Definitions

Below are some commonly used words and acronyms that a beneficiary may hear when talking about Medicare. Their definitions are based upon how they apply to Medicare and the SMP mission. Definitions are derived from different sources, including Medicare.gov, OIG.HHS.gov, MedicareRights.org, HealthCare.gov, ACL.gov, and Merriam-Webster.com.

Note: The blue and green terms are from the SMP’s mission to prevent, detect, and report, health care fraud, errors, and abuse.

Abuse

Practices that may result in unnecessary costs to the Medicare program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.

Advance Beneficiary Notice of Noncoverage (ABN)

This notice is issued by providers physicians, practitioners, and suppliers to Original Medicare (fee for service, or FFS) beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. This form allows the beneficiary to choose whether or not to move forward with the items or services listed on the ABN. If the beneficiary accepts the items or services listed on the ABN, they might have to pay out of pocket. Specific rules that govern how and when providers use ABNs are further described in the Medicare & You handbook. If a provider was required to issue an ABN but didn’t, the beneficiary usually must be reimbursed.

Annual Wellness Visit (AWV)

Different than a physical, this is a yearly appointment with the beneficiary’s primary care provider to create or update a personalized health prevention plan and check routine measurements such as height, weight, and blood pressure. This service is fully covered by Medicare.

Appeal

The action a beneficiary can take if they disagree with a coverage or payment decision made by Original Medicare or a Medicare health or drug plan.

Beneficiary

The person receiving Medicare benefits.

Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

The agency responsible for reviewing complaints and quality-of-care concerns for people with Medicare to improve the effectiveness, efficiency, economy, and quality of services for people with Medicare.

Compounded Medications

Customized medications that meet specific needs of individual patients and are produced in response to a licensed practitioner’s prescription. They are medications, including topical pain creams, that are mixed from other medications. Compounded medications are often more expensive than medications that are not compounded.

Detect

The act of identifying the presence or existence of Medicare fraud, errors, or abuse. Beneficiaries can detect potential problems by keeping a record of health care visits and services received and comparing that list to their Medicare Summary Notices (MSNs) and Explanations of Benefits (EOBs).

Dual-Eligibles

Medicare beneficiaries who are enrolled in both Medicare and Medicaid.

Error

An honest health care service or product mistake related to billing. A pattern of errors by a physician or provider could be considered a red flag or potential fraud or abuse if not corrected.

Explanations of Benefits (EoBs)

The statements a beneficiary in a Medicare Advantage or prescription drug plan receives after their doctor or medical supply vendor submits a claim for products, services, or prescription drugs. These statements provide details such as what was billed, the Medicare-approved amount for each line item, and the amount that may be owed by the beneficiary.

Fraud

Knowingly and intentionally submitting false claims or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist.

Intent

The determination to act in a certain way. In Medicare fraud, it is knowingly doing something illegal for a financial gain from a federal health care program.

Medicaid

The state-administered health insurance program for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.

Medicare

The federal health insurance program for people who are 65 and older, younger people with disabilities, and people with End-Stage Renal Disease (ESRD).

Medicare Beneficiary Ombudsman

The entity that can assist beneficiaries with complaints, grievances, and information requests about Medicare. This entity makes sure that adequate information is available for beneficiaries to make informed health care decisions, understand their Medicare rights and protections, and know how to get issues resolved.

Medicare Improvements for Patients and Providers Act (MIPPA)

The federally-funded national grant program that supports states and tribes to provide outreach and assistance to eligible Medicare beneficiaries. State grantees encourage beneficiaries to apply for benefit programs that help to lower the costs of their Medicare premiums and deductibles.

Medicare Open Enrollment

The span of time from October 15 through December 7 during which Medicare beneficiaries can change their stand-alone prescription drug plan (Part D) and/or their Medicare health plan choice (Original Medicare or a Medicare Advantage plan) for the following year.

Medicare Summary Notices (MSNs)

The statements a beneficiary on Original Medicare receives every three months after their doctor or medical supply vendor submits a claim to Medicare for products or services. These statements explain what was billed, the Medicare-approved amount for each line item, and the amount that the beneficiary may owe.

Opioid

A class of narcotic medication used to reduce pain, often after an injury or surgery. These substances carry the risk of addiction, overdose, and death. As a result, Medicare has begun to implement policies to help Part D Prescription Drug Plans address opioid misuse among Medicare beneficiaries.

Physical

Different than an Annual Wellness Visit (AWV), this is a hands-on physical exam that typically includes bloodwork or other tests. If a beneficiary requests or is billed for a physical, it will not be covered by Medicare, and the beneficiary will be responsible for the costs.

Prevent

The act of keeping from happening or existing. Keep Medicare fraud, errors, and abuse from happening by protecting your medical information, being cautious when red flags arise related to that information, and regularly reviewing Medicare Summary Notices (MSNs) and Explanations of Benefits (EOBs).

Qualified Medicare Beneficiary (QMB) Program

A federally-funded program that provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries.

Report

The act of giving a spoken or written description of a situation or event. Contact the provider and/or Senior Medicare Patrol (SMP) to provide an account of the potential fraud, error, or abuse you have experienced or identified.

Senior Medicare Patrol (SMP)

The federally-funded national program that empowers and assists Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse. Grantees exist in each U.S. state, Puerto Rico, Guam, the District of Columbia, and the U.S. Virgin Islands.

State Health Insurance Assistance Program (SHIP)

The federally-funded national program that provides free local health coverage counseling to Medicare beneficiaries. Grantees exist in each U.S. state, Puerto Rico, Guam, the District of Columbia, and the U.S. Virgin Islands.

Skilled Nursing Facility (SNF) Care

The nursing and therapy care that is provided to treat, manage, and observe a condition and evaluate patient needs. This may include administration of medications, tube feedings, wound care, and other support that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel.

Spoofing

The act of disguising a caller phone number in order to appear as a different, possibly more familiar, number. This is done to trick a beneficiary into thinking the call is local or coming from a trusted provider. This type of fraudulent effort makes it more likely that the beneficiary will give out personal information like their Medicare or Social Security number.

Telehealth

Medical care conducted by phone or video (virtually) by a medical provider to a beneficiary as opposed to being done in person at a health care facility.

Unbundling

When services that should have been included in one bill are billed separately to increase the payment received by the provider.

Waste

Practices that directly or indirectly result in unnecessary costs to the Medicare program, such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but, rather, by the misuse of resources.

Upcoding

When a provider bills for a more advanced billing code than the code that corresponds with the care provided. This action causes an increase in the payment received by the provider.