1. Senior Medicare Patrol (SMP) Fraud prevention, detection and reporting
SHIBA and the
Senior Medicare Patrol (SMP)
Fraud prevention, detection and reporting
Statewide Health Insurance Benefits Advisors (SHIBA )
is a free, unbiased service sponsored by the:
8/26/2014

2. SHIBA mission
SHIBA provides free, unbiased information about health care coverage and access to help improve the lives of all Washington state residents. We cultivate community commitment through partnership, service and volunteering.

3. Who is affected? All of us! Medicare and Medicaid clients Taxpayers
How?
Diminished quality of treatment
Less money for needed benefits
Taxpayers
Billions of tax dollars wasted

4. Senior Medicare Patrol: From idea to national program
Through public law (est. 1997)
Administration on Aging established 12 demonstration projects
To recruit & train retired professionals to detect & report potential error, fraud & abuse
Today we have 54 SMP projects in all states, Wash. DC, Puerto Rico, Guam & U.S. Virgin Islands
Washington state SHIBA program sponsors SMP in our state

5. 3 roles of SHIBA & SMP
Distribute fraud prevention and identification information 1.
Assist clients in resolving issues & complaints 2.
Refer suspected cases of fraud, waste & abuse to investigative entities 3.

6. Protect, detect, report Purpose of SHIBA’s fraud awareness program:
Educate clients (Protect)
Perform 1:1 counseling (Detect)
Refer cases for investigation (Report)
Later on during this presentation, we will discuss in further detail the elements of protecting, detecting and reporting.

7. Little quiz How much does Medicare pay in claims every year?
Answer: About $500 billion
Which state is #1 in losses due to Medicare & Medicaid fraud & abuse?
Answer: Florida
#2, #3, #4 states?
Answer: California, New York and Texas
About $500 Billion
Florida
California , New York, Texas

8. Identify theft is the door to Medicare fraud
SHIBA & The SMP

9. Identify theft
The number on your Medicare card is your Social Security Number
This number is as important to thieves as a credit card

10. = Guard your card! Think of your Medicare card as your
health care credit card! =
Speaker: At this point in the presentation you can ask the audience how many people have their Social Security card with them. Usually very few people do.
Then ask how many have their Medicare card, and usually quite a few people do.
Explain that their Medicare Claim Number includes their Social Security number and suggest they keep their Medicare card at home in a safe place except when visiting providers.

11. Every Medicare benefit can be a potential fraud area
Ambulance services
Clinical lab/independent physiology labs
Durable Medical Equipment (DME) suppliers
Home health agencies
Hospice care
Hospital services
Medicare Advantage/Managed care plans
Medicare prescription drug plans
Mental health services
Nursing facilities
Physician/practitioner services

12. Who commits Medicare fraud & abuse?
People or providers who bill Medicare OR benefit from Medicare getting billed
Doctors & health care providers
Durable Medical Equipment (DME suppliers)
Employees of doctors or suppliers
Home health agencies, hospice
Medicare clients

13. Some of the most wanted fraud fugitives
The U.S. Inspector General is searching for these fugitives:
Mr. Allonce allegedly gained access to nursing care facilities and patients hospital records to produce fake DME billings to Medicare.
Mr. Barcelo allegedly ran several clinics and charged Medicare for services not needed or rendered.
Ms. Chisanga allegedly worked for a DME supplier and altered prescriptions/authorizations for DME to bill more than allowed.
Mr. Thorsen allegedly had CMS grant money for research deposited directly to his personal checking account.
Etienne
Allonce
Alfredo
Barcelo
Patricia
Chisanga
Poul
Thorsen

14. Examples of fraud
Altering claim forms to get a higher payment amount (called “upcoding”)
Example: Flu shot billed as a Shingles shot
Billing twice for same service or item
Billing separately for services that should be included in a single service fee (“unbundling”)
Example: Comprehensive blood panel billed as individual tests
Billing for services not rendered or supplies not provided

15. Beware of providers who advertise free services
Two Medicare clients – a husband & wife – get a visit at home by a stranger offering free medical services & equipment
Stranger drives them to clinic where they were asked for their Medicare card numbers
They were sent home with a box of Ensure
Their Medicare Summary Notices (MSNs) showed claims for services not rendered, however, Medicare paid the provider
If it seems to good to be true, it likely is. Generally providers do not offer services or products free of charge.

16. Example of fraud conviction
LA doctor convicted of multi-million dollar Medicare fraud case:
Operated a health & beauty clinic
Performed radiofrequency laser & liposuction
Stole Medicare numbers from patients
Got Medicare numbers from others via recruiters
Submitted fraudulent claims for:
Revascularization
Ablation of a bone tumor
Placement of radiotherapy catheter in breast

17. What can happen if you become a Medicare victim
Stolen Medicare numbers can lead to false claims
Medicare may note your file as a problem and as a result, your:
Benefits may stop
Medicare number may be flagged as a “Compromised Number”
A Stolen Social Security Number can lead to theft of your banking information
It is very important that beneficiaries review their Medicare Summary Notice (MSN) or go online to MyMedicare and review their accounts on a regular basis.
Medicare clients should keep a journal of all services/supplies received and dates of services to compare to their MSN.
This can help them to identify any fraudulent activity on their account and may help prevent a situation whereby their Medicare number becomes a “Compromised Number.”

18. Compromised Medicare number
Someone used her Medicare number to submit fraudulent claims for a wheelchair
Medicare paid the claims to the fraudster
When she really needed a wheelchair, Medicare denied her legitimate claim
Wheelchairs and prosthetics are some of the most common items listed in fraudulent claims.
It happened to her

19. Beware of strangers pretending to be from Medicare
Phone scam case followed by a home visit from “Medicare:”
Senior receives a phone call from a woman claiming to be from Medicare.
The woman says she is going to “visit the senior at her home.”
The next day, the senior gets a visit from a man named Richard who says he’s from Medicare.
He tells the senior a new state law requires her to enroll in a Medicare Advantage plan and he’s there to help her. Afraid of losing access to her doctor, the senior gives Robert her Medicare number and Part D plan information.
Senior was enrolled in a health plan, which raised her premium and she lost access to her doctors.
SMP referred the case for investigation.
It’s also important to remind the public that although a representative of a certain insurance company may not be perpetrating fraud, however, the plans they offer may not suit their needs. Encourage audience to contact SHIBA with any questions they might have before switching plans.

20. Fooled by a criminal 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 $1,000 for tests -

21. Telemarketing/phone scams
Fraudster calls consumers in the early morning
Gives a rapid sales pitch, usually with a foreign accent
Deliberately confuses consumers into believing he/she represents Social Security or Medicare
Promises a new Medicare card or medical card – OR offers free medical alert equipment
Purpose: To get your checking account and credit card information!

22. Durable Medical Equipment (DME)
Look for:
Unauthorized, unsolicited supplies sent to you
Why DME?
Until recently:
No professional licensing requirements
Suppliers could set up shop with very little investment
Huge potential for quick profit

23. DME fraud example DME supplier:
Gained access to skilled nursing facilities & board & care homes
95% of his submitted claims were for power wheelchairs
Many clients never received the equipment or didn’t need it
Most of the Medicare numbers were provided by patient recruiters who received kickbacks

24. DMEPOS aims to slow down DME fraud
Implemented in 2 Washington state regions in 2013
Requires competitive bidding & lower prices from equipment suppliers
Forces suppliers to have surety bonds & legit places of business
Reduces the number of suppliers
DMEPOS stands for Durable Medical Equipment, Prosthetics, Orthotics and Supplies.
DMEPOS has reduced fraud in the regions it has been implemented, however in the areas where it hasn’t been implemented many providers report being “bombarded” by requests for approvals of potentially fraudulent DME claims.

25. The face of home health fraud
Social worker employed in several home health agencies
Found opportunities to obtain more Medicare funds
Did bookkeeping, cleaned cabinets, played cards
Submitted claims for all these activities to Medicare but coded as Medicare – covered services

26. Picked up at downtown emergency drop-in center by fraudster
Transported to local hospital with questionable diagnosis
Homeless Medicare client on Skid Row
Moved to skilled nursing facility; promised 90 days of housing paid by Medicare

27. Fraud & lab services Why Lab services? What to look for:
Doctors don’t see what’s billed to Medicare
Labs aren’t required to submit diagnosis information to support the need for the services
What to look for:
Medically unnecessary services billed
Providers “strongly urging” patients to go to a specific clinic
Unbundling (e.g., one blood panel listed by individual test)
Tests not ordered, but performed & billed
Keep in mind the provider who orders the lab tests may not have any knowledge of what the lab actually bills for.

28. Fraud & hospice care Why hospice care? What to look for:
End of life issues extremely vulnerable situation
Clients & families are usually unaware of items billed to Medicare
What to look for:
Clients who are not terminally ill enrolled in hospice
Hospice agencies promising “all the oxygen you need”
Clients who don’t understand how hospice is covered

29. Fraud & Medicare Advantage
(MA) plans
Why MA plans?
Major increase in number of managed care plans
They hire independent agents
No statements sent to members (except EOBs for Part D plans)
What to look for:
Insurance agent marketing violations
Agents switching to their plan without client consent or knowledge
Cold calling (if no prior relationship)
Again, even if the agent/producer representing the plan is not potentially committing a fraudulent act or violating insurance marketing rules, it is always very important for the beneficiary to weigh their options very carefully before making any changes.
NEW: Effective October 2014, Medicare Summary Notices must be sent

30. Fraud & pharmacies Part D prescription drug program started in 2006
$50+ billion dollar program
Most likely fraud cases:
Billing hundreds of Rx for a single client
Dispensing less than the prescribed amount of pills
Claims for brand name drugs but dispensing generics
Large amount of claims for refills, but never requested

31. 2013 CVS Caremark Corp. fraud investigation
Second largest drug store chain in the U.S.
Customers have been surprised to find that CVS renewed their prescriptions & billed their insurance without their consent
CVS was ultimately issued a fine due to this practice.

32. Fraud & hospitals In-patient vs. outpatient status
Hospitals charge for a significant amount of line items
Typically don’t give you an itemized statement when you’re discharged
One hospital statement could involve multiple people generating a single patient’s bill
American Medical Association – “Nearly 20% of claims have errors”
If at all possible, have a family member or close friend at the hospital with you so they can help journal services received and communicate with all providers involved in their care. You may request an itemized bill upon discharge.

33. Health Benefits Exchange
Complexity = confusion = opportunity for fraud
Medicare WA
Health Benefits Exchange
Because of all the changes recently due to the Affordable Care Act, many in the public are confused, and this creates many opportunities for fraudsters.
Affordable Care Act

34. If you have Medicare… Your Medicare coverage is protected
Medicare isn’t part of the Health Exchange so you don’t have to replace your Medicare coverage with an Exchange plan
No matter how you get Medicare, you still have the same benefits & security
You don’t need to do anything during the Exchange’s open enrollment period
Make sure that the audience knows the dates of Medicare open enrollment, ask them to write it down.
Oct. 15 – Dec. 7

35. Example of ACA-related Medicare fraud
Someone contacts Medicare client via phone or
They tell client they need a new Medicare ID card or plan number due to ACA or “Obama care”
They ask client to confirm personal information, including Social Security number
Client then becomes victim of ID theft

36. The Affordable Care Act (ACA)
Adds ability for Dept. of Health & Human Services to disallow provider enrollment
Implements a “smart, automated system” to proactively ID fraudulent claims
Fraud prevention system
Integrates Medicare & Medicaid
Partners with private insurers & MA plans
Increases law enforcement – Office of Inspector General
Along with fraud prevention, Payment Integrity goes a long ways towards preventing fraud.
“Payment Integrity” is making sure the claims being paid are legitimate.
Medicare now has a sophisticated computer claims processing system that helps to identify anomalies and outliers and helps to prevent payment of fraudulent claims i.e. billing for a pregnant man etc.

37. Protect, detect, report Educate clients (Protect)
Perform 1:1 counseling (Detect)
Refer cases for investigation (Report)

38. Protect Treat your Medicare card as your credit card or SSN card
Don’t carry it with you until you need it for visits to the doctor, clinic or pharmacy
Never give your Medicare number to a stranger
Record doctor visits, tests & procedures in a personal health care journal or calendar
Save MSNs and Part D EOBs; shred when you no longer need it
Remember: Medicare does NOT call or visit sell you anything.

39. Detect
Review MSNs & Part D Explanation of Benefits (EOBs) for possible mistakes
Access myMedicare.gov account
Compare MSNs & EOBs to personal health care journal and Rx drug receipts to ensure they’re correct
Look on billing statement for:
Charges for item/service you didn’t receive
Billing for same thing twice
Services your doctor didn’t order

40. Example of MSN
Speaker: Review the different parts of the MSN with the audience, encourage them to review it carefully, and compare it to their journal of appointments and services.

41. Report fraud to SHIBA at:
Ask questions
Seek help
Use written records
Contact SHIBA
Collect evidence
Marketing flyers
Business cards
MSNs
Narratives
Report fraud to SHIBA at:

42. Volunteer for SHIBA! Become a volunteer! Call: 1-800-562-6900
Do you want to help explain health care benefits
or options to:
Friends?
Neighbors?
You community?
Help people become better informed consumers?
Become a volunteer! Call:

43. Need help with other insurance questions?
The Office of the Insurance Commissioner can also help you with questions, information, and complaints about all types of insurance, such as:
Call our Insurance Consumer Hotline
Homeowner
Auto
Life
Annuities
Health
And more!