Senior Medicare Patrol (SMP) Fraud prevention, detection and reporting SHIBA and the Senior Medicare Patrol (SMP) Fraud prevention, detection and reporting Statewide Health Insurance Benefits Advisors (SHIBA ) is a free, unbiased service sponsored by the: 8/26/2014

SHIBA mission SHIBA provides free, unbiased information about health care coverage and access to help improve the lives of all Washington state residents. We cultivate community commitment through partnership, service and volunteering.

Who is affected? All of us! Medicare and Medicaid clients Taxpayers How? Diminished quality of treatment Less money for needed benefits Taxpayers Billions of tax dollars wasted

Senior Medicare Patrol: From idea to national program Through public law 104-208 (est. 1997) Administration on Aging established 12 demonstration projects To recruit & train retired professionals to detect & report potential error, fraud & abuse Today we have 54 SMP projects in all states, Wash. DC, Puerto Rico, Guam & U.S. Virgin Islands Washington state SHIBA program sponsors SMP in our state

3 roles of SHIBA & SMP Distribute fraud prevention and identification information 1. Assist clients in resolving issues & complaints 2. Refer suspected cases of fraud, waste & abuse to investigative entities 3.

Protect, detect, report Purpose of SHIBA’s fraud awareness program: Educate clients (Protect) Perform 1:1 counseling (Detect) Refer cases for investigation (Report) Later on during this presentation, we will discuss in further detail the elements of protecting, detecting and reporting.

Little quiz How much does Medicare pay in claims every year? Answer: About $500 billion Which state is #1 in losses due to Medicare & Medicaid fraud & abuse? Answer: Florida #2, #3, #4 states? Answer: California, New York and Texas About $500 Billion Florida California , New York, Texas

Identify theft is the door to Medicare fraud SHIBA & The SMP

Identify theft The number on your Medicare card is your Social Security Number This number is as important to thieves as a credit card

= Guard your card! Think of your Medicare card as your health care credit card! = Speaker: At this point in the presentation you can ask the audience how many people have their Social Security card with them. Usually very few people do. Then ask how many have their Medicare card, and usually quite a few people do. Explain that their Medicare Claim Number includes their Social Security number and suggest they keep their Medicare card at home in a safe place except when visiting providers.

Every Medicare benefit can be a potential fraud area 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

Who commits Medicare fraud & abuse? People or providers who bill Medicare OR benefit from Medicare getting billed Doctors & health care providers Durable Medical Equipment (DME suppliers) Employees of doctors or suppliers Home health agencies, hospice Medicare clients

Some of the most wanted fraud fugitives The U.S. Inspector General is searching for these fugitives: Mr. Allonce allegedly gained access to nursing care facilities and patients hospital records to produce fake DME billings to Medicare. Mr. Barcelo allegedly ran several clinics and charged Medicare for services not needed or rendered. Ms. Chisanga allegedly worked for a DME supplier and altered prescriptions/authorizations for DME to bill more than allowed. Mr. Thorsen allegedly had CMS grant money for research deposited directly to his personal checking account. Etienne Allonce Alfredo Barcelo Patricia Chisanga Poul Thorsen http://oig.hhs.gov/fraud/fugitives/index.asp

Examples of fraud Altering claim forms to get a higher payment amount (called “upcoding”) Example: Flu shot billed as a Shingles shot Billing twice for same service or item Billing separately for services that should be included in a single service fee (“unbundling”) Example: Comprehensive blood panel billed as individual tests Billing for services not rendered or supplies not provided

Beware of providers who advertise free services Two Medicare clients – a husband & wife – get a visit at home by a stranger offering free medical services & equipment Stranger drives them to clinic where they were asked for their Medicare card numbers They were sent home with a box of Ensure Their Medicare Summary Notices (MSNs) showed claims for services not rendered, however, Medicare paid the provider If it seems to good to be true, it likely is. Generally providers do not offer services or products free of charge.

Example of fraud conviction LA doctor convicted of multi-million dollar Medicare fraud case: Operated a health & beauty clinic Performed radiofrequency laser & liposuction Stole Medicare numbers from patients Got Medicare numbers from others via recruiters Submitted fraudulent claims for: Revascularization Ablation of a bone tumor Placement of radiotherapy catheter in breast

What can happen if you become a Medicare victim Stolen Medicare numbers can lead to false claims Medicare may note your file as a problem and as a result, your: Benefits may stop Medicare number may be flagged as a “Compromised Number” A Stolen Social Security Number can lead to theft of your banking information It is very important that beneficiaries review their Medicare Summary Notice (MSN) or go online to MyMedicare and review their accounts on a regular basis. Medicare clients should keep a journal of all services/supplies received and dates of services to compare to their MSN. This can help them to identify any fraudulent activity on their account and may help prevent a situation whereby their Medicare number becomes a “Compromised Number.”

Compromised Medicare number Someone used her Medicare number to submit fraudulent claims for a wheelchair Medicare paid the claims to the fraudster When she really needed a wheelchair, Medicare denied her legitimate claim Wheelchairs and prosthetics are some of the most common items listed in fraudulent claims. It happened to her

Beware of strangers pretending to be from Medicare Phone scam case followed by a home visit from “Medicare:” Senior receives a phone call from a woman claiming to be from Medicare. The woman says she is going to “visit the senior at her home.” The next day, the senior gets a visit from a man named Richard who says he’s from Medicare. He tells the senior a new state law requires her to enroll in a Medicare Advantage plan and he’s there to help her. Afraid of losing access to her doctor, the senior gives Robert her Medicare number and Part D plan information. Senior was enrolled in a health plan, which raised her premium and she lost access to her doctors. SMP referred the case for investigation. It’s also important to remind the public that although a representative of a certain insurance company may not be perpetrating fraud, however, the plans they offer may not suit their needs. Encourage audience to contact SHIBA with any questions they might have before switching plans.

Fooled by a criminal 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 $1,000 for tests -

Telemarketing/phone scams Fraudster calls consumers in the early morning Gives a rapid sales pitch, usually with a foreign accent Deliberately confuses consumers into believing he/she represents Social Security or Medicare Promises a new Medicare card or medical card – OR offers free medical alert equipment Purpose: To get your checking account and credit card information!

Durable Medical Equipment (DME) Look for: Unauthorized, unsolicited supplies sent to you Why DME? Until recently: No professional licensing requirements Suppliers could set up shop with very little investment Huge potential for quick profit

DME fraud example DME supplier: Gained access to skilled nursing facilities & board & care homes 95% of his submitted claims were for power wheelchairs Many clients never received the equipment or didn’t need it Most of the Medicare numbers were provided by patient recruiters who received kickbacks

DMEPOS aims to slow down DME fraud Implemented in 2 Washington state regions in 2013 Requires competitive bidding & lower prices from equipment suppliers Forces suppliers to have surety bonds & legit places of business Reduces the number of suppliers DMEPOS stands for Durable Medical Equipment, Prosthetics, Orthotics and Supplies. DMEPOS has reduced fraud in the regions it has been implemented, however in the areas where it hasn’t been implemented many providers report being “bombarded” by requests for approvals of potentially fraudulent DME claims.

The face of home health fraud Social worker employed in several home health agencies Found opportunities to obtain more Medicare funds Did bookkeeping, cleaned cabinets, played cards Submitted claims for all these activities to Medicare but coded as Medicare – covered services

Picked up at downtown emergency drop-in center by fraudster Transported to local hospital with questionable diagnosis Homeless Medicare client on Skid Row Moved to skilled nursing facility; promised 90 days of housing paid by Medicare

Fraud & lab services Why Lab services? What to look for: Doctors don’t see what’s billed to Medicare Labs aren’t required to submit diagnosis information to support the need for the services What to look for: Medically unnecessary services billed Providers “strongly urging” patients to go to a specific clinic Unbundling (e.g., one blood panel listed by individual test) Tests not ordered, but performed & billed Keep in mind the provider who orders the lab tests may not have any knowledge of what the lab actually bills for.

Fraud & hospice care Why hospice care? What to look for: End of life issues extremely vulnerable situation Clients & families are usually unaware of items billed to Medicare What to look for: Clients who are not terminally ill enrolled in hospice Hospice agencies promising “all the oxygen you need” Clients who don’t understand how hospice is covered

Fraud & Medicare Advantage (MA) plans Why MA plans? Major increase in number of managed care plans They hire independent agents No statements sent to members (except EOBs for Part D plans) What to look for: Insurance agent marketing violations Agents switching to their plan without client consent or knowledge Cold calling (if no prior relationship) Again, even if the agent/producer representing the plan is not potentially committing a fraudulent act or violating insurance marketing rules, it is always very important for the beneficiary to weigh their options very carefully before making any changes. NEW: Effective October 2014, Medicare Summary Notices must be sent

Fraud & pharmacies Part D prescription drug program started in 2006 $50+ billion dollar program Most likely fraud cases: Billing hundreds of Rx for a single client Dispensing less than the prescribed amount of pills Claims for brand name drugs but dispensing generics Large amount of claims for refills, but never requested

2013 CVS Caremark Corp. fraud investigation Second largest drug store chain in the U.S. Customers have been surprised to find that CVS renewed their prescriptions & billed their insurance without their consent CVS was ultimately issued a fine due to this practice.

Fraud & hospitals In-patient vs. outpatient status Hospitals charge for a significant amount of line items Typically don’t give you an itemized statement when you’re discharged One hospital statement could involve multiple people generating a single patient’s bill American Medical Association – “Nearly 20% of claims have errors” If at all possible, have a family member or close friend at the hospital with you so they can help journal services received and communicate with all providers involved in their care. You may request an itemized bill upon discharge.

Health Benefits Exchange Complexity = confusion = opportunity for fraud Medicare WA Health Benefits Exchange Because of all the changes recently due to the Affordable Care Act, many in the public are confused, and this creates many opportunities for fraudsters. Affordable Care Act

If you have Medicare… Your Medicare coverage is protected Medicare isn’t part of the Health Exchange so you don’t have to replace your Medicare coverage with an Exchange plan No matter how you get Medicare, you still have the same benefits & security You don’t need to do anything during the Exchange’s open enrollment period Make sure that the audience knows the dates of Medicare open enrollment, ask them to write it down. Oct. 15 – Dec. 7

Example of ACA-related Medicare fraud Someone contacts Medicare client via phone or email They tell client they need a new Medicare ID card or plan number due to ACA or “Obama care” They ask client to confirm personal information, including Social Security number Client then becomes victim of ID theft

The Affordable Care Act (ACA) Adds ability for Dept. of Health & Human Services to disallow provider enrollment Implements a “smart, automated system” to proactively ID fraudulent claims Fraud prevention system Integrates Medicare & Medicaid Partners with private insurers & MA plans Increases law enforcement – Office of Inspector General Along with fraud prevention, Payment Integrity goes a long ways towards preventing fraud. “Payment Integrity” is making sure the claims being paid are legitimate. Medicare now has a sophisticated computer claims processing system that helps to identify anomalies and outliers and helps to prevent payment of fraudulent claims i.e. billing for a pregnant man etc.

Protect, detect, report Educate clients (Protect) Perform 1:1 counseling (Detect) Refer cases for investigation (Report)

Protect Treat your Medicare card as your credit card or SSN card Don’t carry it with you until you need it for visits to the doctor, clinic or pharmacy Never give your Medicare number to a stranger Record doctor visits, tests & procedures in a personal health care journal or calendar Save MSNs and Part D EOBs; shred when you no longer need it Remember: Medicare does NOT call or visit sell you anything.

Detect Review MSNs & Part D Explanation of Benefits (EOBs) for possible mistakes Access myMedicare.gov account Compare MSNs & EOBs to personal health care journal and Rx drug receipts to ensure they’re correct Look on billing statement for: Charges for item/service you didn’t receive Billing for same thing twice Services your doctor didn’t order

Example of MSN Speaker: Review the different parts of the MSN with the audience, encourage them to review it carefully, and compare it to their journal of appointments and services.

Report fraud to SHIBA at: Ask questions Seek help Use written records Contact SHIBA Collect evidence Marketing flyers Business cards MSNs Narratives Report fraud to SHIBA at: 1-800-562-6900

Volunteer for SHIBA! Become a volunteer! Call: 1-800-562-6900 Do you want to help explain health care benefits or options to: Friends? Neighbors? You community? Help people become better informed consumers? Become a volunteer! Call: 1-800-562-6900

Need help with other insurance questions? The Office of the Insurance Commissioner can also help you with questions, information, and complaints about all types of insurance, such as: Call our Insurance Consumer Hotline 1-800-562-6900 Homeowner Auto Life Annuities Health And more!