Funded by the U.S. Department of Health & Human Services - Administration on Community Living / Administration on Aging
60 Minute tes Video Clip (click link below to to view on Yo You Tube) http://www.google.com/url? sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&cad=rja&ved=0CEMQtwIwAQ&url=http%3A%2F %2Fwww.youtube.com%2Fwatch%3Fv %3DmDvpnRw0NVM&ei=r6zeUqjnAsfuoATd64KoCg&usg=AFQjCNHMd2dSwxK- TbR3Fd7UeqOLPDn89w&bvm=bv.59568121,d.cGU
Who is Affecte ted? All of All of Us! Us! Medicare an Medicare and Medicaid Ben d Medicaid Benef eficiaries iciaries • How How? ? • Diminished quality of treatment • Less money for needed benefits Taxpayers Taxpayers • How How? ? • Billions of tax dollars wasted
Senior Medicare Patr trol: From Idea to to Nati tional Program Through Public Law 104-208 (est. t. 1997) } Administr trati tion on Aging esta tablished 12 demonstr trati tion projects ts } To recruit t and tr train reti tired professionals to to dete tect t and report t pote tenti tial error, fraud, and abuse } Th There ere no now are 54 SMP projects ts in all sta tate tes, Washingto ton DC DC, Puerto to Rico, Guam, and th the U.S. Virgin Virgin Island Islands. s.
3 Roles 3 Roles of of S SMP MP s s 1 1 2 2 3 3 Assist t beneficiaries Refer suspecte ted cases Di Disseminate te SMP in resolv in resolvin ing issu issues es of fraud, waste te, and Fraud Preventi tion and complaints ts abuse to to investi tigati tive and Identi tificati tion enti titi ties Informati tion
Prote tect, t, De Dete tect, t, Report t Ø Purpose of th this Module Ø Prepare volunte teers to to recognize fraud Ø Ed Educate te beneficiaries (Prote tect) ) Ø P Perf erform orm 1/1 cou 1/1 counselin eling ( (De Dete tect) ) Ø Refer cases for investi tigati tion (Report Report) )
} How much does Medicare pay in claims every year? ◦ _____________________________ } Which state is #1 in losses due to Medicare and Medicaid fraud and abuse? ◦ _____________________________ } #2, #3, #4 states? Source: Congressional Business Office (CBO) for 2012
Identi tity ty Theft t … …
= = G Guard you ard your card! r card!
Ev Every Medicare Benefit t can be a Pote tenti tial Fraud Area Amb Ambulance ulance Services Services 1. 1. Clinical Lab/Independent t Physiology Labs 2. 2. Du Durable Medical Eq Equipment t (DM DME) E) Suppliers 3. 3. Home Health th Agencies 4. 4. Hosp Hospice ice Care Care 5. 5. Hospita tal Services 6. 6. Medicare Advanta tage / Managed Care Plans 7. 7. Medicare Prescripti tion Dr Drug Plans 8. 8. Menta tal Health th Services 9. 9. 10. Nursing Faciliti ties 10. 11. Physician/Practi titi tioner Services 11.
Who Perpetr trate tes Medicare Fraud an Frau d and Abu d Abuse? se? Fraud can be committe tted by any person or provider able to to bill Medicare OR benefit t from Medicare being billed Docto Do tors and health th care practi titi tioners Suppliers of durable medical equipment t (DM DME) E) Em Employees of physicians or suppliers Home Health th Agencies, Hospice Benef Ben eficiaries iciaries
Some of OIG’s Most t Wante ted Fugiti tives http ttp://oig.hhs.gov/fraud/fugiti tives/index.asp
Some Ex Examples of Fraud } Alte tering claim forms to to obta tain a higher payment t amount t – – UPCODI DING ◦ Ex Example: A flu shot t billed as a shingles shot t } Billing tw twice for th the same service or ite tem } Billing separate tely for services th that t should be included in a single service fee service fee - - UNBUNDL DLING ◦ Ex Example: A comprehensive blood panel billed as individual te tests ts } Billing for services not t rendered or supplies not t provided
Beware of providers who adverti tise free fr ee ser servic vices es • Capper case (reported by Ventura HICAP) • Two beneficiaries, husband and wife, were visited at home by a stranger offering free medical services and equipment • Stranger drove them to a clinic where they were asked for their Medicare numbers • They were sent home with a box of Ensure • Their Medicare Summary Notices showed claims for services not rendered however Medicare paid the provider • SMP referred case to OIG for investigation in August 2013
L.A. Do Docto tor Convicte ted of Multi ti- Million Do 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
Beneficiaries Are th the Victi tims of Medicare Fraud Medicare Frau d • Identi tity ty Theft t – – sto tolen Medicare/Medi Medi-Ca -Cal numbers can lead to to false claims • Beneficiary’s Medicare file may be nota tate ted as a problem problem • Benefits ts may be sto topped – – Medicare number ma may be fl flagge gged as s a “Co “Comp mpromi mise sed Numb Number” ” • DO DO NOT PAY Y • Theft t of SSN can lead to to th theft t of banking informati tion
Compromised Comp romised Med Medicare icare # # Ø Someone used her Medicare number to submit fraudulent claims for a wheelchair Ø Medicare paid the claims to the fraudster Ø When she needed a wheelchair, Medicare denied her legitimate } It t Happened to to Her claim
Beware of str trangers masquerading as Medicare as Medicare Phone scam case followed by a home visit from “Medicare” • Senior in Sherman Oaks received a phone call on 10/23/2013 from a woman • claiming to be from Medicare. The woman said she was ‘going to visit the senior at her home.” • The next day, she was visited by a man named Richard who said he was from • Medicare. He told the senior that a new state law requires her to enroll in a Medicare • Advantage plan (HMO) and he was there to help her. The senior was afraid of losing access to her doctor so she gave him her Medicare number, Medi-Cal number and Part D plan information. Senior was enrolled in a health plan which raised her premium and she lost • access to her doctors. SMP referred the case for investigation. •
Fooled by a Crimin Fooled by a Crim inal al Ø 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
Telemarketi ting/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 Ø Promises a new Medicare card or medical card OR OR Ø offers free medical alert equipment Ø Purpose: To get their checking account and credit card information
Du Durable Medical Eq Equipment t (DM DME) E) Ø Why DM DME? E? Look For Look For ◦ Until recently: } Unauthorized, unsolicited supplies sent to ◦ no professional beneficiaries licensing requirements } Doctors receive fax from ◦ Suppliers could set supplier requesting up shop with very authorization for supplies little investment } DME providers obtaining ◦ Huge potential for medical information quick profit illegally
$1 Million DM DME E Fraud } DME supplier in Southern California } Gained access to skilled nursing facilities and board and care homes } 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
} Implemented in many counties in California } Requires competitive bidding and lower prices from equipment suppliers } Forces suppliers to have surety bonds and legitimate places of business } Reduces the number of suppliers } So fraudsters will move to ‘greener pastures’
The face of Home Health th 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 Medicare- covered services
Picked up at t downto town Em Emergency Drop- in Cente Dr ter by fraudste ter Transporte ted to to a local Homeless Med Homeless Medicare icare hospita tal with th benef ben eficiary on iciary on S Skid Row kid Row questi tionable diagnosis Moved to to Skilled Nursing Facility ty; promised 90 days days of of h hou ousin ing paid f paid for by Medicare or by Medicare
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