HEALTHCARE FRAUD & ABUSE PARTNERSHIP & PREVENTION Presented By: Linda Chavez, Director Foothill Communities RSVP and Micki Nozaki, Project Director California Senior Medicare Patrol

MEDICARE FRAUD Medicare is a $60 to $90 billion dollar problem

TOUGHER CRIMINAL PENALTIES MEDICARE FRAUD

Types of Medicare Fraud Identity Theft Ambulance Transport Dialysis Transport Laboratory Diagnostic Testing Facilities Sleep Studies Home Health & Hospice Durable Medical Equipment (DME)

MEDICARE FRAUD Recent case involving a local physician (Dr. “P”) who operated his own cosmetic health clinic in Beverly Hills, California Performed cosmetic surgeries and face lifts Billed for surgeries not performed Never expected his patients to report him CASE STUDY

MEDICARE FRAUD Case Facts Submitted a total of $7.5 million in bogus claims Services alleged to have provided included Revascularization Ablation of a bone tumor Placement of radiotherapy catheter in breast Lacked the equipment to perform these services FACTS

MEDICARE FRAUD Bad Guys Cannot Commit Fraud Without Stealing Someone’s Identity 300,000 compromised beneficiary ID’s In 2014 – 2.3 million victims of ID theft One third lost health insurance as a result of the theft President Obama signed a bill that requires HHS to issue Medicare cards that do not contain Social Security Numbers. IDENTITY THEFT

MEDICARE FRAUD Strike Force Information Expanded to nine cities To date, 2,300 defendants charged with healthcare fraud related crimes $7 billion in fraudulently billed claims HEALTHCARE FRAUD AND ENFORCEMENT ACTION TEAM (HEAT) STRIKE FORCE Current HEAT Strike Force Cities MiamiLos AngelesDetroit HoustonBrooklynTampa Bay Baton RougeChicagoDallas

Couldn’t Get a Wheelchair Taken for a Ride VICTIMS MEDICARE FRAUD

Senior Medicare Patrol (SMP) was established in SMP’s in the U.S. Fraud prevention education Protect Detect Report Refer allegations of fraud to law enforcement SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD Seniors Helping Seniors Critical partnership with RSVP Recruit, train and manage volunteers Fraud prevention education Protect Detect Report SENIOR MEDICARE PATROL (SMP) AND RSVP

MEDICARE FRAUD Educating & Empowering Seniors SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD Medicare Fraud via Telephone Equipment vendor calls beneficiaries Sales pitch is done rapidly, usually in a foreign accent Masquerades as Social Security Administration or Medicare Promises new Medicare care or FREE equipment Obtains beneficiary’s personal information SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD Insurance Agent Marketing Misconduct CMS marketing guidelines prohibit: Cold Calling Offering prizes for Medicare numbers Enrolling beneficiaries without their authorization Offering money to enroll in Medicare Advantage plan. SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD Protect: Your Medical Identity Medicare fraud IS identity theft Your Medicare number is the Social Security number. SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD Detect: Fraudulent Billing Medicare Summary Notice (MSN) Parts A and B Sent quarterly What Medicare covers, paid What beneficiary owes Part C, D Explanation of Benefits myMedicare.gov (daily) SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD Report: Medicare Fraud and Abuse California SMP toll-free hotline HICAPs ( ) Micki Nozaki - SENIOR MEDICARE PATROL (SMP)

Measure H2 – Number of clients to whom information on health insurance, health care access and health benefits programs is delivered Definition of key terms: – Health insurance: risk arrangement that assures financial coverage for a defined range of health care services, known as benefits, only if these are required. Coverage is offered to an individual or group in exchange for regular payments (premiums paid regardless of use of benefits) by a licensed third party (not a health care provider) or entity, usually an insurance company or government agency that pays for medical services but does not receive or provide health care services. How to calculate (Measure/Collect Data) – The information may be delivered using methods such as individual level interactions, group- level interactions, hotlines, clearinghouses, etc. – Count unduplicated new individuals who are provided with information, as a result of the grantee’s activities. If more than one method of delivery is used (e.g., a group-level interaction followed by an individual-level interaction), count the client only once. – Grantee reports and logs of interactions with clients. RSVP BENCHMARKS HOW SMP FITS