Railroad Medicare Protects the Trust Fund

Published 03/07/2018

With millions of claims submitted to Railroad Medicare each year, fraudulent or abusive billing is a possibility that cannot be ignored.  Railroad Medicare is no different than Original Medicare, in that the same providers submitting claims to Original Medicare can also be submitting claims to Railroad Medicare.

Knowing that the potential for fraud and abuse exists, the Centers for Medicare & Medicaid Services (CMS) established seven Zone Program Integrity Contractors (ZPICs), which investigate potential fraudulent and abusive billing for multiple states and jurisdictions.

Railroad Medicare has its own dedicated Benefit Integrity Unit (BIU), which (just like the ZPICs) uses data analysis and referrals from beneficiaries, as well as the Medical Review and Appeals units in house, to ensure that claims are paid correctly.  If the BIU discovers moneys have been improperly paid (which impacts the life of the Medicare Trust Fund), it takes aggressive steps to recover those claims payments.

The BIU works with law enforcement and refers cases to the Railroad Retirement Board Office of Inspector General (RRB OIG) to pursue on a case-by-case basis. Examples of a just a few of the types of issues the BIU investigates:

  • Doctors billing for the same service for the same beneficiary for more visits than would normally be expected 

When examining claims, the unit looks for an intentional deception or misrepresentation (fraud) that could result in payment of an unauthorized Medicare benefit. They also pursue abusive billing - incidents or practices that are inconsistent with accepted, sound medical practices or are medically unnecessary.

Our BIU works hard to fight fraud and abuse, but you can help, too. Sometimes the first indication of fraud or abuse is evident on a Medicare Summary Notice (MSN). When you receive your MSN, please read it carefully. Look to see if: 

  • Your name, address and Medicare number are correct
  • The date(s) of a service on the statement match when you actually had a service
  • The description of the services your doctor billed to Railroad Medicare is correct

If you need help reading your MSN, or you find something on it that appears to be wrong, you can call our toll-free Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. until 7:00 p.m. ET. We offer a TTY/TDD line at 877-566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours Customer Service Representatives are available.

You may also call the Office of Inspector General Medicare Fraud Hotline to report suspected fraud and abuse. Their toll free number is 800-447-8477, or for TTY 800-377-4950.

To keep up to date with what’s happening with Railroad Medicare, you can sign up for email updates at www.PalmettoGBA.com/RR. Click ‘Listserv’ in the bar across the top of the Web page and complete the registration process. We also encourage you to visit us on our Facebook page at www.facebook.com/myrrmedicare.

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