momsie Asked May 2013
Can I ask the nursing home for copies of the bills they send to medi-cal for my husband's care?
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My husband, who lives in a nursing home, wears dentures. In January he went to the dentist to be evaluated for dentures,after taking x-rays, they said the best they could do was to repair his dentures. I paid for this out of pocket . Two weeks ago, in May, a "new" dentist came into the nursing home. The patients were all lined up for dental x-rays, the social worker was insisting my husband have the xrays done regardless of his January x-rays and the fact he has no teeth. We were told the x-rays would not cost anything---and they want a baseline. I have a feeling these x-rays were were billed to medicare or medical.
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Your husband's dentist could have provided copies of the ones he had. The Social worker doesn't really have the right to insist that he get new x-rays.
You can actually get this info from CMS - Centers for Medicaid and Medicaid. CMS is the federal clearinghouse for all funds spent by the states and the feds on these programs. For my mom, all items billed to Medicare for her are itemized and sent on a pretty regular basis to her home address by CMS. She still has her home and that address is where SS has as her permanent address so that is why Medicare send it there. The statements show for example: physical therapy gait training, .30 time at $ 150 hr etc. You can go on-line to see this stuff too. Just Google CMS and then go to the drop-down list to request payment details.
The NH is probably getting his Medicare statements so you don't see them. But you can request as his representative and spouse to get them. Again you can do this on the CMS website.
For Medicaid, that's state managed. For TX it's really difficult to get sent to you individually. If I wanted it, I would have to get it from the business office or send a faxed request to the state program. Takes a bit to get it too and then you get like it in triplicate months later.
If you suspect fraud or duplication of services and Medicare or Medicaid paid for the services (either total or in part), then you can request a Stark Law review of the providers by the state or federal program. Stark is not something to do in a fit of pique or being annoyed at the facility as it is totally sticky. Stark gets to be a pretty serious investigation into the providers and it is a federal offense. If you do Stark, you should (in my opinion and experience) wait to file it when you are about to move your DH to another NH. Stark places a big time penalty at the best and huge financial lein or license removal at the worst on a provider or facility. Most Stark issues come about when the facility has providers doing services and being paid for them when they have a degree of ownership in the facility or a degree of control on having the NH resident referred to them for billable services. Like NH owner is also co-owner of an INC which is the pharmacy which the NH buys med's from OR the NH owners wife owns a LLC that provides the linen service to the NH - and Medicare or Medicaid pays for a part of those costs and the costs are significantly inflated, then there could be a Stark issue. So if the dentist has this sort of relationship with the NH there could be a Stark issue. CMS has an outside contractor - HMS - who does duplication of service and fraud compliance which can lead to a Stark complaint against a provider. HMS is very very good at what they do, and seem to have whole algorithm programs to verret out fraud. Plus being quasi-fed's they can have access to databases on all payments to vendors. Often a single letter questioning a payment to a NH or a provider will lead to a investigation by CMSin which HMS does the background and details. If something is amiss,there can be an investigation which can lead to a federal action to be brought against the NH or providers. Stark is pretty serious and what most Medicare / Medicaid fraud is done through. Stark only works if payment is via Medicare or Medicaid, doesn't work for private pay or LTC insurance stuff.