1. Medicare Fraud and Scams
Hello,
Thank you for being here. My name is…and I represent… I’m here to talk to you about Medicare Fraud and Scams.
Funding provided by the Administration for Community Living
(Department of Health and Human Services)
California Health Advocates (c) 2018

2. Agenda Who is Senior Medicare Patrol (SMP)
SMP Message: Protect, Detect & Report
CA-SMP Current Trends
Common Fraud Trends
Other Types of Health Care Scams
Non- Health Care Related Scams
How to Stay Connected with SMP

3. California Health Advocates (CHA) Our Focus
Providing quality Medicare and related healthcare coverage information, education and policy advocacy
Advocacy – Bring the experiences of Medicare beneficiaries to the public, and especially legislators and their staff at federal and state levels, through media and educational campaigns.
Policy – Conduct public policy research to support recommendations for improving rights and protections for Medicare beneficiaries and their families.
Education – Provide timely and high-quality information on Medicare through our website, fact sheets, policy briefs and educational workshops.
Our Senior Medicare Patrol (SMP) grant is administered through California Health Advocates (known as CHA), whose mission is providing quality Medicare and related healthcare coverage information, education and policy advocacy. We kindly encourage all of you to like us on Facebook and subscribe to our e-newsletter to stay connected with important Medicare and Medicare fraud updates.
California Health Advocates (c) 2018

4. Senior Medicare Patrol (SMP)
SMP is a federally funded project
Established in 1997
SMPs empower and assist Medicare beneficiaries, their families and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling and education
54 SMPs across the country
Senior Medicare Patrol’s funding is provided by the Administration for Community Living
(Department of Health and Human Services). Our mission is to empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education.
Congress regularly is briefed about fraud
Back to the 1980s
HIPAA legislation mandated

5. 4/16/2014
Three Roles of SMPs
1. Provide Medicare fraud prevention education via health fairs, presentations, etc.
Address complaints reported via our SMP State-wide fraud hotline
3. Refer potential Medicare fraud cases to appropriate investigative entity.

6. SMP Message: Protect Medical Identity by guarding the Medicare card
Detect Fraudulent Billing
by reviewing Medicare Summary Notices and Explanation of Benefits
Report Medicare Fraud
by calling SMP at
SMP follows a 3-step approach and that is: PROTECT medical identity by guarding the Medicare card, DETECT errors by reviewing Medicare Summary Notices and Explanation of Benefits & REPORT suspicious billings by calling SMP at the toll free number provided,

8. It’s fraud associated with these two cards below:
Medicare fraud:
It’s fraud associated with these two cards below:

9. Not a victimless crime! 2015: Michigan doctor sentenced to 45 years
-Misdiagnosed patients as having cancer, when in fact, they did not.
-Gave patients medically unnecessary infusions or injections. Some patients died.
-Collected $17.6 million from Medicare.
Medicare fraud is not a victimless crime. Let’s start this discussion by giving this doctor a couple minutes of shame. In 2015, a Michigan doctor was sentenced to 45 years in prison for misdiagnosing patients as having cancer, then providing chemotherapy to patients who did not even have cancer, all for the sole purpose of making money off of Medicare. While this doctor ripped off Medicare of over 17 million dollars, lives were lost. Some patients died for receiving unnecessary infusions and injections as a result of having been misdiagnosed.

10. How serious is the problem
How serious is the problem? It’s serious enough for the Office of Inspector General (OIG) to have a top 10 Most wanted list depicting fugitives of healthcare related crimes.
OIG.GOV

11. Program Accountability
The SMP program is accountable to:
The Federal Government
ACL
OIG
Tax payers
As a government-funded program, the SMP program is accountable to the federal government and ultimately to tax payers. SMPs must meet ACL requirements for reporting their activities and outcomes. SMP is unique in that annual SMP program outcomes are analyzed and published by the Office of Inspector General (OIG) Office of Evaluation and Inspections. The OIG usually performs this activity for federal agencies, not federal grantees. The OIG’s annual report of SMP performance outcomes is the result of the 1997 Omnibus Consolidated Appropriations Act and a formal agreement with ACL.
ACL = U.S. Administration for Community Living
OIG = Office of Inspector General
Chapter 1

12. Why Should We Care?
Theft of Medicare/Medi-Cal numbers leads to false claims
Higher premiums
Billions of tax dollars wasted
When it comes to Medicare fraud, everyone loses! It should be in everyone’s best interest to save the integrity of the program for future generations.

13. Current trends: Durable Medical Equipment (DME)/Brace Scams Hospice
Allegations of Agent Misconduct & Plan Marketing Violations via TV commercials, mail, telephone or in-person
Billing
Recently pubished report from the Government Accountability Office (GAO) – the top Congressional watchdog –and chief oversight investigative tool for monitoring executive branch spending and management
“IT would be nice to know how much fraud there is in Medicare …”
A properly enrolled Medicare provider could submit a claim that looks perfectly legitimate but bills for services that were either never provided or were more complex than the service actually done
Very difficult to catch

14. Beware of Durable Medical Equipment (DME) Brace Scams
Unsolicited phone calls offering free braces covered by Medicare.
TV commercials and newspaper ads offering “free” Medicare approved braces to alleviate pain.
Urgently marked postcards notifying beneficiaries of pending eligibility for free Medicare-covered back and/or knee braces.
Suspicious packages containing braces that were not ordered by your doctor.
Charges on your Medicare Summary Notice statements for braces or other DME that you did not want or were not ordered by your doctor.
Durable medical equipment (DME) scams, specifically around braces, continue to victimize Medicare beneficiaries throughout the state of CA. Some beneficiaries disclosed personal information to callers offering them braces. Others responded to TV commercials advertising braces to alleviate pain and later received a low quality brace or no brace at all. In both instances, Medicare paid hundreds of dollars for DME that was medically unnecessary and/or DME that was not rendered. To prevent Medicare waste and protect Medicare benefits, we continue to urge beneficiaries to guard their Medicare cards and remind them that if they are in need of any DME, they should consult with their doctor first to obtain medical necessity. With that said, please contact SMP to report any DME concerns you may have.

15. Medicare Summary Notice: Take a look at how much Medicare is paying for braces. It’s extremely costly!

16. Beware of Questionable Hospice Enrollment
Beware of hospice companies enrolling patients who do not have a terminal illness with 6 months or less to live.
Don’t get tricked by hospice companies offering free services such as housekeeping, home health, nurse visits, durable medical equipment and/or medications for “free". Medicare does not pay for this!
Report hospice companies who give presentations at senior housing facilities and offer assistance with cooking and cleaning.
Beware of calls or unannounced visits by hospice companies offering additional benefits such as help with cooking and cleaning.
The second trend SMP would like to bring to your attention is related to the new Medicare card. In this scheme, scammers use the Medicare card as a hook to obtain personal information from Medicare beneficiaries. Scammers call beneficiaries offering to send the new Medicare card if they have yet to receive it, offering to activate the new card, and most popular, offering to send the new card along with a complimentary brace. Just this week, we learned about a scam call where caller said the new Medicare card made of paper was just a temporary one, and by verifying the old Medicare number, which contains a Social Security, they would send a plastic card. Please contact SMP if you or someone you know believes the old or new Medicare cards have been compromised.

17. -Ordered to pay $1,344,204 in restitution.
2016:Pasadena Doctor Sentenced to 4 Years in Prison for Falsely Certifying Patients As Terminally Ill
-Ordered to pay $1,344,204 in restitution.
-Falsely certified that patients were terminally ill.
-Sentenced to four years in federal prison.
2016 Pasadena Doctor sentenced: to 4 years in prison for falsely certifying patients as terminally ill, when in fact, they were not. This doctor was ordered to pay over 1 million dollars in restitution. As mentioned earlier, in addition to the Medicare waste, there can be consequences when beneficiaries are signed up for a service they do not need.

18. Beware of Agent/Broker Misconduct
An agent enrolled a beneficiary into a plan without their permission.
Agent told the beneficiary that their physician takes the plan.
Agent offers free trips, meals in return for signing up.
Agent misrepresents the plans benefits.
Agent tells beneficiary they have to sign up or they will lose their Medicare.
The second trend SMP would like to bring to your attention is related to the new Medicare card. In this scheme, scammers use the Medicare card as a hook to obtain personal information from Medicare beneficiaries. Scammers call beneficiaries offering to send the new Medicare card if they have yet to receive it, offering to activate the new card, and most popular, offering to send the new card along with a complimentary brace. Just this week, we learned about a scam call where caller said the new Medicare card made of paper was just a temporary one, and by verifying the old Medicare number, which contains a Social Security, they would send a plastic card. Please contact SMP if you or someone you know believes the old or new Medicare cards have been compromised.

19. “Betty and the Medicare Health Plan – Making the Right Choice” is now available in electronic format in English/Spanish (one side is in English/one side is in Spanish).
Betty and the Medicare Health Plan – Making the Right Choice” is now available. Flyers are in color form with English content on one side, Spanish content on the other. To get your order today, please contact us.

20. DETECT-Review MSNs & EOBs
Keep track of medical appointments
-Use journal or calendar
Look for three things on your statements:
-Charges for something you didn’t get
-Billing for the same services or supplies twice
-Services that weren’t ordered by your doctor
Medicare Summary Notice (MSN)
Statement that shows what providers and suppliers billed Medicare in a 3-month period
Accessible 24/7 via mymedicare.gov
Explanation of Benefits (EOB)
In addition to our “Guard your Medicare card” message, please help us share the word about how important it is to review Medicare Summary Notices and Explanation of Benefits statement. Checking these statements for errors will truly reduce Medicare waste and will ensure Medicare benefits have not been compromised. To learn how to read and review any of these two statements, call SMP.

21. Medicare Errors & Other Situations That May Not Be Fraud
Beneficiary does not understand 20% patient responsibility and suspects double billing.
Beneficiary does not recognize name of provider on Medicare statement, but turns out to the provider who read/interpreted results.
Beneficiary forgot about medical appointment and suspected Medicare was billed for something not rendered.
It is important to not immediately jump to the conclusion of fraud if something doesn’t look right on an MSN or EOB. Because of Medicare’s complexity, beneficiaries may have trouble understanding their Medicare statements and bills from providers or they may be suspicious of a charge or service that is actually legitimate. That’s why SMPs encourage beneficiaries to contact their providers with questions as a typical first step in addressing suspected fraud, errors, and abuse.
If contacting the provider doesn’t clarify whether or not an error occurred or whether the billing practice was consistent with Medicare rules, then Medicare fraud or abuse may be suspected. A pattern of error by a particular provider increases the likelihood of fraud or abuse and is considered a red flag.
Chapter 3

22. Beware of: Genetic Testing marketing New Medicare Card related scams
Recently pubished report from the Government Accountability Office (GAO) – the top Congressional watchdog –and chief oversight investigative tool for monitoring executive branch spending and management
“IT would be nice to know how much fraud there is in Medicare …”
A properly enrolled Medicare provider could submit a claim that looks perfectly legitimate but bills for services that were either never provided or were more complex than the service actually done
Very difficult to catch

23. Beware of Genetic Testing Schemes
Promise personalized medicine. Free cancer screenings.
Covered by Medicare!
Cheek swab is taken.
Medicare pays thousands of dollars worth of unnecessary genetic testing.
SMP has cases where people are giving presentations to seniors or offering ice cream socials while also conducting
“cheek swabs” for genetic testing. These tests can help alert people about potentially negative interactions to medications they are taking, as genetically some people don’t respond well to certain drug therapies. Yet, Medicare only covers such a test if there are already signs, symptoms, complaints, or personal history of disease or injury warranting a test, and a person’s physician orders
it. Medicare does NOT cover it as part of a generic group screening. swabs”

24. -Used fear-based tactics to get seniors to participate.
New Jersey 2015: Man Charged for Deceiving Seniors Into Unnecessary Genetic Testing:
-“ICE CREAM SOCIAL EVENTs” held at low-income senior housing complexes.
-Used fear-based tactics to get seniors to participate.
-Promised a “personalized medicine.”
-DNA swabs taken by non-medical personnel.
-Providers recruited via Craigslist
advertisements to get tests authorized.
-Providers were paid thousands of dollars per month to sign their names.
-Billed Medicare more than $1 million!
2015 New Jersey case: Man charged for deceiving seniors into unnecessary genetic testing.
-“ICE CREAM SOCIAL EVENTs” held at low-income senior housing complexes.
-Used fear-based tactics to get seniors to participate.
-Promised a “personalized medicine.”-DNA swabs taken by non-medical personnel.
-Providers recruited via Craigslist
advertisements to get tests authorized.
-Providers were paid thousands of dollars per month to sign their names.
Billed Medicare more than $1 million!

25. Beware of New Medicare Cards Scams
Caller claims to be from Medicare and offers to send your new Medicare card in exchange for personal information.
Caller offers to activate your new Medicare card.
Caller agrees to send your new Medicare card along with a complimentary back brace.
Caller wants to send you a plastic new Medicare card.
The second trend SMP would like to bring to your attention is related to the new Medicare card. In this scheme, scammers use the Medicare card as a hook to obtain personal information from Medicare beneficiaries. Scammers call beneficiaries offering to send the new Medicare card if they have yet to receive it, offering to activate the new card, and most popular, offering to send the new card along with a complimentary brace. Just this week, we learned about a scam call where caller said the new Medicare card made of paper was just a temporary one, and by verifying the old Medicare number, which contains a Social Security, they would send a plastic card. Please contact SMP if you or someone you know believes the old or new Medicare cards have been compromised.

26. Treat you Medicare card like a credit card number.
PROTECT- Guard Your Card =
Treat you Medicare card like a credit card number.
Don’t carry your Medicare card unless you need it.
Only take it to medical appointments, visits to your hospital or clinic, or trips to the pharmacy.
Never give your Medicare number to a stranger.
PROTECT: There is still SMP work to be done even with the implementation of new Medicare cards. A new Medicare card does not mean the end of Medicare fraud. If the new Medicare card becomes compromised, it leaves the potential for medical theft which may lead to false claims submitted to Medicare. For this reason, we must continue the “Guard your card” message and remind Medicare beneficiaries to never give this number to a stranger and to only carry their Medicare card if they need it for medical appointments.

27. Common Health Care Scams:
Free Health Screenings – a vendor offers to provide “free” health care screenings, lab tests or other services but asks for a person’s Medicare number.
Counterfeit Prescription Drugs – beneficiaries purchase medication over the Internet to save money, but the drugs they receive are not the right medication or the right dosage.
Insurance Bait & Switch or Cross-selling – licensed agents present information about a Medicare Advantage plan, describing benefits and services that the plan doesn’t actually offer, and then sign people up for a plan that isn’t right for them.

28. SMP Fraud Alerts are available in different languages including:
English –Chinese –Spanish –Vietnamese –Korean –Russian –Farsi
You may access these fraud alerts by visiting our California Health Advocates website at:

29. Part D Fraud Schemes to Falsely Bill Medicare
Billing for drugs not prescribed.
Billing for amounts beyond the quantity prescribed.
Billing for brand name drugs but dispensing generic drugs instead.
Billing in excess of a physician’s prescription.
Prescription forged by a provider or supplier.
Prescription written and signed by a physician who has not treated or seen the recipient.
Part D:
-Billing for drugs not prescribed
-Billing for amounts beyond the quantity prescribed
-Billing for brand name drugs but dispensing generic drugs instead

30. Other Types of Health Care Scams

31. Billing for more miles than traveled for transport.
Look For:
Falsification of documentation to provide the appearance of medical necessity, when medical necessity did not exist.
Billing for more miles than traveled for transport.
Billing nonemergency trips as emergency trips.
Billing the beneficiary instead of Medicare, if the provider participates in Medicare and the trip met Medicare’s coverage criteria.
Many claims from beneficiaries receiving collection notices from ambulance companies – they were all transported in emergency situations to hospitals by ambulance; ambulance company submitted claims to Medicare but they were denied; ambulance companies then send bills to Medicare beneficiaries.
Improper coding by ambulance companies

32. Medicare “Gotchas”: 21161 SMP case:
-Client received $ ambulance bill
-Medicare denied claim because it was coded as non-emergency transport, when it actually was a medically necessary transport
Medicare “Gotchas”:
Ambulance Transport
Impacts Medicare coverage
Must be emergency
Must be only method of transportation (medically)

33. Home Health Care Services
What to look out for:
The beneficiary is asked to sign forms that verify a nurse or therapist showed up at her home and provided services, when none were provided.
Fraudulent physicians certify that a beneficiary is home bound, when in fact the beneficiary is not.
The beneficiary will be offered cash on a monthly basis or provided a home health aide that only prepares meals or cleans. Medicare does not cover cooking and cleaning!
Tips:
Make sure your physician approves your care plan.
Beware of an agency that offers you free goods and services in exchange for your Medicare number
Do not sign blank documents, especially timesheets.
Check your medical statements for services, such as missed visits from agency staff or visits when nothing was done, or equipment that was not necessary or never received.

34. Nursing Homes/Skilled Nursing Facilities
What to look our for
A skilled nursing facility provides physical therapy to 10 residents in a group for one hour (all at one time). However, when the facility bills Medicare, they bill as if they provided each of those 10 individuals with 1 hour of individual therapy.
Beneficiary participates in Bingo sessions, but bills Medicare for mental health therapy.
A skilled nursing facility orders their staff to enroll patients into physical therapy when the patients do not need (and do not qualify for) physical therapy.
Tips:
Check your medical statements for accuracy.

35. Mental Health What to look out for:
Mental health providers billing Medicare when patients are non- communicative or can’t benefit from therapy, e.g., the patient who was in a coma for 3 months.
Up-coding: billing for a more complex diagnosis or billing for 50 minute session and only seeing patient for 5 minutes.
Billing group therapy sessions as individual therapy visits.

36. Hospitals What to look out for:
Medicare “Gotchas”
Hospital in-patient vs observation status
Impacts Medicare coverage if you move to a SNF
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
What to look out for:
Hospitals billing for a more days than days beneficiary was actually in the hospital.
Billing for services and tests not provided.

37. Non-Health Care Related
Scams

38. Grandparent Phone Scam
Masquerades as your grandchild
In trouble – please help!
“Don’t tell my parents!”
“Just send me $$”
IRS Phone Scam
If you know or think you owe taxes, call the IRS at
If you know you don’t owe taxes or have no reason to think that you owe any taxes, then call and report the incident to TIGTA at
You can file a complaint using the FTC Complaint Assistant; choose “Other” and then “Imposter Scams.” If the complaint involves someone impersonating the IRS, include the words “IRS Telephone Scam” in the notes.
SMP does not take reports about non-Medicare related scams, but we do mention them in our outreach to bring awareness

39. National Do Not Call Registry
-managed by the FTC -May register by phone at

40. 1-855-613-7080 Get connected today!
Like & follow our CHA &SMP Facebook pages
Subscribe to our e-newsletter
To order free materials or
schedule a presentation at no-charge, call
Get connected today with materials and updates! We kindly encourage all of you to like us on Facebook and subscribe to our e-newsletter to stay connected with important Medicare and Medicare fraud updates. There’s our website and toll-free Medicare fraud hotline We’re a phone call away if you would like to report any potential Medicare fraud concerns you may have.

41. SMP placemats available in English and Spanish.
SMP Scam Pyramid Placemat: Another free resource available to you is our SMP scam pyramid placemat. They have content on the front and back, come in bundles of 125 and are available in English and Spanish. For placemats, please contact Jasmine. Materials are free and shipping is free.
SMP placemats available in English and Spanish.
To place an order, contact Jasmine at

42. FIGHT FRAUD IN YOUR COMMUNITY
Tips you can share:
Spread our Protect, Detect and Report Message
Share and post our CA-SMP fraud alerts
To order free materials, schedule a presentation at no-charge, or to report a case, call
THANK YOU!
To fight against Medicare fraud in your community, share our protect, detect and report message and contact us for materials, presentations, and to report cases. THANK YOU!