2. SMP: Senior Medicare Patrol – Medicare fraud prevention program 1997: Senator Tom Harkin had an idea… Today: nationwide program in 50 states, DC, & U.S. territories Peer education model: SMPs recruit and train senior volunteers to conduct outreach and education to their peers and caregivers about Medicare fraud prevention SMP Program: Empowering Seniors to Prevent Health Care Fraud Mission: 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.

3. SMP Message Prevent fraud by protecting personal information, knowing how to detect fraud, and knowing where and how to report suspected fraud, errors, and abuse Protect!Detect!Report!

4. SMP Program: Empowering Seniors to Prevent Healthcare Fraud Receive complaints of potential healthcare fraud, errors and abuse and either resolve or refer to OIG for investigation. ScamWire Alerts Emerging scams throughout PA Distribute to volunteers and partners Home delivered meals initiative Legislative outreach To join listserv: carmody@carie.org Outreach and Education Professional groups Caregivers Limited English Proficiency groups

5. SMP Program: Empowering Seniors to Prevent Healthcare Fraud SMP Program since 1997: 60,000 volunteers trained Over 104,000 complaints handled 3.5 million people educated 94,000 group education sessions 1.2 million 1-on-1 counseling sessions Over 1.9 million media airings Over $106 million in savings Prevention hard to quantify Health Care Fraud and Abuse Control Program

6. Take a Guess… How much do you think is lost to Medicare fraud and abuse each year?

7. Why Should We Care About Healthcare Fraud And Abuse? Each year, Medicare loses over $60 billion to fraud, abuse, and errors

8. Why Should We Care About Healthcare Fraud And Abuse?. Increased out of pocket costs Beneficiaries Money lost for caregiver support programs Caregivers Increased taxes Taxpayers

9. What Does Healthcare Fraud Look Like? Traditional Medicare  Fee-for-service  Incentive for fraud is to bill over and above what was actually provided to get higher reimbursement.  Over bill, up-code, send more supplies  Overutilization of system  Fee-for-service  Incentive for fraud is to bill over and above what was actually provided to get higher reimbursement.  Over bill, up-code, send more supplies  Overutilization of system Managed Care  Capitated payment  Incentive for fraud is to enroll beneficiaries into plans and keep capitated payments in-hand rather than spend on patient care.  Underutilization of system  Capitated payment  Incentive for fraud is to enroll beneficiaries into plans and keep capitated payments in-hand rather than spend on patient care.  Underutilization of system

10. What Fraud Looks Like: Traditional Medicare Billing for a service using a deceased person’s Medicare number. Scammers offering free services or products in exchange for a peek at Medicare number. Billing for services or supplies never received Double-billing: Billing twice for the same service or item Up-coding: Billing for services different than what was rendered Sending more medical supplies than ordered or needed

11. What Fraud Looks Like: Managed Care Medicare marketing violations by managed care and Part D plans Enrollment and disenrollment schemes Denial of needed medical care A long delay in providing a service; for example, waiting several months for approval for durable medical equipment Much harder to identify

12. Case Examples Patient complained of sore throat Doctor confirmed and wrote prescription Doctor billed for laryngoscopy! Patient called office, they fixed the “error” R&V Medical Supplies dropping off scooters to seniors in NE Philadelphia Claimed they had been selected by City of Philadelphia and local AAA to receive scooter Needed to verify Medicare number One woman knew better, reported the company, and exposed a fraud ring.

13. Fraud in the News oBrotherly Love Ambulance, Inc. – Owner pleaded guilty for committing $2 million fraud scheme involving submitting false claims and paying kickbacks to patients. oHome Care Hospice – Owner charged with submitting $14.3 million in false claims for patients who were ineligible for hospice. oDr. Joseph Kubacki – Temple University Opthamologist convicted and sentenced to 7 years in prison for falsifying patient charts and submitting $3 million in false claims.

14. Telephone Scams: Recent Reports from Pennsylvania $299 Prescription drug scam Calling from drug company Promise something too good to be true Ask for bank account # Diabetic supply scams Is someone in the home diabetic? Promises free supplies delivered to home No prescription necessary New Medicare card scam Calling from Medicare or Social Security Verify basic information Request Medicare or bank account # Use fear / make threats

15. Protect  Detect  Report Protect!Detect!Report! Prevent fraud by protecting personal information, knowing how to detect fraud, and knowing where and how to report suspected fraud, errors, and abuse

16. How Can Beneficiaries Protect Themselves? Never give any personal information to unsolicited callers or people who show up at their door. Remember that Medicare and Social Security will never try to sell a service or product. Encourage beneficiaries to work directly with their doctor if they need medical supplies or equipment. Don’t accept equipment from people who call or show up at the door. Do not carry Medicare card on SEPTA Their Medicare # IS their Social Security # Never sign blank insurance forms. Be wary of high pressure sales tactics. Don’t enroll unless you’re sure.

17. How Can Beneficiaries Detect Fraud? Keep a healthcare journal/calendar Review & reconcile statements Dates of services Provider names Services or supplies received If they don’t receive statements, request them. Track claims in real time: www.mymedicare.govwww.mymedicare.gov If Medicare pays for something medically unnecessary now, it may not pay for something medically necessary in the future. Be an informed consumer; ask questions.

18. What to do if Beneficiaries Suspect Fraud or Abuse? Report it! Call the provider, rule out error. Call the Pennsylvania SMP: 1-800-356-3606 We will work with them to resolve case or refer it to OIG. Their call can help warn others via our ScamWire alerts 

19. So, How Do I Help My Clients? Understanding how fraud and abuse directly affects the beneficiaries you assist. Reinforcing the message of protect, detect, report. Be on the lookout for red flags Stockpiles of supplies unsolicited visitors/callers Encouraging clients to keep healthcare journals. Helping to create an account on www.mymedicare.gov Helping to review statements and bills to check for accuracy. Knowing who to call for help, and calling for help. Materials distribution – Scam Wire.

20. Contact Us 1-800-356-3606 Program Manager  Rebecca Nurick – nurick@carie.org Regional Volunteer Coordinators  Jennifer Carmody – carmody@carie.org o Southeast PA and Central PA/Capital Region  Vanessa Miller – miller@carie.org o Lehigh Valley and Northeast PA  Alisha Nash - nash@carie.org o Southwest PA and Northwest PA

21. Thank You Any Questions?