By Betty Berry, Tuesday, June 22, 2010  Q: We have heard over and over that we, the users of the system, should review our Medicare Summary Notices and report any errors found.

What action can we expect from the Medicare System when we make a fraud complaint? What, if anything, is done to the providers who are found guilty of fraud?

Also, I understand that the healthcare reform that has just been passed will be addressing Medicare fraud — what can we expect?

A: An excellent question. Your question is also very timely as a panel presentation on this very subject is scheduled this month.

“Medicare Fraud — How Does It Happen? — How Is It Detected? — How Is It Investigated?” is scheduled for Monday from 1:30 to 3 p.m. at the Goebel Senior Adult Center, 1385 E. Janss Road, Thousand Oaks.

Panel presenters from the Centers for Medicaid and Medicare and the Senior Medicare Patrol will discuss how fraud happens, areas in which it occurs and what to look for.

The presenters will also provide tips on what you can do to help prevent fraud and abuse. As a consumer you are often in the best position to alert Medicare to possible fraudulent activity.

This should be an eye-opening presentation and one that every user of the Medicare program should attend to learn how scammers work.

If you have questions about how fraud affects your benefits or how it taxes the system overall, this is the seminar you should attend.

Q: I can’t understand why they make senior healthcare coverage so difficult to understand. Plans refer to deductibles, coinsurance, copayments and share-of-cost. Are these terms interchangeable?

A: The insurance industry, like all other businesses, has a unique vocabulary to describe its services. The government plans that cover senior healthcare are no different.

While the terms you mention do sound alike there are subtle differences and the terms are used in conjunction with different types of healthcare coverage.

A deductible is the initial specific amount of money that the insured is required to pay toward healthcare expenses before the insurance company will start to cover the cost. You’ll find this term is used by Medicare in Part A (hospital coverage), which has a deductible of $1,100 each time you enter the hospital. Part B (medical coverage) has an annual deductible of $155 before Medicare covers the costs and Medicare Part D (prescription coverage) plans have variable deductibles of zero to $310 depending on the plan selected.

Coinsurance is the percentage of the cost of care the insured is required to pay after the healthcare plan has paid. Medicare Part B’s coinsurance is usually 20 percent of the Medicare approved amount.

Many employer’s plans also use the 80/20 coinsurance ratio with the insurance paying 80 percent of the cost and the patient being responsible for the remaining 20 percent.

A copayment is a fixed amount the insured is required to pay for each medical service received, such as a doctor’s visit or prescription purchase. Co-payments are usually found in managed care coverage such as HMO and PPO plans. They usually range from $5 to $25 per service.

The term share-of-cost is associated with the Medi-Cal program. It is actually another way of describing a deductible. The amount of share-of-cost, however, is not a fixed amount but varies depending on the income of the insured.

— Betty Berry is a senior advocate for Senior Concerns. The advocates are at the Goebel Senior Adult Center, 1385 E. Janss Road, Thousand Oaks, CA 91362; phone 495-6250 or e-mail You are invited to submit questions on senior issues.


Print Friendly, PDF & Email