Funded by the U.S. Department of Health & Human Services - - PowerPoint PPT Presentation
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
Funded by the U.S. Department of Health & Human Services – Administration on Community Living
} Administr
} Th
Di Disseminate te SMP Fraud Preventi tion and Identi tificati tion Informati tion th through media,
treach cam campaig paigns, s, community ty events ts, etc tc. Assist t beneficiaries in in resolv resolvin ing issu issues es and complaints ts re: Medicare, Medicaid, Medicare, Medicaid, and oth ther relate ted health th care and con consu sumer issu er issues es Make ref Make referrals errals of
suspecte ted cases of fraud, waste te, and abuse to to appropriate te investi tigati tive enti titi ties (e.g (e.g., Medicare ., Medicare contr tracto tors, MFCU, AG, AG, OIG, OIG, CMS) CMS)
} Thank you for being an advocate
} Ombudsman play a vita
} Keep th
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} Preventi
} Consumers
} “Skilling” Patients who do not require
} Upcoding-resident has cold Medicare
} Everyone has a wheelchair, walker,
} Our most vulnerable population is being used
} Medicare is billed for services not received } Or paying for more expensive services then
} This puts a strain on the Medicare system and
} Similar to Home Health Fraud as Medicare is
} Example:
} Recruited doctors to submit fraudulent applications to
} Doctors owned and controlled 3 healthcare clinics } Recruited and transported non-English speaking seniors to
} 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
} Largest for-profit hospice chain in the U.S. } May 2013 Department Of Justice lawsuit } Filed by whistleblowers / insiders } Hospice care paid by Medicare:
workers that specializes in the relief of the pain, symptoms and stress of serious illness)
medical symptoms requiring skilled nursing services on a short term basis)
Crisis care is the most expensive hospice benefit provided by Medicare
} Fraud involved:
} Billing Medicare for one ‘crisis care’ patient
} Billing Medicare for one ‘crisis care’ patient
} Social worker in Colorado } Worked through several
} Found opportunities to
} Did bookkeeping, cleaned
} Submitted claims for all of
} Owner targeted elderly Korean beneficiaries } Paid kickbacks to doctors and ‘marketers’ } Signed up patients that did not qualify for
} Submitted ‘up-coded’ claims to Medicare } Created false medical records for the claims } Billed Medicare for home doctor visits
authorization
wheelchair vs power wheelchair); submitting claim for higher-cost equipment
supplier
who contracts with numerous nursing homes
pretenses
specialized wound care
never ordered or provided
manufacture charts in an effort to legitimize their billing
} It
Ø Someone used her
Ø Billed Medicare for
Ø When she needed a
} By P
By Pharm armacies acies
Billing multiple payors for the same prescription Billing for non-existent prescriptions Billing for brand when generics are dispensed Billing for an item not dispensed
} One hospital statement could involve tens
} American Medical Association- “Nearly 20%
} ICD -9 Codes: approx 15,000 } ICD – 10 Codes: 68,000 new codes
} Sales and Marketi
ting Misconduct t
} By Mem
By Members bers
supplies, or equipment
Affordable Care Act Covered California Cal Medi- Connect
} Report beneficiaries/your suspicions
} Assist
} For Rx-Receive an Explanation of Benefits
REP EPORT DET DETEC ECT PROTEC ECT
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