Funded by the U.S. Department of Health & Human Services – Administration on Community Living
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 } 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 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.
Th Three Roles ree Roles of of S SMP MPs 1 1 2 2 3 3 Disseminate Di te SMP Assist t beneficiaries Make ref Make referrals errals of of Fraud Preventi tion in resolv in resolvin ing issu issues es suspecte ted cases of and Identi tificati tion and complaints ts re: fraud, waste te, and Informati tion Medicare, Medicaid, Medicare, Medicaid, abuse to to appropriate te through media, th and oth ther relate ted investi tigati tive enti titi ties outr treach health th care and (e.g (e.g., Medicare ., Medicare cam campaig paigns, s, consu con sumer issu er issues es contr tracto tors, MFCU, community ty AG, AG, OIG, OIG, CMS) CMS) events ts, etc tc.
You Make a Di Yo Difference } Thank you for being an advocate te for seniors } Ombudsman play a vita tal role in preventi ting, identi tifying and reporti ting pote tenti tial health th care f care frau raud an d and abu d abuse se } Keep th this Medicare Fraud hot t line number handy … … 855- 855-613- 613-7080 7080
Th The P e Problem roblem: : Medicare is Medicare is P Pay an ay and Ch d Chas ase e Th The Medicare prog e Medicare program ram los loses es billion billions of dollars each year as a result t of errors, errors, fr fraud ud, an and abu d abuse se
Who is Affecte ted? Medicare and Medicaid Ben Medicare an 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
Common Common Fraud Fraud Areas Areas 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 & Kickbacks 11.
How Fraud Occurs … …
Who Perpetr trate tes Medicare Fraud an Frau d and Abu d Abuse? se? Fraud can be committe tted by an by any pers person on or or bu busin ines ess in a positi tion to bill th to the Medicare program or to to benefit t from Medicare being billed � Do Docto 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 � Ben Benef eficiaries iciaries
} Preventi tion really is th the best t medicine } Consumers Consumers can can mak make e a a big ig difference ifference by: ◦ Knowing what t th their health th care covers ◦ Not t giving out t th their Medicare number to to str trangers ◦ Creati ting a good relati tionship with th th their docto tor ◦ Review (and save) lette tters, bills and insurance sta tate tements ts (“th this is Not t a Bill”) ◦ Report Report unusual acti tiviti ties
} “Skilling” Patients who do not require or cannot benefit from PT, OT or speech } Upcoding-resident has cold Medicare is billed for pneumonia } Everyone has a wheelchair, walker, durable medical equipment, whether they need it or not ◦ How is this fraud?
} Our most vulnerable population is being used to bilk the Medicare system } Medicare is billed for services not received } Or paying for more expensive services then are being given } This puts a strain on the Medicare system and may result in the beneficiaries claims to be analyzed and ultimately not payed.
} Similar to Home Health Fraud as Medicare is paying for unnecessary services: } Example: ◦ Podiatry-Medicare pays for Medically Necessary foot care ◦ The Podiatrist comes out to the home and trims everyone's toenails A Diabetic needs a skilled podiatrist to trim nails to prevent infections. Most people do NOT need a skilled podiatrist to trim nails, but Medicare is billed for a higher end service such as debridement of a nail. Patient unlikely to report
◦ Billing for unnecessary care ◦ Upcoding (billing for more expensive service) ◦ Incorrect coding/billing practices ◦ Fraudulent diagnoses ◦ Billing for services not rendered ◦ Kickbacks/solicitations ◦ Unbundling (e.g., billing for individual lab tests)
} Recruited doctors to submit fraudulent applications to Medicare to obtain billing numbers } Doctors owned and controlled 3 healthcare clinics } Recruited and transported non-English speaking seniors to the clinics; paid them $100 in exchange for Medicare # } Clinics were staffed largely by unlicensed persons } Doctors never saw nor treated patients } False charts were created } Doctors established Medicare provider numbers for the clinics and established bank accounts where Medicare reimbursements were deposited
◦ Recruiting persons to obtain their Medicare numbers for fraudulent billing ◦ Selling members’ or providers’ identification ◦ Billing for persons not eligible for home health ◦ Misrepresenting facts in order to deny or grant benefits ◦ Obtaining kickbacks for referrals ◦ Enrolling patients in hospice who are not terminal
} Largest for-profit hospice chain in the U.S. } May 2013 Department Of Justice lawsuit } Filed by whistleblowers / insiders } Hospice care paid by Medicare: ◦ Palliative care (medical care provided by physicians, nurses and social workers that specializes in the relief of the pain, symptoms and stress of serious illness) ◦ Continuous Home Care (crisis care for patients experiencing acute medical symptoms requiring skilled nursing services on a short term basis) Crisis care is the most expensive hospice benefit provided by Medicare
} Fraud involved: ◦ Knowingly submitted false claims for crisis care services that were not necessary, not actually provided or not performed in accordance with Medicare requirements } Billing Medicare for one ‘crisis care’ patient whose medical records indicated that she was playing bingo at the time } Billing Medicare for one ‘crisis care’ patient who was noted to be ‘very healthy given her age’
} 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
Example: Home Health Ex th Agency Fraud } Owner targeted elderly Korean beneficiaries } Paid kickbacks to doctors and ‘marketers’ } Signed up patients that did not qualify for home health care } Submitted ‘up-coded’ claims to Medicare } Created false medical records for the claims } Billed Medicare for home doctor visits conducted by unlicensed persons or were never conducted at all
◦ Obtaining beneficiary medical records illegally ◦ Sending authorizations to doctors to obtain fraudulent equipment orders ◦ Delivering supplies to beneficiaries without prescription/ authorization ◦ Delivering more supplies than required (e.g., test strips) ◦ Billing for equipment but not delivering any equipment ◦ Delivering lower cost equipment than is prescribed (e.g., manual wheelchair vs power wheelchair); submitting claim for higher-cost equipment ◦ Paying beneficiaries for the illegal use of their Medicare numbers
MEDI EDICAL EQ EQUIPMEN ENT FRAUD D • Owner of fraudulent durable medical equipment supplier • Allegedly posed as employee of a legitimate supplier who contracts with numerous nursing homes • Gained access to several nursing homes under false pretenses • Accessed medical charts for residents who require specialized wound care • Billed Medicare for wound care supplies that were never ordered or provided • Stole medical information from medical charts to manufacture charts in an effort to legitimize their billing
It t Could Happen to to Anyone .. Ø Someone used her Medicare number Ø Billed Medicare for durable medical equipment including a wheelchair Ø When she needed a wheelchair, Medicare denied the claim } It t Happened to to Her
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