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LGBT Older Adults and Medicare Fraud: PowerPoint created by: SAGE (Services & Advocacy for GLBT Elders) What Can You Do to Help Prevent Healthcare Fraud?

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Presentation on theme: "LGBT Older Adults and Medicare Fraud: PowerPoint created by: SAGE (Services & Advocacy for GLBT Elders) What Can You Do to Help Prevent Healthcare Fraud?"— Presentation transcript:

1 LGBT Older Adults and Medicare Fraud: PowerPoint created by: SAGE (Services & Advocacy for GLBT Elders) What Can You Do to Help Prevent Healthcare Fraud? 1

2 What is the Senior Medicare Patrol?  Help Medicare and Medicaid beneficiaries prevent, detect and report healthcare fraud  Protect older people and help preserve the integrity of the Medicare and Medicaid programs  Rely on volunteers to help perform SMP work SMPs 2

3 What is Medicare?  Federal health insurance program for people 65 years and older; also for people with disabilities under 65  Created by Congress in 1965  Administered by the Centers for Medicare & Medicaid Services (CMS)  Medicare covers most medically necessary services a person needs 3

4 Medicare Cost Terms Premium Deductible Copay Coinsurance 4

5 Parts of Medicare Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Part D: Prescription Drugs Medicare Supplemental Insurance (Medigap) is insurance sold by private companies that pays some or all of the copayments and coinsurances associated with Original Medicare. People with Medicare Advantage plans cannot have Medigap policies. 5

6 Part A: Hospital Insurance  Inpatient hospital care  Inpatient skilled nursing care  Some home health care services  Hospice care Part A covers: 6

7  Doctor services  Durable medical equipment (DME)  Some home health care services  X-rays, lab services  Therapy services (physical, occupational, speech)  Outpatient services  Most mental health services  Preventive health care services Part B: Medical Insurance Part B covers: 7

8  Medicare run by private insurance companies  The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to offer all Medicare benefits through a private plan  Must cover all Part A and Part B services  May offer extra benefits  Usually includes prescription drug coverage (Part D)  Beneficiaries are encouraged to compare plans each year  Visit or call 800-MEDICARE for more information Part C: Medicare Advantage Part C, known as Medicare Advantage, is a way to get Medicare Parts A, B and D through a private insurance company 8

9  Part D is Medicare drug coverage  Only offered through private plans  The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to offer Part D plans to people with Medicare  Beneficiaries are encouraged to compare plans each year  Visit or call 800-MEDICARE for more information Part D: Prescription Drugs Part D plans cover prescription drugs purchased at a pharmacy or through mail order 9

10 Intentionally billing Medicare for services that were not received, or billing for a service at a higher rate than is actually justified. What is Medicare Fraud? 10

11 What is Medicare Abuse? Providers supply services or products that are not medically necessary or that do not meet professional standards. 11

12 Fraud & Abuse includes:  Billing for services, supplies or equipment that were not provided  Billing for excessive medical supplies  Obtaining or giving a Medicare number for “free” services  Improper coding to obtain a higher payment  Unneeded or excessive x ‐ rays and lab tests  Claims for services that are not medically necessary  Using another person’s Medicare number, or letting someone else use your number, to obtain medical care, supplies or equipment 12

13 What About Errors?  Healthcare services and billing are complicated, which can lead to errors  Only a review and investigation of the issue will determine if it is an error, fraud or abuse 13

14 Medicare Fraud, Errors, and Abuse Affect:  Billions of taxpayer dollars lost to improper claims  Medicare trust fund at risk Everyone People with Medicare  Copays or coinsurances paid toward unnecessary services or services not received  Higher premiums  Less money for needed benefits  Quality of treatment 14

15  If a Medicare number is stolen, it can’t be cancelled or changed by Medicare  Your file may be flagged “do not pay”  Errors in medical history records can result in benefits being denied later when you need them Consequences to People with Medicare Fraudulent use of your Medicare number may affect YOUR Medicare benefits! 15

16  Your Social Security Number and your identity  Your medical identity  Your banking and credit information Theft of your Medicare number may also lead to theft and misuse of: 16 Consequences to People with Medicare

17  Can be criminal and/or civil  May result in prison sentences, restitution and/or steep fines  Result in mandatory exclusion from the Medicare program for a specific length of time Consequences for Committing Fraud Fraud convictions: 17

18 Stories of Medicare Fraud and Abuse 18

19 Protect Three Steps to Prevent Health Care Fraud Detect Report 19

20  Treat your Medicare card and number like your credit cards  Watch out for identity theft  Be aware that Medicare doesn’t call or visit to sell you anything  Give out your Medicare number except to your doctor or other Medicare provider  Carry your Medicare card unless you will need it Do Don’t 20 Protect

21  Services you didn’t receive  Double-billing  Services not ordered by your doctor Review your Medicare Summary Notices (MSNs) and Explanation of Benefits (EOBs) for: Detect 21

22  View most recent MSNs or EOBs  Check Part B deductible status  View eligibility information  Track available preventive services Access your Medicare information online at MyMedicare.gov or at your Medicare Advantage plan’s website 22 Detect

23  Record doctor visits, tests and procedures in this journal, and take it with you to appointments  Ask yourself questions about your healthcare— write the answers and other information in your journal  Compare your MSNs and other statements to your journal to make sure they are correct Use your Personal Healthcare Journal 23 Detect

24  Call the provider  Gather information and documentation  Contact your SMP—this is a free and confidential service! If you detect Medicare fraud or abuse: 24 Report

25 SMP Volunteers  Help other Medicare beneficiaries protect, detect and report?  Give presentations?  Provide one-on-one counseling?  Perform administrative work? Would you like to: Join the SMP program as a volunteer! 25

26 Contact your local Senior Medical Patrol  To report suspect fraud/abuse  For training, speakers and/or materials  To volunteer with the SMP program [your SMP name] For more information, visit us online at: yourwebsite.com Or call toll-free [your phone number] 26

27 Questions? For more information, visit: smpresource.org sageusa.org lgbtagingcenter.org This project was supported, in part by grant number 90SM0011, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy. 27


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