1. Medicare Fraud: Don’t Be A Victim! Funded by the U.S. Department of Health & Human Services - Administration on Community Living / Administration on Aging

2.  How much does Medicare pay in claims annually?  _____________________________  How much does Medicare lose to fraud and abuse annually?  ______________________ ◦ Source: Congressional Business Office (CBO) for 2012

4. 1. 1. Ambulance Services 2. 2. Clinical Lab/Independent Physiology Labs 3. 3. Durable Medical Equipment (DME) Suppliers 4. 4. Home Health Agencies 5. 5. Hospice Care 6. 6. Hospital Services 7. 7. Medicare Advantage / Managed Care Plans 8. 8. Medicare Prescription Drug Plans 9. 9. Mental Health Services 10. 10. Nursing Facilities 11. 11. Physician/Practitioner Services & Kickbacks Common Fraud Areas

5.  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 Examples of Fraud

6. Medicare Fraud and Abuse Stay out of hot water!

7. Your Medicare Card is Your Health Care Credit Card =

8.  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’

9.   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..

10.   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 It Could Happen to Anyone..

11. Some of OIG’s Most Wanted Fugitives

12. 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

13. Charging for therapy services for patients who do not require or cannot benefit from therapy “Skilling Patients” 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!!

14.   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 Foot Fraud

15.  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”

16.   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) Hospice Care

17.  2 nd 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

18.   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) Medicare Advantage (MA) Plans

19. Know Your Medicare

20.  Abdominal aortic aneurysm screening Abdominal aortic aneurysm screening  Alcohol misuse screenings & counseling Alcohol misuse screenings & counseling  Bone mass measurements (bone density) Bone mass measurements (bone density)  Cardiovascular disease screenings Cardiovascular disease screenings  Cardiovascular disease (behavioral therapy) Cardiovascular disease (behavioral therapy)  Cervical & vaginal cancer screening Cervical & vaginal cancer screening  Colorectal cancer screenings Colorectal cancer screenings  Depression screenings Depression screenings  Diabetes screenings Diabetes screenings  Diabetes self-management training Diabetes self-management training  Glaucoma tests Glaucoma tests  HIV screening HIV screening  Mammograms (screening) Mammograms (screening)  Nutrition therapy services Nutrition therapy services  Obesity screenings & counseling Obesity screenings & counseling  One-time “Welcome to Medicare” preventive visit One-time “Welcome to Medicare” preventive visit  Prostate cancer screenings Prostate cancer screenings  Sexually transmitted infections screening & counseling Sexually transmitted infections screening & counseling  Shots: ◦ Flu shots Flu shots ◦ Hepatitis B shots Hepatitis B shots ◦ Pneumococcal shots Pneumococcal shots  Tobacco use cessation counseling Tobacco use cessation counseling  Yearly "Wellness" visit Yearly "Wellness" visit

21.  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 Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO)

22. Complexity = Confusion = Opportunity for Fraud

23. 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

24.   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 Telemarketing/Phone Scams

25.   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 Social Networking

26. 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 $$”

27. 12 3 3 Roles of Senior Medicare Patrol

28.   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! Protect

29.   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 \   Review MSNs and Part D Explanation of Benefits (EOB) for possible errors   Access myMedicare.gov account Detect

30. Call SMP toll free hot line 855-613-7080 Report   Ask questions   Seek assistance   Use written records