Transcript Medicare Fraud: Don`t Be A Victim

Funded by the U.S. Department of Health & Human Services - Administration on
Community Living / Administration on Aging




How much does Medicare pay in claims
annually?
_____________________________
How much does Medicare lose to fraud and
abuse annually?
______________________
Common Fraud Areas
1.
Ambulance Services
2.
Clinical Lab/Independent Physiology Labs
3.
Durable Medical Equipment (DME) Suppliers
4.
Home Health Agencies
5.
Hospice Care
6.
Hospital Services
7.
Medicare Advantage / Managed Care Plans
8.
Medicare Prescription Drug Plans
9.
Mental Health Services
10.
11.
Nursing Facilities
Physician/Practitioner Services & Kickbacks
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
Medicare Fraud and Abuse
Stay out
of hot
water!
Your Medicare Card is Your
Health Care Credit Card
=

Theft of Medicare number leads to false claims

False claims go on your Medicare file

False claims may prevent you from getting
legitimate services/products

Too many false claims could lead to ‘flagged for
non-payment’
It Could Happen to Anyone ..



Someone used her
Medicare number
Billed Medicare for
durable medical
equipment including a
wheelchair
When she needed a
wheelchair, Medicare
denied the claim
It Could Happen to Anyone ..
Stranger called her to
verify her Medicare
number
 Promised her gloves
for her arthritis
 Drove her 300 miles
for an ‘exam’
 Had her ‘sign’ a form
 Billed Medicare
$1000 for tests

Some of OIG’s Most Wanted
Fugitives
MEDICAL EQUIPMENT FRAUD
• Owned equipment supply company
• Posed as employee of a legitimate
supplier who contracts with numerous
nursing homes
• Accessed medical charts for residents
who require specialized wound care
• Billed Medicare for wound care
supplies that were never ordered or
provided
• On the lam - $12 million richer
“Skilling Patients”
Charging for therapy
services for patients who
do not require or cannot
benefit from therapy
• Ran a rehabilitation center
• Paid residents to sign for unneeded
outpatient therapy and speech therapy
• Submitted claims for therapy that was not
given to residents
• Billed therapy for patient in coma!!
Foot Fraud

Podiatrist trims everyone's toenails (for free!)
◦ Most people do not need a skilled podiatrist to do a
pedicure
◦ Medicare does not pay for pedicures
 Exception: patients with Diabetes Mellitus
◦ Medicare is billed for a higher end service such as
debridement of a nail
◦ Patient gets the service so may be unlikely to report

Michigan oncologist Farid Fata

Billed Medicare for $62 million

(2009 to 2013)
Intentionally misdiagnosed healthy
people with cancer

Pumped dying patients with chemo

“Just to make money”
Hospice Care
 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)


2nd 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
Medicare Advantage (MA) Plans
 Why



MA Plans?
Dramatic increase in
the number of
managed care plans
$1000 / month /
member
Exaggerate how sick
their members are to
overcharge the
government
Look For


Charges for unnecessary
services or medications
Insurance agent’s
marketing violations


Agents switching to
their plan without
beneficiary consent or
knowledge
Cold calling (if no prior
relationship)
Know Your Medicare

Abdominal aortic aneurysm screening

Nutrition therapy services

Alcohol misuse screenings & counseling

Obesity screenings & counseling



Bone mass measurements (bone
density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral
therapy)



One-time “Welcome to Medicare”
preventive visit
Prostate cancer screenings
Sexually transmitted infections
screening & counseling

Cervical & vaginal cancer screening

Colorectal cancer screenings
◦ Flu shots

Depression screenings
◦ Hepatitis B shots

Diabetes screenings
◦ Pneumococcal shots

Diabetes self-management training

Tobacco use cessation counseling

Glaucoma tests

Yearly "Wellness" visit

HIV screening

Mammograms (screening)

Shots:

Hospital in-patient vs observation status
◦ Impacts Medicare coverage if you move to a SNF

Ambulance Transport
◦ Impacts Medicare coverage
◦ Must be emergency
◦ Must be only method of transportation (medically)

Hospital Discharge
◦ You have the right to an immediate review by the
Beneficiary and Family Centered Care Quality
Improvement Organization (BFCC-QIO) in your if
you think you are not ready to be discharged from
the hospital
Complexity = Confusion = Opportunity for
Fraud
Cal MediConnect
Covered
California
Affordable Care
Act
The Affordable Care Act
 Medicare benefits aren’t changing
 Marketplace doesn’t affect your Medicare
 Medicare is not part of the Marketplace
 Additional Medicare benefits:
 Free Welcome to Medicare Wellness Visit
 Annual Prevention Plan
◦ More Help with Prescription Drugs
 Coverage Gap closed 2020
Telemarketing/Phone Scams
 Fraudster calls consumers early in the a.m.
 Sales pitch is done rapidly, usually with a foreign
accent
 Deliberately confuses people into believing the
caller represents Social Security or Medicare
Promises a new Medicare card or medical card OR
offers free medical alert equipment
 To get their checking account information
Social Networking

Fraudster makes a fake profile to "friend" you on
Facebook

Browses through your profile and personal information

Uses that information to contact you; obtain additional
information

You never know who is on the other side of that friendly
picture!

Check privacy settings
Common Scams
Grandparent Phone Scam





Gets your information
from social media?
Masquerades as your
grandchild
In trouble; need
grandparent’s help
“Don’t tell my parents!”
“Just send me $$”
3 Roles of Senior Medicare Patrol
1
Disseminate SMP
Fraud Prevention
Information
2
Assist beneficiaries
to resolve issues
and complaints
3
Refer cases for
investigation
Protect

Treat the
Medicare card as
your credit card

Don’t carry with
you until you need
it for initial visit to
doctor, clinic or
pharmacy

Never give your
Medicare number
to a stranger
Remember: Medicare does
not call and ask for your
Medicare number!
Detect
\
 Review MSNs and
Part D Explanation
of Benefits (EOB)
for possible errors

Access
myMedicare.gov
account
 Look on billing statement for:
 Charges for item or service
not received
 Billing for same thing twice
Billing for a more expensive
service
 Services not ordered by
doctor
Report
 Ask
questions


Seek
assistance
Use written
records
Call SMP toll free hot line
855-613-7080