SMP Referrals Protocols August 9 th, 2011 National SMP Conference Ginny Paulson SMP Resource Center Director

2 Fraud Referrals Protocols Overview: Suspected Fraud Any Part of Medicare OIG Suspected Fraud Original Medicare ZPIC/PSC Suspected Fraud - Part C and Part D Benefits ( not Marketing) MEDIC Part C and Part D Marketing Complaints CMS RO DOI Liaisons

Referrals in Transition: Overview Dual Reporting to OIG Hotline and CMS Program Integrity (PI) AoA, Center, OIG, CMS developing more fine-tuned referrals protocols for SMPs SMP Unique ID with Medicare Completion of SMP Complex Issues Manual --Will resume this Fall 3

Suspected Fraud? Now Dual Reporting to OIG and CMS Program Integrity Contractors Future More fine-tuned protocols based on fraud vs. abuse 4

Suspected Abuse? Now: Contact your CMS Program Integrity Contractor for Guidance Possible referral to CMS PI Future: Enhanced relationship with Medicare 5

Dual Referrals - OIG and CMS False Claims Kickbacks Medical Identity Theft Door-to-door solicitation of Medicare/Medicaid beneficiaries (related to health insurance) Misrepresentation – Such as of Medicare Private Plans 6

ACTIVITY Pick a Table Leader Review Handouts, which includes Scenarios Respond to Scenarios, using key pad Thank You to The National Medicare Training Program for offering this Audience Response System 7

Scenario #1 A nurse for a skilled nursing facility called the SMP to report hospice care fraud on the part of her employer. She was aware that the facility director was altering patient records to falsely indicate they needed a hospice level of care in order to obtain higher reimbursement from Medicare. The nurse did not want her employer to know about her report to the SMP but was willing to be identified to investigators. 8

What is the primary violation? (select one) A. Kickbacks B. False Claims C. Medical ID Theft D. Misrepresentation by Plan E. Door-to-Door Solicitation 9

ANSWER: B. False Claims 10

Who Should Get the Referral? A. OIG Hotline B. ZPIC/PSC/MEDIC C. CMS RO DOI Liaison D. A, B, and C E. A and B 11

ANSWER: E. OIG Hotline and ZPIC/PSC/MEDIC 12

Scenario #2 An anonymous senior housing coordinator informant contacted the SMP to report that residents at a senior apartment complex were being visited by ABC Medicare Advantage Plan agents. The senior housing residents had not asked for or expected these visits, but let the agents into their apartments because the agents said they had been sent by the residents’ clinic, Your Health, Inc. The agents proceeded to enroll the residents in the ABC Medicare Advantage Plan and also attempted to sell life insurance. 13

What is the most obvious violation? (select one) A. Kickbacks B. False Claims C. Door-to-Door Solicitation D. Medical Identity Theft E. Misrepresentation by Plan 14

ANSWER: C. Door-to-Door Solicitation 15

What is another possible violation? (select one) A. Kickbacks B. Medical Identity Theft C. Misrepresentation D. All of the Above 16

ANSWER: D. All of the Above 17

Who Should Get the Referral? A. OIG Hotline B. MEDIC C. CMS RO DOI Liaison D. All of The Above E. ZPIC 18

ANSWER: D. All of the Above 19

Questions? Contact: Ginny Paulson SMP Resource Center Director