Senior Medicare Patrol: Fighting Medicare Fraud Funded by the U. S. Department of Health & Human Services - Administration on Community Living / Administration on Aging
SMP: From Idea to National Program Through Public Law 104 -208 ( est. 1997) — Administration on Aging established 12 demonstration projects recruit and train retired professionals to detect and report potential error, fraud, and abuse There now are SMP projects in all states, Washington DC, Puerto Rico, Guam, and the U. S. Virgin Islands.
Three Roles of SMPs 1 Disseminate SMP Fraud Prevention and Identification Information through media, outreach campaigns, community events, etc. 2 Assist beneficiaries in resolving issues and complaints re: Medicare, Medicaid, and other related health care and consumer issues 3 Make referrals of suspected cases of fraud, waste, and abuse to appropriate investigative entities (e. g. , Medicare contractors, MFCU, AG, OIG, CMS)
Little Quiz How many Medicare beneficiaries in the state of California ◦ _______________ How much did Medicare pay in claims? ◦ _______________ What is the #1 state for losses due to Medicare and Medicaid fraud and abuse? ◦ _______________ #2, #3, #4 states? ◦ Source: Congressional Business Office (CBO) for 2012
Background: The Problem is Pay and Chase The Medicare program loses billions of dollars each year as a result of errors, fraud, and abuse. * *Source: DHHS Office of Inspector General
Identity Theft is the Door to Medicare Fraud - Compromised Beneficiaries
It is important to note that the number used by Medicare on its insurance cards contains a Social Security Number. This number is as important to thieves as a credit card.
Who is Affected? Medicare and Medicaid Beneficiaries • How? • Diminished quality of treatment • Less money for needed benefits Taxpayers • How? • Billions of tax dollars wasted
Common Fraud Areas 1. Ambulance Services 2. Clinical Lab/Independent Physiology Labs 3. 4. 5. 6. 7. 8. 9. 10. 11. Durable Medical Equipment (DME) Suppliers Home Health Agencies Hospice Care Hospital Services Medicare Advantage / Managed Care Plans Medicare Prescription Drug Plans Mental Health Services Nursing Facilities Physician/Practitioner Services & Kickbacks
Who Perpetrates Medicare Fraud and Abuse? Fraud can be committed by any person or business in a position to bill the Medicare program or to benefit from Medicare being billed Doctors and health care practitioners Suppliers of durable medical equipment (DME) Employees of physicians or suppliers Home Health Agencies, Hospice Beneficiaries
Beware of providers who advertise free services -Capper situation -Received case from Ventura HICAP -Capper situation: Two beneficiaries, husband wife, were home when they received a visit from an unknown person who was offering free services and was willing to drive them to fake clinic where they were then asked for Medicare numbers. Case accepted and submitted to the OIG on 8 -1 -13
Examples of Fraud Billing for services or supplies not provided Altering claim forms to obtain a higher payment amount - UPCODING Billing twice for the same service or item Billing separately for services that should be included in a single service fee - UNBUNDLING
Manhattan Doctor Pleads Guilty To $8. 5 Million Medicare Fraud Scheme Dr. ROBERTO AYMAT participated in scheme to defraud Medicare out of approximately $8. 5 million through the use of fraudulent HIV/AIDS clinics. Billed Medicare for medications never administered or not medically necessary. Recruited HIV/AIDS patients eligible for Medicare, and paid them kickbacks. Billed Medicare for more than 10 times the number of units of prescription drugs actually purchased.
L. A. Doctor Convicted of Multi. Million Dollar Medicare Fraud Case Operated a Health and Beauty Clinic Performed radiofrequency laser and liposuction Stole Medicare numbers from patients Obtained Medicare numbers from others via recruiters Submitted fraudulent claims for: ◦ Revascularization ◦ Ablation of a bone tumor ◦ Placement of radiotherapy catheter in breast
It Could Happen to Anyone. . Ø Doctor’s provider ID stolen Ø Used prescription pads to order large quantities of pain meds Ø Sold on the streets of L. A. Ø Doctor’s rep ruined It Happened to Her
Medical Billing Codes One hospital statement could involve tens of people generating a single patient’s bill American Medical Association- “Nearly 20% of claims have errors” ICD -9 Codes: approx 15, 000 ICD – 10 Codes: 68, 000 new codes ◦ Implementation deadline extended to 2014
Consequences to Beneficiaries Theft of Medicare/Medi-Cal numbers leads to false claims Beneficiary’s file may be notated as a problem Benefits may be affected— file may be flagged (CNC) DO NOT PAY Theft of SSN often leads to identify theft and theft of banking information
Telemarketing/Phone Scams Ø Fraudster calls consumers early in the a. m. Ø Sales pitch is done rapidly, usually with a foreign accent Ø Deliberately confuses people into believing the caller represents Social Security or Medicare ØPromises a new Medicare card or medical card OR Øoffers free medical alert equipment Ø To get their checking account information
It happened to her… Phone scam followed by a home visit from "Medicare" -Woman in Sherman Oaks, CA received a call on 10/23/2013 from a woman who claimed to be from Medicare. The woman told beneficiary "we're going to your home. " -The following day she was visited by "Richard from Medicare“ -Told that the state is forcing everyone to use HMO and that she has to be switched into one. Beneficiary was concerned about losing access to her doctor and gave her Medicare number, Medi -Cal number, and her Part D information.
Fooled by a criminal Stranger called her to verify her Medicare number Ø Promised her gloves for her arthritis Ø Drove her 300 miles for an ‘exam’ Ø Had her ‘sign’ a form Ø Billed Medicare $1000 for tests Ø
Social Networking Ø Fraudster makes a fake profile to "friend" you on Facebook Ø Browses through your profile and personal information Ø Uses that information to contact you; obtain additional information Ø You never know who is on the other side of that friendly picture! Ø Check privacy settings
Durable Medical Equipment (DME) Ø Why DME? ◦ Until recently: ◦ no professional licensing requirements ◦ Suppliers could set up shop with very little investment ◦ Huge potential for quick profit Look For Unauthorized, unsolicited supplies sent to beneficiaries Doctors receive fax from supplier requesting authorization for supplies DME providers obtaining medical information illegally
$1 Million DME Fraud DME supplier in Southern California 95% of his submitted claims were for power wheelchairs Many of the beneficiaries never received the equipment or did not need the equipment Most of the Medicare numbers were provided by patient recruiters who received kickbacks
Compromised Medicare # Ø Someone It Happened to Her used her Medicare number Ø Billed Medicare for durable medical equipment including a wheelchair Ø When she needed a wheelchair, Medicare denied the claim
The face of Home Health Fraud Social worker in Colorado Worked through several home health agencies Found opportunities to obtain more Medicare funds Did bookkeeping, cleaned cabinets, played cards Submitted claims for all of these activities to Medicare but coded as Medicarecovered services
Clinical Laboratories Ø Why Laboratory Services? ◦ Physicians do not see what is billed to Medicare ◦ Labs not required to submit diagnosis information to support the need for the services Look For Medically unnecessary services billed Providers ‘strongly urging’ patients to go to a specific clinic Unbundling (e. g. , one blood panel listed by individual test) Tests (not ordered) performed and billed
Hospice Care Ø Why Hospice Care? ◦ End of life issues create extremely vulnerable situation ◦ Beneficiaries (and families) unaware of items billed to Medicare Look For Beneficiaries who are not terminally ill enrolled in hospice Beneficiaries who do not understand how hospice is covered Confusion with MA plan members (regular Medicare pays for hospice under Part A)
Medicare Advantage (MA) Plans Ø Why MA Plans? Dramatic increase in the number of managed care plans Look For Insurance agent’s marketing violations They hire independent agents No statements sent to members (except EOBs for Part D plans) Agents switching to their plan without beneficiary consent or knowledge Cold calling (if no prior relationship) New: Medicare Summary Notices to be sent effective October 2014
Pharmacies Part D Prescription Drug Program 2006 ◦ $50+ billion dollar program Approx 60, 000 pharmacies in U. S. Typically do not report suspicious patterns Most likely fraud: ◦ Kansas: 1000+ Rx for 2 patients ◦ Los Angeles: $8. 4 million billed (9 times the national average) Billing hundreds of Rx for a single beneficiary Claims for brand name drugs but dispensing generics Large # of claims for refills, never requested
2013 CVS Caremark Corp. Fraud Investigation 2 nd largest drug store chain in the United States Customers in California and other states have been surprised to find that CVS had renewed their prescriptions and billed their insurers without their consent
Some of OIG’s Most Wanted Fugitives http: //oig. hhs. gov/fraud/fugitives/index. asp
Complexity = Confusion = Opportunity for Fraud Cal Medi. Connect Covered California Affordable Care Act
If you have Medicare… If you have Medicare Your Medicare coverage is protected. Medicare isn’t part of the Health Insurance Marketplace established by ACA, so you don't have to replace your Medicare coverage with Marketplace coverage. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you’ll still have the same benefits and security you have now. You don’t need to do anything with the Marketplace during Open Enrollment. 46
The Affordable Care Act Adding ability for Department of Health & Human Services to disallow provider enrollment Implementing a ‘smart, automated system’ to proactively identify fraudulent claims ◦ “Fraud Prevention System” Integrating Medicare and Medi-Cal Partnering with private insurers and Medicare Advantage Plans Increasing law enforcement – Office of Inspector General
Same Sex Marriage & Delaying Enrollment in Part B (Medical Insurance): Medicare Part B covers a portion of: -Doctors' services -Outpatient physical therapy -Certain ambulance services -Outpatient hospital care -Laboratory tests -Outpatient speech therapy -Certain home health care -Certain medical equipment and supplies Part B coverage is optional. If you and/or your spouse still works when you become eligible for Medicare, you will need to decide whether to sign up for Medicare or postpone your enrollment. The Medicare Part B premium ($104. 90 in 2014) Get informed and find out how this may affect your coverage: - Her spouse presently works and they are covered under the county health plan as employee and spouse. - When she turned 65 in 2012, Social Security told her she did not have to sign up for Medicare Part B since she was covered under the Employer Group Health Plan (EGHP). -Everything was fine until May of 2013, when Medicare contacted her and said that she had been given incorrect information. She did in fact have to sign up for Part B since the Federal Government does not recognize same sex marriage. If you have questions about how a same-sex marriage may affect your claim, please call 1 -800 -772 -1213 (TTY 1 -800 -325 -0778) or visit the Social Security Administration (SSA) website at http: //www. ssa. gov/same-sexcouples/
Update: Medicare and Gender Reassignment Surgery The Obama administration is set to re-examine the ban that prohibits Medicare from covering gender reassignment surgery. “Current Medicare standards are based on science from the 1960 s. The ban on gender reassignment surgery: “Fails to account for development in the care and treatment” for transgender people over the course of the last 30 years. The current scientific evidence overwhelmingly shows that sex-reassignment surgeries are effective and medically necessary treatments for some transgender individuals.
Protect, Detect, Report Ø Purpose of this Module Ø Prepare volunteers to recognize fraud Ø Educate beneficiaries (Protect) Ø Perform 1/1 counseling (Detect) Ø Refer cases for investigation (Report)
Protect üTreat the Medicare card as your credit card üDon’t carry with you until you need it for visits to doctor, clinic or pharmacy üNever give your Medicare number to a stranger üRecord doctor visits, tests and procedures in personal healthcare journal or calendar üSave MSNs and Part D Explanation of Benefits; shred when no longer needed Remember: Medicare does not call or visit to sell anything
Detect üReview MSNs and Part D Explanation of Benefits (EOB) for possible mistakes üAccess my. Medicare. gov account üCompare MSNs and EOBs to personal health care journal and prescription drug receipts to ensure they are correct üLook on billing statement for: § Charges for item or service not received § Billing for same thing twice § Services not ordered by doctor
Report Ø Ask questions Ø Seek assistance Ø Use written records Ø Contact SMP üCollect Evidence ü Marketing Flyers ü Business Cards ü MSNs ü Narratives üCall SMP toll free hot line 855 -613 -7080
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