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If you suspect that your doctor, hospital or other health care provider is performing unnecessary or inappropriate services or is billing Medicare for services you did not receive, you should report such fraud or abuse immediately to the Medicare carrier or intermediary who handles your claims.

If the Medicare carrier or intermediary does NOT adequately respond to your letter reporting Medicare fraud or abuse, you may send this letter to: HHS - Tips, P.O. Box 23489, Washington, D.C. 20026.

If you prefer to make your complaint by telephone, the toll-free Hotline number is 1-800-447-8477. This number is staffed from 8:00 a.m. until 5:30 p.m. Eastern Standard Time, Monday through Friday. You should ONLY write or phone the Hotline if you have NOT received a satisfactory response from the Medicare carrier or intermediary.

Medicare is a health insurance program for: * people age 65 or older, * people under age 65 with certain disabilities, and * people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). Medicare has:

Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

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Medicare consists of two parts. Part A (hospital insurance) covers hospital care, limited post-hospital skilled nursing facility care, part-time home health services, and hospice care. If you are 65 years old or over, you can receive Medicare Part A insurance without having to pay a premium if you are currently receiving or eligible to receive but have not yet filed for either Social Security or Railroad Retirement benefits or if you or your spouse had Medicare-covered employment by the government. If you are under 65, you can receive Medicare Part A insurance without having to pay a premium if you have received either Social Security or Railroad Retirement benefits for twenty-four (24) months or if you are a kidney transplant or kidney dialysis patient.

Deductibles and coinsurance amounts must be paid by the Medicare beneficiary.

Medicare measures the amount of covered hospital care and skilled nursing care in benefit periods. A benefit period begins on the first day you receive care and terminates after you have been out of the hospital or skilled nursing facility and have not received care in any other facility for 60 consecutive days. Medicare does not limit the number of benefit periods any one beneficiary can have. Beneficiaries are entitled to a lifetime reserve of 150 days of in-patient services.

Medicare Part A covers 90 days of inpatient hospital care for each benefit period. If you need skilled nursing or rehabilitative services after a hospital stay and meet certain conditions, Medicare Part A helps pay for up to 100 days in a participating skilled nursing facility for each benefit period. For the first 20 days in a participating skilled nursing facility, Medicare pays for all approved charges. You must pay a coinsurance amount for the 21st day through the 100th day.

If you qualify, Medicare pays for all approved costs of covered home health care services. You will have to pay a 20% coinsurance charge for certain medical equipment, such as a wheelchair or a walker.

The terminally ill Medicare beneficiaries who select the hospice care benefit are not required to pay deductibles but are required to pay a limited amount for certain drugs and inpatient respite care.

This document provides a letter to request that Medicare reconsider its decision on a Part A claim. Providers of Part A services submit claims for their services directly to Medicare. The provider will charge you for any part of the Part A deductible that you have not met and any coinsurance payments that you owe.

You will receive a determination explaining the decision that Medicare has made on the claim. (If you have received a "Notice of Noncoverage," this is not an official determination. Ask your provider to submit your claim so that you can receive a determination from Medicare explaining the noncoverage of the claim.)

If you disagree with a decision on the amount Medicare will pay on a claim or whether services you received are covered by Medicare, you have 60 days after receipt of the initial determination, which is presumed to be five days after the date of the initial determination notice, to request a reconsideration. (There are procedures to establish good cause for filing a late request for reconsideration.) The first step in the appeal process is to ask for a "reconsideration" of the decision. The initial determination contains the address and phone number of the organization to contact about your appeal.

You will receive a written response of the reconsideration that explains the reasons for the decision. If you disagree with the reconsideration of the decision, AND if the amount in question is $100 or more, then you have 60 days from the date you receive the reconsideration notice to request a hearing with an Administrative Law Judge.

If you are considering such a request, you should contact your local social security office or your personal attorney regarding your appeal as soon as possible. Additional appeals are available and it is important that you carefully observe the time limit for requesting each appeal step.

You may also be able to request a reconsideration by telephone. Contact your local social security office for more information.

Medicare recipients who have diabetes may ask, "Are diabetic supplies covered by Medicare?" Fortunately, the answer is, "Yes." The supplies are covered under two parts of Medicare.

Part B is a medical insurance benefit of Medicare. This part covers "medically-necessary" services such as outpatient care, doctors' services, home health care services, and medical equipment.

For people with diabetes, Part B covers blood sugar self-testing equipment, which includes blood sugar test strips, blood sugar test monitors, lancets and lancet devices.

According to Medicare, the amount of supplies a person receives will vary. For instance, people who use insulin can get a lancet device twice a year and a maximum of 100 test strips and lancets on a monthly basis. People who do not use insulin can also get a lancet device twice a year and 100 test strips and lancets every three months.

When doctors believe it is essential for their patients to receive more test strips and lancets than what has already been issued, Medicare will pay for those supplies.

For people who meet certain conditions, Part B also covers external insulin pumps and the insulin that these pumps use.

The costs for therapeutic shoes and inserts are also covered under Medicare for people suffering with severe foot problems that stem from their diabetes. Before receiving these items, however, patients must first have their doctors confirm that they actually need the shoes or inserts. Then, a podiatrist, prosthetist, pedorthist, or orthotist must prescribed the therapeutic shoes or inserts.

Medicare requires recipients to pay 20 percent of the Medicare-approved amount for these supplies.

Medicare Part D covers the cost of prescription drugs and certain medical supplies. The diabetes supplies that fall under this category are those used for injecting insulin, such as needles, syringes, alcohol swabs, gauze and inhaled insulin devices.

Also covered is insulin that is not injected with an insulin pump.

A co-pay is required from Medicare recipients who also may have to pay a Part D deductible.

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Medicare consists of two parts. Part B (Supplemental Medical Insurance) covers physician's services, certain outpatient hospital services (including emergency room visits), ambulances, diagnostic tests, laboratory services, certain preventive care services such as mammography and pap smear screening, outpatient therapy services, durable medical equipment and supplies, and home health care services not covered by Part A.

Medicare Part B pays 80% of approved charges for most covered services. The beneficiary is responsible for paying a $100 deductible each calendar year as well as the remaining 20% of the Medicare approved charges. The beneficiary may have to pay additional charges if the doctor providing the care does not agree to Medicare's approved charges.

Medicare Part B is a voluntary program and is partially financed through monthly premiums, deductions, and coinsurance payments. The balance is funded by the federal government.

This document provides a letter to request that Medicare review its decision on a Part B claim. Doctors, suppliers, and other providers of Part B services submit claims directly to Medicare. The provider will charge you for any part of the Part B deductible that you have not met and any coinsurance payments that you owe.

A written notice, such as a Notice of Noncoverage, from your doctor is not an official Medicare determination that Medicare will not consider a particular service reasonable or necessary and will not pay for it. Ask your doctor to submit a claim for payment to the Medicare carrier to obtain an official Medicare decision.

If you disagree with a decision on the amount Medicare will pay on a claim or whether services you received are covered by Medicare, you have the right to appeal the decision. The first step in the appeal process is to ask for a "review" of the decision. Many times the initial determination fails to sufficiently explain the reasons for the denial. By asking for a reconsideration or review, the basis for denial will be clarified.

Your appeal can be processed much more quickly if you include a copy of the notice(s) that you received about your claim. If you do not attach a copy of the "Explanation of Medicare Benefits" form to your appeal letter, you will need to describe the services, provide the name of the service provider, and indicate the date the services were provided.

This review must be requested by the patient in writing WITHIN SIX MONTHS after the date of the initial decision. (This period can be extended upon a showing of good cause.) You must request the review in writing and file it at an office of the carrier, the Social Security Administration, or the Health Care Financing Administration (HCFA) office. The address and phone number of the organization to contact regarding your appeal is contained on the notice informing you of the decision made on your request for payment.

You will receive a written response of the review explaining the reasons for the decision and advising you of your right to a hearing and how to request it. If you disagree with the review determination, AND if the amount in question is at least $100 but less then $500, then you have SIX MONTHS after the date of the review determination to request a hearing before the carrier's hearing officer. (This period can be extended upon a showing of good cause.) If you are considering requesting a hearing, you should contact your local social security office or your personal attorney regarding your appeal as soon as possible. Additional appeals are available and it is important that you carefully observe the time limit for requesting each appeal step.

You may also be able to request a review by telephone. Contact your local social security office for more information.

Through the Pharmaceutical Benefits Scheme (PBS), the Australian Government makes a range of necessary prescription medicines available at affordable prices to all Australian residents and those overseas visitors eligible under Reciprocal Health Care Agreements.

Australian residents and visitors from countries with Reciprocal Health Care Agreements with Australia are entitled to subsidised medicines under the PBS. Some clients Centrelink and the Department of Veterans' Affairs are entitled to a further reduced concessional rate. PBS Safety Net provides financial assistance to individuals and families who use a lot of medicines in a calendar year.

The Department of Health and Ageing is responsible for program policy development and overall management of the PBS including administration of the Pharmaceutical Benefits Schedule . Similarly the Department of Veterans' Affairs is responsible for the overall policy for the Repatriation Pharmaceutical Benefits Scheme (RPBS).

Under the PBS and RPBS Medicare Australia makes payments to pharmacists to subsidise medicines on the Pharmaceutical Benefits Schedule. Medicare Australia also makes payments to pharmacists for other PBS related issues including the issue of Safety Net cards, payments in support of rural or remote pharmacies and for the supply of medicines to Aboriginal Medical Services and for the Emergency Drug (Doctor's Bag) system.

Authority prescription approvals are administered by Medicare Australia for prescriptions for which the Pharmaceutical Benefits Advisory Committee limits supply in specified circumstances. We also administer the approval of pharmacists to supply medicines under the PBS, the approval of health care providers in remote areas where there are no adequate pharmacy services and the approval of hospitals to supply PBS medicines to their patients. (SourceThe Australian Government Medicare Australia)

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Peer Review Organizations (PRO's) are groups of practicing doctors and other health-care professionals who review the reasonableness, medical necessity, appropriateness, and quality of hospital care given to Medicare patients. PRO's primarily review complaints from beneficiaries and their representatives regarding Medicare Part A benefits. PRO's have the authority to deny payments if care is not medically necessary or not delivered in an appropriate setting.

PRO's process complaints in one of two ways: (1) concurrently -- while the patient is still in the medical facility receiving services; or (2) retrospectively -- after the patient has been discharged from the facility and is no longer receiving services. Whether the review is concurrent or retrospective, the timing of a PRO's review begins when a complaint is received in writing from a beneficiary or their representative and when the PRO has adequate information to begin the review (e.g. received medical records).

The PRO's must then acknowledge receipt of the complaint. This can be done either in writing or orally. For concurrent review, the PRO's must acknowledge receipt of the complaint within one full working day from receipt. The PRO's have five calendar days to acknowledge receipt for retrospective review.

Whether or not the reviewing PRO identifies any quality concerns during retrospective review, the PRO's completed review or notice must be sent to the medical provider within 15 calendar days after receipt of the medical records. Whether or not the reviewing PRO identifies any quality concerns during concurrent review, the PRO's completed review or notice must be completed and sent to the medical provider within one full working day after receipt of the medical records.

When a patient is admitted to a Medicare participating hospital, the patient receives a publication entitled "AN IMPORTANT MESSAGE FROM MEDICARE." It explains the patient's rights as a hospital patient and provides the name, address, and phone number of the PRO for that patient's state. Carefully read the description of the time frames in which you must take action depending upon various circumstances. Failure to make your appeal within the specified time frames may impact the portion of your hospital stay for which you will be responsible for paying.