because of the confusion, Medicare, earlier this month, offered two letters that can be given to patients who ask about the charges. You can see those here and here.

The practice also said the oncologist denied making the statements about farmers and crops to Birenkrant, but he did remember a conversation in which the oncologist explained it was a government program.

And all patients included in the program receive a beneficiary notice, the practice said.

Birenkrant maintains that she never received the document, and she’s not happy about being in the program.

“Who would have thought? $160 a month because of a little pill?” she said.

She said she still doesn’t want to be in the program, so she may start shopping for a new oncologist.

While Birenkrant was wrong about her initial fear of Medicare fraud, her instinct to question charges that didn’t make sense was spot on.

All consumers need to carefully read their benefits statements to make sure the charges are correct.

If you suspect Medicare fraud, consider enlisting the Senior Medicare Patrol, a squad of senior volunteers trained to be advocates and recognize fraud and other billing errors.

You can learn more about SMP and its efforts online, or call (877) SMP-4359.

Have you been Bamboozled? Reach Karin Price Mueller at Bamboozled@NJAdvanceMedia.com. Follow her on Twitter @KPMueller. Find Bamboozled on Facebook. Mueller is also the founder of NJMoneyHelp.com. Stay informed and sign up for NJMoneyHelp.com’s weekly e-newsletter.

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