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LGBT Older Adults and Medicare Fraud:

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Presentation on theme: "LGBT Older Adults and Medicare Fraud:"— Presentation transcript:

1 LGBT Older Adults and Medicare Fraud:
Suggested Script Thank you for allowing me to take a few minutes of your time. My name is (name) and I am here with the (State) Senior Medicare Patrol program. In today’s presentation, I will talk to you about Medicare fraud and abuse, how they affect YOU, and how you can help fight fraud and abuse in three easy steps: protect, detect, and report. SMP Group Education Presentation for LGBT Older Adults Notes that are in italics are meant as notes to the facilitator, not to be read aloud. This presentation is adapted from information and resources available from the National Resource Center on LGBT Aging, led by Services and Advocacy for GLBT Aging (SAGE), and from PowerPoint presentations developed by the SMP Resource Center as part of the SMP Group Education Manual. For more information on LGBT aging, visit lgbtagingcenter.org or sageusa.org. For more information on Medicare fraud prevention, visit the SMP Resource Library at seniormedicarepatrol.org/ResourceLibrary. Suggested reading before presentation (available at the SMP Resource Library): Providing Services to LGB Older Adults: Tips for SMP Staff and Volunteers Providing Services to Transgender Older Adults: Tips for SMP Staff and Volunteers Lesbian, Gay, Bisexual Older Adults and Medicare Fraud Prevention Transgender Older Adults and Medicare Fraud Prevention Recruiting LGBT Volunteers for Your SMP Program Content & Timing: 20 – 30 minute presentation SMP Program Overview: 1 minute Medicare Overview: 1-3 minutes Medicare Fraud & Abuse: 1 minute How Medicare Fraud affects YOU: 1 minute Additional cost/consequences of Fraud & Abuse: 1 minute Examples of Fraud & Abuse (stories): 3 – 6 minutes Protect, Detect, Report: 6 minutes How to be an SMP Volunteer: 1 minute Q&A session: 5 – 10 minutes What Can You Do to Help Prevent Healthcare Fraud? PowerPoint created by: SAGE (Services & Advocacy for GLBT Elders)

2 What is the Senior Medicare Patrol?
SMPs 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 Suggested script First, what is the Senior Medicare Patrol? Senior Medicare Patrol programs, or SMPs, help Medicare and Medicaid beneficiaries prevent, detect and report health care fraud. They not only protect older persons, they also help preserve the integrity of the Medicare and Medicaid programs. Because this work often requires face-to-face contact to be most effective, SMPs nationwide rely on approximately 5,000 volunteers who are active each year to help in this effort. Since 1997, more than 25 million people have been reached during SMP community education events, more than 3 million beneficiaries have been educated in group sessions or one-on-one counseling, and more than 24,000 volunteers have been active. The total savings to Medicare, Medicaid, beneficiaries and other payers attributed to the SMP projects is $106 million.*” (* If asked: The source of the statistics provided above is the May 2011 OIG Performance Report.) Suggested Handout: SMP Fact Sheet, available to download at the SMP Resource Library:

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 Note: If you only have 1-2 minutes to talk about Medicare, use slides 3-4 and skip slides 5-8. If the presentation is intended to be very short, skip straight to slide 9 to begin the discussion of Medicare fraud. This presentation is not intended to be a detailed discussion on who is eligible for Medicare, or how the Supreme Court’s decision to strike down the Defense of Marriage Act (DOMA) affects legally married same-sex couples with regard to Medicare benefits. However, you may receive questions asking for more details on this subject. A suggested handout is “After DOMA: What it Means for You - Medicare Spousal Protections,” available at the National Resource Center on LGBT Aging (http://www.lgbtagingcenter.org/resources/resource.cfm?r=611). This document contains detailed information on how federal recognition of marriage affects Medicare spousal protections and benefits. Have copies ready to hand out. Suggested Script Medicare is the federal health insurance program created for people 65 years and older, or for those under 65 who have a disability, End-Stage Renal Disease or ALS (also known as Lou Gehrig’s Disease). Medicare was created by Congress in 1965 and is administered by the Centers for Medicare & Medicaid Services (CMS). Medicare covers most services a person needs, but there are costs associated with Medicare coverage.

4 Medicare Cost Terms Premium Deductible Copay Coinsurance
Suggested Script Before we continue with more information about Medicare benefits, we should pause to go over some cost terms that people with Medicare should be familiar with. While Medicare is very comprehensive coverage, it does not cover 100% of a person’s medical costs. Know these cost terms so you can know how much you are spending on your Medicare. A premium is the amount someone must pay for Medicare, a private health plan or Part D plan for coverage. A premium is generally paid on a monthly basis. Many of you likely pay the Part B premium of $ per month. A deductible is the amount an individual must pay for their health care services before their health insurance begins to pay. A copay is a set amount someone is required to pay for each medical service they receive (example: a person has to pay $20 each time they go to the doctor). Finally, a coinsurance is the portion of the cost of care that someone is required to pay after their health insurance pays(example: they pay 20% for most Medicare approved services).

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. Suggested Script Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) together are known as “Original Medicare” and are run by the federal government. Both have deductibles and coinsurances for most covered services. Beneficiaries will have Original Medicare unless they choose to join a Medicare Advantage health plan (Part C). Medicare Advantage plans cover the same services as Original Medicare except coverage is provided by private insurance companies instead of the federal government. Beneficiaries also have the choice of joining a Medicare Prescription Drug Plan (Part D) to add outpatient prescription drug coverage to their Medicare package. Part D, like Medicare Advantage plans, is offered by private insurance companies and beneficiaries must choose and enroll in a plan in order to receive coverage. Finally beneficiaries who choose to stay with Original Medicare may also decide to purchase private Medicare supplemental insurance known as a Medigap. These policies provide coverage for some or all of the Part A and Part B deductibles and copayments for Original Medicare-covered services. If you decide to purchase a Medigap policy to supplement your Original Medicare coverage, you will have to pay an additional premium.

6 Part A: Hospital Insurance
Part A covers: Inpatient hospital care Inpatient skilled nursing care Some home health care services Hospice care Slide can be read as is. If asked about home health care services: Part A home health care covers part-time or intermittent skilled services required after a hospitalization for homebound patients.

7 Part B: Medical Insurance
Part B covers: 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 Slide can be read as is. If asked about home health care services: Part B home health care coverage doesn't require a hospital stay if the beneficiary’s doctor orders home health. The home health benefits provided by Part A and Part B are identical. The only difference between them is which Medicare part is covering the services. Beneficiaries should not notice a difference.

8 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 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 Suggested script Medicare Part C, more commonly referred to as Medicare Advantage, is a way for people to get their Medicare (Parts A and B) and drug coverage (Part D) through one private insurance plan. If you elect a Medicare Advantage plan you still have Medicare, you are just getting that coverage from a private insurance company rather than straight from the government. Medicare Advantage plans are offered by private insurance companies that sign a contract with Medicare. Medicare Advantage plans must cover all Part A and Part B services but can cover these services with different costs and restrictions. For example, Medicare Advantage plans will usually require members to stay within a network of doctors and hospitals. They may also require members to ask the plan’s permission before obtaining drugs or services. Medicare Advantage plans may offer extra benefits that Medicare doesn’t cover, such as hearing, vision, dental or medical transportation services. Beneficiaries are encouraged to compare plans prior to enrolling since coverage varies. Doctor’s in the plan’s network, doctor’s copayments, drugs covered, drug co-payment amounts, deductibles, and gap coverage are different for each plan. Call 800-MEDICARE for help with plan comparisons. People with Medicare can change how they get their drug coverage every year during Fall Open Enrollment (October 15-December 7). You should compare drug plans every year at this time to make sure you are enrolled in the plan that works best for you.

9 Part D: Prescription Drugs
Part D plans cover prescription drugs purchased at a pharmacy or through mail order 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 Suggested Script Medicare Part D is also referred to as Medicare Prescription Drug Coverage. The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to offer Medicare prescription drug plans to people with Medicare. Beneficiaries are encouraged to compare plans prior to enrolling since coverage varies. Drugs covered, co-payment amounts, deductibles, and gap coverage are different for each plan. A plan comparison tool is available on the Medicare web site: People with Medicare can change how they get their drug coverage every year during Fall Open Enrollment (October 15-December 7). You should compare drug plans every year at this time to make sure you are enrolled in the plan that works best for you.

10 What is Medicare Fraud? Intentionally billing Medicare for services that were not received, or billing for a service at a higher rate than is actually justified. Suggested Script Now that we’ve learned a little bit about Medicare, let’s look at Medicare fraud. Medicare fraud involves intentionally billing Medicare for services that were not received, or billing for a service at a higher rate than is actually justified.

11 What is Medicare Abuse? Providers supply services or products that are not medically necessary or that do not meet professional standards. Suggested Script Next, what is Medicare abuse? Medicare abuse occurs when providers supply services or products that are not medically necessary or that do not meet professional standards. Medicare fraud and abuse are very similar and many times overlap.

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

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 Suggested Script In addition to fraud and abuse, it’s also important to consider errors. Providing and billing for health care services involves a lot of complicated steps, which may lead to errors. Most Medicare payment errors are simply mistakes and are not the result of physicians, providers, or suppliers trying to take advantage of the Medicare system. You may want to call your provider’s office first to ask if improper or double billing was an error. If you do not like the answer you get, call your local SMP!

14 Medicare Fraud, Errors, and Abuse Affect:
Everyone People with Medicare Billions of taxpayer dollars lost to improper claims Medicare trust fund at risk Copays or coinsurances paid toward unnecessary services or services not received Higher premiums Less money for needed benefits Quality of treatment Suggested audience interaction to introduce this slide – ask the audience: How many of you are Medicare beneficiaries? (raise hands) How many of you pay taxes? (raise hands) Suggested Script You might be wondering, why should I care about Medicare fraud? Well, Medicare fraud, errors, and abuse affect everyone! Each year, Medicare loses BILLIONS of taxpayer dollars to improper claims. This puts the Medicare trust fund at risk for everyone, and affects the future of the Medicare program. Medicare fraud, errors and abuse also affect current Medicare beneficiaries, because they result in higher Medicare premiums and waste money that could be used to increase and improve health care services. Older people become targets of scams and fraud every day. LGBT older people are often more vulnerable to fraud than their peers, for reasons such as isolation. LGBT people with Medicare may not know many people in their communities. They may not feel welcome at community centers, churches or senior centers. So, they may not know who to ask for help when they notice Medicare fraud. In addition, changing marriage laws and the overturn of the Defense of Marriage Act (DOMA) means that many LGBT older Americans are now eligible for coverage and benefits from their spouses in a way they were not before. New coverage and changing benefits means LGBT people with Medicare may be targeted by scams claiming to somehow enhance their new eligibility.

15 Consequences to People with Medicare
Fraudulent use of your Medicare number may affect YOUR Medicare benefits! 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 Suggested Script In addition to the impact on the Medicare system, Medicare fraud can also result in serious personal consequences to beneficiaries who are victims of fraud. Fraudulent use of your Medicare number may affect YOUR Medicare benefits! 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! If a false claim is filed under a Medicare number, it can create errors in medical history records and can even result in benefits later being denied to the real person with Medicare when that person needs them.

16 Consequences to People with Medicare
Theft of your Medicare number may also lead to theft and misuse of: Your Social Security Number and your identity Your medical identity Your banking and credit information Suggested Script Theft of your Medicare number may also lead to theft and misuse of: Your Social Security Number and your identity (since your Social Security number is usually part of your Medicare number) Your medical identity (someone may use it to pose as you and receive health care services, altering your medical record) Your banking and credit information.

17 Consequences for Committing Fraud
Fraud convictions: 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 Suggested Script It’s a federal crime to defraud the U.S. Government or any of its programs. So, what are some of the consequences to perpetrators of Medicare fraud? Fraud convictions can be criminal and/or civil. They may result in prison sentences, restitution (repayment of the stolen funds), and/or steep fines. They also result in mandatory exclusion from the Medicare program for a specific length of time.

18 Stories of Medicare Fraud and Abuse
On this slide, be prepared to share one or two stories of Medicare fraud or abuse. Below are some sample stories you can use. Keep the story or stories short, just a few minutes, to ensure that the presentation stays on schedule. Alternately, find recent examples of lesbian, gay, bisexual or transgender older adults in your area that have experienced fraud or abuse. Discuss with your SMP director and/or coordinator of volunteers as needed to identify examples and write the script or talking points. Use pseudonyms if necessary to protect the privacy of anyone whose story you share. Avoid examples that may not be as relevant to LGBT older adults, such as stories of married couples being defrauded (in states where same-sex marriage is not recognized). If desired, delete (or shrink) the picture on this slide and type a few key words to remind you and your audience what the case is about. Story 1 Tara is 81 and has Original Medicare. She wants to select a new doctor who is more welcoming to LGBT patients. She called Dr. G, who she heard of by word of mouth, to see if he is a Medicare participating provider who accepts Medicare payment in full and could take her on as a patient. Dr. G tells her that he is a Medicare participating provider, and when Tara visits his office she sees LGBT magazines in the waiting room, so feels comfortable choosing him. She also calls Medicare to confirm that Dr. G is a participating provider. After Tara’s visit to Dr. G, she receives a bill that is extremely high. She calls Dr. G to get an explanation. Dr. G says that Medicare does not pay in full for one of the services he provided to her, although it is a Medicare covered service. Tara does not think that Dr. G is allowed to select only some services for which he will accept Medicare payment in full, but after bad experiences with other doctors, she is afraid to argue further. She now worries that she is a victim of fraud. Tara’s next step is to call her state SMP to report Dr. G, and to ask for help identifying Medicare fraud. Story 2 Larry and Dan, both in their early 70s, have been together for more than 30 years. They celebrated the Supreme Court ruling striking down DOMA, but are still unsure about how the ruling affects their federal benefits, such as Medicare. Over the years, Larry was the primary breadwinner, while Dan covered the home front. Dan pays a much higher Medicare premium than Larry. It would be best, they both think, if Dan is legally recognized as Larry’s spouse and can therefore qualify for a lower premium. They’ve talked about these issues often with an assistant manager at a neighborhood restaurant they visit regularly. The assistant manager says his uncle and partner had the same questions, and he was able to help them adjust their coverage—all he needs is their Medicare numbers and Social Security numbers. He seems like a nice guy, so Larry and Dan give him the information. Later, when they hear nothing more from the assistant manager, they discover credit cards in their names with thousands in charges. They report him to their local SMP. The SMP helps them report to the crime to the police and address the fraudulent charges. Story 3 Sam is a 71-year-old gay man who is homebound. His partner Lou recently passed away, and Sam does not have any other family members to care for him. Lou and Sam did not tell anyone that they were a couple; they pretended to be roommates. However, Sam’s physician has guessed the truth. Now, in addition to billing Medicare for the home health care services that Sam actually receives, the physician is billing Medicare for several extra home health care services, and has asked Sam to sign forms verifying that a therapist has shown up at his home to provide the made-up services. If Sam does not sign the forms, his physician has threatened to “out” him (tell other people about his sexual orientation without his permission). Sam hears that calls to the Senior Medicare Patrol are confidential, so he reaches out to his local SMP for help reporting the physician to Medicare and the police.

19 Three Steps to Prevent Health Care Fraud
Suggested Script So, what can YOU do to help prevent Medicare fraud, abuse, and errors? I am here to tell you how you can prevent fraud in three easy steps: protect, detect, and report. Protect Detect Report

20 Protect Do Don’t 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 Suggested Script Step one, protect yourself from Medicare fraud and abuse! Treat your Medicare and Social Security cards and numbers like credit cards. Don't give out your Medicare number except to your doctor or other Medicare provider. Don’t carry your Medicare card unless you will need it. Only take it to doctor’s appointments, visits to your hospital or clinic, or trips to the pharmacy. Watch out for identity theft. Scam artists will not only use your Medicare number to defraud the Medicare system, but this is also one way that people can steal your identity, since your Social Security number is typically included in your Medicare number! Be aware that Medicare doesn’t call or visit to sell you anything. However, Medicare does now require their contractors to contact beneficiaries from time to time, so make sure to be vigilant. Keep in mind that you don’t have to talk to anyone who calls you or shows up at your door who you do not trust. Medicare contractors will understand.

21 Detect Review your Medicare Summary Notices (MSNs) and Explanation of Benefits (EOBs) for: Services you didn’t receive Double-billing Services not ordered by your doctor Suggested Script Step two, detect Medicare fraud and abuse: Even when you do everything right, there is a chance that you could be a target of health care fraud. There are a lot of ways that your personal information can be used without your permission. Always review your Medicare Summary Notice and Part D Explanation of Benefits for mistakes. Look for three things on your billing statements: 1. Charges for something you didn’t receive 2. Billing for the same thing twice, and 3. Services that were not ordered by your doctor Suggested Handout: What Is a Medicare Summary Notice? Tip: If you have time, hand out the MSN fact sheet and review it with the group. Explain how to use your MSN to detect fraud, errors, and abuse on page 1, and review the information to look for in each type of statement on page 2.

22 Detect Access your Medicare information online at MyMedicare.gov or at your Medicare Advantage plan’s website View most recent MSNs or EOBs Check Part B deductible status View eligibility information Track available preventive services Suggested Script Medicare Summary Notices are typically sent on a quarterly basis. To better detect potential issues, you may want to access your Medicare information online, if you have access to a computer at home, or through your senior center or LGBT community center. MyMedicare.gov is a helpful tool for beneficiaries to review their MSNs and track their services. Once you register, access to your current Medicare account is available 24 hours a day. If you have a Medicare Advantage plan, your Medicare information will be on your private insurance company’s website. To set up an online account contact your Medicare Advantage plan using the number on the back of your benefit card.

23 Detect Use your Personal Healthcare Journal
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 Suggested Script Another way to help detect fraud, error, and abuse is by using a Personal Health Care Journal. Record doctor visits, tests and procedures in your personal health care journal and/or calendar, and take your journal with you to all of your appointments. Directions for using the Personal Health Care Journal are provided in the front of the journal, and include a short list of questions you may want to ask yourself before your health care appointment, for example: Is this appointment going to be covered by Medicare or my other insurance? What are my symptoms? When did they start? What makes them better or worse? What over-the-counter or prescription medications am I taking? Write down the answer to these questions, as well as what happens during your visit, in your journal. Later, make sure to compare your Medicare Summary Notices and other statements to your personal health care journal and prescription drug receipts to make sure they are correct.” Suggested Handout: Personal Health Care Journal (Available in multiple languages, customize with your SMP’s local information) Tip: If you have time, hand out the Personal Health Care Journal and review it with the group. Point out the instructions in the front of the PHCJ and explain how to use it to track health care visits and what types of questions to consider at each appointment.

24 Report If you detect Medicare fraud or abuse: Call the provider
Gather information and documentation Contact your SMP—this is a free and confidential service! Suggested Script Third, if you detect or suspect fraud or abuse, report it! You will protect other people from becoming victims and help to save your Medicare benefits. Here are the steps you should take to report your concerns: First, if you have questions about information on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB), call your provider or plan to find out if it was an error that they can correct without taking any further action. If you are not satisfied with the response you get, or are not comfortable calling your provider or plan, gather all of the facts that you can about your situation. Make sure you have your MSN or EOB and any other supporting documentation that shows the possible fraud or abuse. Then, contact your SMP if you need help! Please keep in mind that services provided by your SMP are free and confidential.

25 SMP Volunteers Join the SMP program as a volunteer! Would you like to:
Help other Medicare beneficiaries protect, detect and report? Give presentations? Provide one-on-one counseling? Perform administrative work? Suggested Script Now that you have learned how to Protect, Detect, and Report Medicare fraud, errors, and abuse, would you like to help other Medicare beneficiaries do so too? SMP volunteers, like ME, give group presentations like this one, provide one-on-one counseling to people with Medicare, perform administrative work, and more! If you would like to join the SMP program as a volunteer, please talk to me after this presentation or contact the local SMP. Join the SMP program as a volunteer!

26 Contact your local Senior Medical Patrol
[your SMP name] For more information, visit us online at: yourwebsite.com Or call toll-free [your phone number] Editing instructions In each of the following fields with parentheses ( ), enter the applicable information to replace the parentheses and placeholder text, or remove text which is not applicable to your presentation. (Your SMP Name) (Your website) (Your SMP phone#) Suggested Script If you need to reach us at the (Your SMP Name), please visit us online or call us. Our contact information is provided on the screen and/or in the handouts. To report suspect fraud/abuse For training, speakers and/or materials To volunteer with the SMP program

27 Questions? For more information, visit: smpresource.org sageusa.org
lgbtagingcenter.org Suggested Script If any of you have questions, please ask them now or feel free to talk to me after the presentation. Notes: Answer questions or have your assigned partner answer questions; see Group Education Training manual and/or SMP Counselor Training manual for guidance during the Q&A session. I hope today’s presentation has been useful in showing you how to prevent Medicare fraud and abuse by taking the three important steps. 1. Protect your Medicare number, 2. Detect fraud, errors, and abuse by reviewing your Medicare Summary Notices, and 3. Report any potential issues to your SMP. Thank you for your time and for participating in this session! Further notes: Suggested handout to take home: LGBT Older Adults & Medicare Fraud Prevention, available at 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.


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