Palmetto_rgb_webFor many years, the Centers for Medicare & Medicaid (CMS) has funded programs to reduce claims payment errors (either paying too much, paying too little or payments being made when none should be).  Some of these programs are handled through systematic checks that look for anomalies and mismatched services, and some are handled through clinical reviews of specific claims. 

The program integrity initiatives pertaining to Railroad Medicare include:

Medically Unlikely Edits (MUEs) – These are systematic checks that look for claims that exceed the maximum number of services expected to be reported, in most cases, for a single patient by the same provider on a single day.

National Correct Coding Initiative (NCCI) Edits – These are also systematic checks, and they look for combinations of codes that should not be reported together in all or most situations.  Either we would not expect both services to occur in one treatment, or Medicare does not reimburse both services when performed together.  This could be two codes that represent different methods of performing the same service, such as a laparoscopic gallbladder removal and an open incision gallbladder removal.  It could also be two codes that are components of each other, such as a rhythm electrocardiograph (ECG) and a cardiovascular stress test, which by definition includes an ECG.

Medical Review Program – This initiative involves complex reviews by Medicare (including Railroad Medicare) in which documentation is requested, and then the reviews determine if the claim was correctly billed and properly documented, and that the services meet Medicare coverage criteria. 

Comprehensive Error Rate Testing (CERT) Program – This initiative involves complex reviews in the same manner as the Medical Review program.  External entities include the CERT Review Contractor, the CERT Documentation Contractor, and the CERT Statistical Contractor, and they work together to review a random sample of claims and determine an error rate for local Medicare, as well as Railroad Medicare.  They do this by:

  • Requesting medical records from providers who submitted claims
  • Reviewing claims and medical records for compliance with Medicare coverage, coding and billing rules

The CERT program calculates an improper payment rate, and it also develops an improper payment rate by claim type, to measure Medicare (and Railroad Medicare’s) performance processing claims correctly. 

Working together, these initiatives reduce the number of claims that are underpaid, overpaid or should never have been paid. 

If you have any questions about your Railroad Medicare coverage, please call Palmetto’s Beneficiary Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. Members can sign up for email updates. To do so, visit Palmetto’s website at and click ‘Email Updates’ on the top of the webpage to start the process. 

Visit Palmetto’s Facebook page at

Palmetto_rgb_webThe start of a new year is the time for resolutions. Railroad retirees covered under Medicare can receive the help they need in making some of their resolutions a reality.

According to, the top three New Year’s resolutions are:

  1. Lose Weight
  2. Volunteer
  3. Quit Smoking

The year 2015 can be a year of change with the help of Medicare’s coverage of obesity counseling.

All Medicare patients with body mass indexes (BMI) of 30 or more are eligible for counseling if performed in a primary care setting – such as in a doctor’s office. When conducted in a doctor’s office, it can be coordinated with a personalized prevention plan. The patient will pay nothing for this service as long as the primary care provider accepts Medicare assignment. Patients should also ask questions if their doctor recommends other services to be sure that Medicare covers them.

Some of the covered counseling services include one face-to-face visit each week for the first month, one face-to-face visit every other week for months two through six, and then one face-to-face visit every month for the seventh through 12th months, as long as the patient has lost at least 6.6 pounds during the first six months.

Medicare is now covering counseling in a group setting for two to 10 people when conducted by providers in the following categories:

  1. General practice
  2. Family practice
  3. Obstetrics/Gynecology
  4. Pediatric Medicine
  5. Geriatric Medicine
  6. Nurse practitioner
  7. Certified clinical nurse specialist
  8. Physician’s assistant

Medicare is also tackling number three on the list of most popular New Year’s resolutions: quitting smoking. Smoking and tobacco-use cessation counseling is a benefit which offers up to eight face-to-face visits in a 12-month period for patients who have not been diagnosed with a smoking-related illness.

The counselor must be a qualified doctor or other Medicare-approved practitioner. The following resources are available to those considering quitting smoking:

For additional resources on smoking and tobacco cessation, visit Medicare’s webpage at

If you have questions about Medicare’s coverage of obesity counseling or smoking/tobacco-use cessation, call the Railroad Medicare Beneficiary Contact Center at (800) 833-4455. Representatives are available Monday through Friday from 8:30 a.m. to 7 p.m. ET.

Email updates are available on Medicare’s website at To register, look for ‘email updates’ under the ‘Stay Connected’ part of the lower left-hand side of the webpage.

You may also receive updates through Twitter or Facebook called ‘My RR Medicare’ located at

Palmetto_rgb_webIf you find yourself in need of a doctor, and you don’t know if one practices near you, or if they participate in Medicare, and you have internet access, you can use the ‘Physician Compare’ tool at

Physician Compare is a website maintained by the Centers for Medicare and Medicaid Services (CMS), and it houses a wealth of information, including physicians’:

  • Names
  • Specialties
  • Gender
  • Addresses and phone numbers
  • Hospital affiliations
  • Medicare assignment status
  • Language spoken

If you don’t know what kind of doctor you need, you can use an advanced search and pick the part of your body that you would like a doctor to examine. The search tool asks more questions and leads you to a listing of doctors in your area who would be a good fit for you.

The website also provides you with maps and driving directions. If you have a account you can save the search results in ‘your favorites’ (at

If you are looking for a practice/group of doctors by specialty, Physician Compare can find these for you, as well.

If you do not have access to the Internet, you can either call 1-800-MEDICARE or our Beneficiary Contact Center, and Customer Service Staff can do the search with you on the telephone. You can reach our toll-free Beneficiary Customer Service Line at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD 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.

We encourage you to visit our Facebook page at We also invite you to join our listserv/e-mail updates. Just select the ‘E-Mail Updates’ in the ‘Stay Connected’ section on the lower left-hand side of our main webpage at

This article, provided by Palmetto GBA Railroad Medicare, outlines the various “parts” of Medicare and explains which types of services are covered under each.

What Is Part A?

Part A includes inpatient hospital, skilled nursing facility (or SNF), nursing home, hospice and home health services care. It also includes long-term care acute care (LTAC). Part A Medicare claims are processed by the local Medicare administrative contractor for your state. Railroad Medicare processes your Part B claims, while your local Medicare administrative contractor handles your Part A claims.

 What is Part B?

Part B services include medically necessary services and preventive services provided by doctors/physicians/surgeons and practitioners (such as nurse practitioners, physician assistants, qualified clinical psychologists, clinical social workers, certified midwifes and certified registered nurse anesthetists). Other providers and suppliers in the Part B program include chiropractors, podiatrists, ambulance services, and laboratories. Claims for these types of services are processed by Railroad Medicare/Palmetto GBA in Augusta, Ga.

 What is Part C?

Part C is Medicare Advantage plans, such as Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO). These plans are offered by private companies that contract with Medicare to cover your Part A and B benefits. Other Medicare Advantage Plans include:

* Private Fee-For-Service (PFFS) – PFFS are offered by private insurance companies and let you receive health care from any doctor or other health care provider or hospital in the PFFS plan. Prescription drug coverage may also be offered by a PFFS plan.

* Special Needs Plans (SNP) – SNP limits membership to patients with specific illnesses and customizes their benefits to serve the needs of their members. For more information on SNP, please visit

* Medical Savings Accounts (MSA) – MSAs have a high deductible and in many cases only pays for covered Part A and B services once you have reached your deductible.  The plan deposits funds (which typically are less than the deductible) into a designated account to pay for your health care services during the year.

 What is Part D?

Part D is coverage for prescription drugs, and like Part C, the program is administered by private insurance companies. Part D plans have their own list of covered medicines, with a tiered pricing system. This means that some drugs, such as generics, may be in the lowest tier and have the lowest copayment. Drugs in the highest tiers would have the highest copayment. If you sign up for a Part D plan when you are first eligible you avoid paying a penalty. A penalty would be assessed if you don’t join when you were first eligible and you don’t have other drug coverage or don’t receive “Extra Help”. Beneficiaries with limited income and assets may qualify for “Extra Help” to help pay for prescription drugs. This program is administered through the Social Security program and Medicare. For more information, please visit


DMEPOS stands for coverage of Durable Medical Equipment, Prosthesis and Prosthetic Devices, Orthotics and Supplies. DMEPOS would include items such as walkers, wheelchairs, diabetic shoes, and hospital beds, to name a few. Claims for these and many more products are filed to Durable Medical Equipment (DME) Medicare Administrative Contractors. Railroad Medicare doesn’t handle DME claims.

 An example of how the letters work together

An example of how one procedure is covered by multiple parts of Medicare is for individuals receiving a cardiac pacemaker. The actual pacemaker (which is a DMEPOS — prosthetic device) is billed to your local DME Medicare administrative contractor.  Hospital charges fall under your Part A benefit, and the physician’s fee, including post-surgical care, is billed to Part B.

 If you have questions about your Railroad Medicare (Part B) claims, call Palmetto’s beneficiary contact center at (800) 833-4455, Monday through Friday, 8:30 a.m. until 7 p.m. ET. For the hearing impaired, call TTY/TDD 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 can also visit Palmetto’s website at

For more information about the general Medicare program, or specifically about Part C or Part D, you can contact your local state health insurance counseling and assistance program, or SHIP. SHIP is a free program offered by all 50 states, as well as Guam, Puerto Rico and the Virgin Islands. SHIP counselors can help you learn more about the Medicare program and Medicare supplemental plans, as well as other long-term insurance options. To find a SHIP office for your state, visit and enter “SHIP — State Health Insurance Assistance Program” and select your state. Or you may call (800) MEDICARE for more information.

Would you accept a job paying $1 million to count out $2 billion in $1 bills?

Think again, because working a 40-hour week and counting out $1 per second, you would require 266 years to count out the $2 billion total.

Now that you have an idea how much $2 billion is, consider that in the 12 months ending Sept. 30, 2010, the federal government, through the Department of Justice, recovered $2.6 billion in Medicare health care fraud judgments and settlements from 726 separate defendants.

This $2.6 billion total has exploded from $490 million in 1999, meaning that Medicare health care fraud is on the rise, according to PalmettoGBA, which administers Railroad Medicare.

As we struggle to preserve Medicare – and keep a lid on what we, as current and future retirees must pay for its coverage — it is necessary to do all we can to keep a lid on Medicare inflation.

We can help keep those costs down and help preserve Medicare by recognizing, reacting to and reporting Medicare health care fraud.

Here is what you can do:

  • Examine carefully your Medicare Summary Notices (MSNs).
  • Be alert for charges for services you didn’t receive, double billings for the same service, and procedures or services not ordered by your physician.
  • Keep your Medicare card in a safe place. If it becomes lost or stolen, notify your Medicare provider immediately.

If you see a charge or a date of service that is incorrect, first call your provider and ask about it. If the billing is not corrected, or if you suspect a pattern of improper billing, call the Department of Health and Human Services Medicare fraud hotline at (800) 447-8477, which will initiate an investigation and keep your identity confidential.

For more information on Medicare fraud, visit

If we don’t take the initiative to help keep Medicare costs down, we place the future of Medicare – and our own health care futures – in jeopardy.