Protecting Residents from Medicare Fraud - PowerPoint Presentation

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Protecting Residents from Medicare Fraud

Senior Medicare PatrolLTC Ombudsman Program 2014-2015

Funded by the U.S. Department of Health & Human Services – Administration on Community LivingSlide2

Administration on Aging established 12 demonstration projects

recruit and train retired professionals to detect and report potential error, fraud and abuseThere now are SMP projects in all states, Washington DC, Puerto Rico, Guam, and the U.S. Virgin Islands. Objectives: Protect, Detect, ReportSenior Medicare Patrol:From Idea to National Program2Slide3

Protect

DetectReportThree Roles of SMPs3Slide4

Older adults residing in assisted living facilities and/or RCFE facilities are oftentimes the targets of Medicare fraud and abuse

The Medicare program loses billions of dollars each year as a result of fraud and abuse The Problems4Slide5

Why Do We Care?Slide6

Ambulance Services

Clinical Lab/Independent Physiology Labs

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

Common

Fraud Areas

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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. How Fraud Occurs …

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Fraud can be committed

by any person or business in a position to bill the Medicare program or to benefit from Medicare being billed Who Perpetrates Medicare Fraud and Abuse?8Slide9

Please stay tuned. More information about these fugitives coming right up.

9Some of OIG’s Most Wanted FugitivesSlide10

Ombudsman are

&Advocate for residents’ rights and quality care Educate consumers and providers Resolve residents' complaints Provide information to the public Investigation of Allegations of Abuse and NeglectWitnessing of AHCD

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You walk into the door of your facility… What do you see?

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Some Warning Signs

Resident has a medical billing statement or Medicare Summary Notice and says they did not see that provider or did not receive the services billedResident states s/he has questions about their prescriptionsResident receives an unexpected visit from an insurance agent12Slide13

Some Warning Signs

Resident receives calls from strangers claiming they are from Medicare13Slide14

It Happened to HerSomeone used her Medicare numberBilled Medicare for durable medical equipment including a wheelchair

When she needed a wheelchair, Medicare denied the claim

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Some Warning Signs

There is durable medical equipment (DME) that appears to be unnecessaryAll the residents have the exact same equipment (e.g., wheelchair, walker)Resident has been enrolled in hospice but is not terminal15vs.Slide16

MEDICAL EQUIPMENT FRAUD

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 pretensesAccessed medical charts for residents who require specialized wound careBilled Medicare for wound care supplies that were never ordered or providedStole medical information from medical charts to manufacture charts in an effort to legitimize their billing16Slide17

Recruiting persons to obtain their Medicare numbers for fraudulent billing

Billing for persons not eligible for home health Misrepresenting facts in order to deny or grant benefitsEnrolling patients in hospice who are not terminal Fraud by Home Health, Hospice17Unfamiliar face in building, kind of going door-to-doorNotice resident is receiving service that he/she may not need

notice resident complains about needed benefits/servicesnotice resident is receiving service that he/she may not needSlide18

Social worker in Colorado

Worked through several home health agenciesFound opportunities to obtain more Medicare fundsDid bookkeeping, cleaned cabinets, played cardsSubmitted claims for all of these activities to Medicare but coded as Medicare-covered servicesThe face of Home Health Fraud Fraud18Slide19

Owner targeted elderly Korean beneficiaries

Paid kickbacks to doctors and ‘marketers’Signed up patients that did not qualify for home health careSubmitted ‘up-coded’ claims to MedicareCreated false medical records for the claims

Billed Medicare for home doctor visits conducted by unlicensed persons or were never conducted at all

Example: Home Health Agency Fraud

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Largest for-profit hospice chain in the U.S.

May 2013 Department Of Justice lawsuitFiled by whistleblowers / insidersHospice 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 MedicareHospice Fraud20Slide21

Fraud involved:

Knowingly submitted false claims for crisis care services that were not necessary, not actually provided or not performed in accordance with Medicare requirementsBilling 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’Hospice Fraud continued21Slide22

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)Other forms of Fraud22Slide23

“Skilling” patients who do not require or cannot benefit from therapy

Some Warning SignsRan a rehabilitation centerPaid residents to sign for unneeded outpatient therapy and speech therapySubmitted claims for therapy that was not given to residents23Slide24

Podiatrist comes out to the home/facility 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 nailsMedicare is billed for a higher end service such as debridement of a nailPatient gets the pedicure so may be unlikely to reportSome Warning Signs24Slide25

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

Consequences

to Beneficiaries

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As an Ombudsman You

have the Power to Stop FraudReport beneficiaries/your suspicions IF it just doesn’t feel rightAssist Reading Medicare Summary Notice (MSN) and Explanation of Benefits (EOB)This is not a bill26Slide27

SMP case 20650 July 2013-Long Term Care Ombudsman from Glendale, CA filled out complaint form on behalf of beneficiary. Beneficiary's Medicare Summary Notices shows Medicare has been billed for a chair that is not in the beneficiary's possession, which prevents her from obtaining a chair that is fitted for her needs. Beneficiary was not given the opportunity to be properly fitted for a chair that met her needs. She never saw the physician's prescription for the new wheelchair because it was sent directly to DME supplier without her knowledge.

This case was referred to Medicare fraud investigators that same month.Actual cases referred to SMP by an ombudsman27Slide28

Homeless Medicare beneficiary on Skid Row

Picked up at downtown Emergency Drop- in Center by fraudsterTransported to a local hospital with questionable diagnosis

Moved to Skilled Nursing Facility; promised 90 days of housing paid for by Medicare

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Complexity = Confusion = Opportunity for FraudSlide30

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 rights you have now. You don’t need to do anything with the Marketplace during Open Enrollment. FYI, proposed dates for Covered CA Open Enrollment for 2015: start Nov 15 until Feb.46If you have Medicare…Slide31

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-CalPartnering with private insurers and Medicare Advantage PlansIncreasing law enforcement – Office of Inspector GeneralThe Affordable Care ActSlide32

REPORT TO US

SENIOR MEDICARE PATROL – Our Message32Slide33

Treat the Medicare card as your credit cardDon’t carry with you until you need it for visits to doctor, clinic or pharmacyNever give your Medicare number to a stranger

Record doctor visits, tests and procedures

Save

MSNs and Part D Explanation of

Benefits

Remember

: Medicare does

not

call or visit to sell

anything

Protect

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Compare MSNs and EOBs to personal health care journal and prescription drug receipts to ensure they are

correctLook on billing statement for: Charges for item or service not received Billing for same thing twice Services not ordered by doctor\Review MSNs and Part D Explanation of Benefits (EOB) for possible

mistakesAccess myMedicare.gov account

Detect

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Call SMP toll free hot line

855-613-7080 Report Ask questions Seek assistance Use written records Contact Senior Medicare Patrol

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Again We

Thank you for being an advocate for seniors and for being our partner in protecting the Integrity of the Medicare Program so that

Medicare can continue to serve future generations.Keep this Medicare Fraud hot line number handy …855-613-7080

You Make a Difference

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