CMS CENTERS FOR MEDICARE AND MEDICAID SERVICES (HEALTH CARE FINANCING ADMINISTRATION) RENAMED IN 2004)

CENTERS FOR MEDICARE AND MEDICAID SERVICES IS WITHIN THE U. S CENTERS FOR MEDICARE AND MEDICAID SERVICES IS WITHIN THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES.

OPERATES MEDICARE AND MEDICADE PROGRAMS OPERATES CHILDREN’S HEALTH INSURANCE PROGRAM

REGULATES ALL LABORATORY TESTING (EXCEPT RESEARCH) PERFORMED ON HUMANS IN THE UNITED STATES.

IN CONJUNCTION WITH DEPARTMENTS OF LABOR AND TREASURY, HELP SMALL COMPANIES GET AND KEEP HEALTH INSURANCE.

MAGNITUDE OF THE PROGRAM

CMS SPENDS OVER $360 BILLION A YEAR BUYING HEALTH CARE SERVICES FOR THE BENFICIARIES OF MEDICARE, MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM.

ASSURES THAT THE MEDICAID, MEDICARE AND CHILDREN’S HEALTH INSURANCE PROGRAMS ARE PROPERLY RUN BY ITS CONTRACTORS AND STATE AGENCIES.

ESTABLISHES POLICIES FOR PAYING HEALTH CARE PROVIDERS.

CONDUCTS RESEARCH ON THE EFFECTIVENESS OF VARIOUS METHODS OF HEALTH CARE MANAGEMENT, TREATMENT, AND FINANCING; AND

ASSESSES THE QUALITY OF HEALTH CARE FACILITIES AND SERVICES AND TAKING ENFORCEMENT ACTIONS AS APPROPRIATE.

AREAS OF SPECIAL INTEREST

FIGHTING FRAUD AND ABUSE

CMS HAS A COMPREHENSIVE PROGRAM TO COMBAT FRAUD AND ABUSE. TAKES STRONG ENFORCEMENT ACTION AGAINST THOSE WHO COMMIT FRAUD AND ABUSE

PROTECTS TAXPAYERS DOLLARS GUARANTEES SECURITY OF MEDICARE, MEDICAID, AND CHILD HEALTH PROGRAMS

QUALITY ASSESSMENT AND PERFORMANCE REVIEW

DEVELOPING AND ENFORCING STANDARDS THROUGH SURVEILLANCE MEASURING AND IMPROVING OUTCOMES OF CARE

EDUCATING HEALTH CARE PROVIDERS ABOUT QUALITY IMPROVEMENT OPPORTUNITIES EDUCATING BENEFICIARIES TO MAKE GOOD HEALTH CARE CHOICES

MEDICARE AND MEDICAID BASICS

WHAT IS MEDICARE?

MEDICARE IS A HEALTH INSURANCE PROGRAM FOR

PEOPLE 65 YEARS OF AGE OR OLDER SOME PEOPLE WITH DISABILITIES, UNDER 65 YEARS OF AGE. PEOPLE WITH END-STAGE RENAL DISEASE (PERMANENT KIDNEY FAILURE REQUIRING DIALYSIS OR A TRANSPLANT

MEDICARE HAS FOUR PARTS PART A (HOSPITAL INSURANCE) – PEOPLE DO NOT HAVE TO PAY FOR PART A HELPS PAY FOR HOSPITALS, SKILLED NURSING FACILITIES, HOSPICE, AND SOME HOME HEALTH CARE

NO PREMIUM CHARGE IF MEDICARE TAXES WERE PAID WHILE WORKING

PART B (MEDICAL INSURANCE) – MOST PEOPLE PAY MONTHLY FOR PART B HELPS PAY FOR DOCTORS, OUTPATIENT HOSPITAL CARE, AND SOME OTHER MEDICAL SERVICES NOT COVERED IN PART A.

BASIC COST TO THE ENROLLEE IS $96 BASIC COST TO THE ENROLLEE IS $96.50 A MONTH AND HIGHER DEPENDING ON YOUR INCOME REVEALED ON YOUR INCOME TAX STATEMENT. MAXIMUM IS $238.40.

PART C – MEDICARE ADVANTAGE PART C – MEDICARE ADVANTAGE. PEOPLE WITH MEDICARE A & B CAN RECEIVE CARE THROUGH AN HMO.

PART D – PRESCRIPTION DRUG COVERAGE

MEDICAID

MEDICAID IS A HEALTH INSURANCE PROGRAM FOR CERTAIN LOW-INCOME PEOPLE MEDICAID IS A HEALTH INSURANCE PROGRAM FOR CERTAIN LOW-INCOME PEOPLE. IT IS FUNDED AND ADMINISTERED THROUGH A STATE-FEDERAL PARTNERSHIP.

STATES HAVE A WIDE DEGREE OF FLEXIBILITY TO DESIGN THEIR PROGRAMS

MAY ESTABLISH ELIGIBILITY STANDARDS DETERMINE WHAT BENEFITS AND SERVICES TO COVER SET PAYMENT RATES

WHO QUALIFIES? ON ANY GIVEN DAY ABOUT 33 MILLION PEOPLE ARE ELIGIBLE FOR MEDICAID.

LOW-INCOME FAMILIES WITH CHILDREN BLIND OR DISABLED PEOPLE LOW INCOME PREGNANT WOMEN AND CHILDREN PEOPLE WITH VERY HIGH MEDICAL BILLS.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996

HIPAA Administrative Simplification The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers.

It also addresses the security and privacy of health data It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.

FRAUD AND ABUSE

IT IS ESTIMATED THAT FRAUD AND ABUSE COST MEDICARE AND MEDICAID ABOUT $33 BILLION EACH YEAR. SOME HAVE ESTIMATED THAT NUMBER WILL RISE TO $70 BILLION IN 2008.

IN 1995, THE CLINTON ADMINISTRATION LAUNCHED “OPERATION RESTORE TRUST” $23 IN OVERPAYMENTS FOR EVER $1 SPENT LOOKING AT HOME HEATH CARE, SKILLED NURSING FACILITIES, AND SUPPLIERS OF DURABLE MEDICAL EQUIPMENT.

AT A COST OF $100,000,000 NEW TOOLS WERE CREATED TO COMBAT FRAUD ABUSE NEARLY $1,000,000,000 WAS RETURNED TO THE MEDICARE TRUST FUN FROM FINES, JUDGEMENTS, AND SETTLEMENTS.

2,700 FRAUDULENT HOME CARE PROVIDERS AND ENTITIES WHO WERE THEN EXCLUDED FROM DOING BUSINESS WITH MEDICARE

CONVICTIONS UP 20% NEW CIVIL HEALTH FRAUD CASES UP 61%

TESTIMONY FROM CONVICTED FELONS: ACQUIRED $7 MILLION DOLLARS BY CHARGING $5 T0 $7 FOR GAUZE SURGICAL DRESSINGS THAT COST A PENNY EACH.

ANOTHER SHAKEDOWN PRACTICE CONSISTED OF SUBMITTING BILLS FOR THE TREATMENT OF DEAD PATIENTS. SCAM ARTISTS USE THEIR COMPUTERS TO FIND HOLES IN THE MEDICARE AND MEDICAID PAYOUT SYSTEM TO COMMIT MASSIVE FRAUD.

IN A RECENT FLORIDA CASE, A BUSINESS CONSISTING OF TWO RENTED MAILBOXES AND A BEEPER PHONE WAS PAID $2.1 MILLION BY MEDICARE IN FIVE MONTHS – BEFORE THE OWNER VANISHED.

BEN CARROLL OF KISSIMEE, FLA BEN CARROLL OF KISSIMEE, FLA., COLLECTED $51 MILLION BY CHARGING MEDICARE $8.45 PER “FEMALE-URINARY-COLLECTION DEVICE” COMMONLY KNOWN AS AN “ADULT DIAPER” AND SOLD FOR 35 CENTS EACH.

COLUMBIA SETTLEMENT

COLUMBIA/HCA WILL SETTLE WITH THE JUSTICE DEPARTMENT FOR CIVIL CLAIMS FILED AGAINST THE COMPANY. INVOLVED CODING ISSUES, OUTPATIENT LAB BILLING, AND HOME HEALTH CARE.

AGREEMENT INCLUDES TERMS OF A CORPORATE INTEGRITY AGREEMENT WITH HEALTH AND HUMAN SERVICES DEPARTMENT. IN ADDITION TO THE $745 MILLION DOLLAR SETTLEMENT, COLUMBIA WILL PAY 6.5% ON THAT AMOUNT ACCRUING IMMEDIATELY.

THERE ARE ALSO CRIMINAL CHARGES INVOLVED

DETECTION TIPS

YOU SHOULD BE SUSPICIOUS IF THE PROVIDER TELLS YOU THAT: THE TEST IS FREE; HE ONLY NEEDS YOUR MEDICARE NUMBER FOR HIS RECORDS.

MEDICARE WANTS YOU TO HAVE THE ITEM OR SERVICE. THEY KNOW HOW TO GET MEDICARE TO PAY FOR IT.

THE MORE TESTS THEY PROVIDE THE CHEAPER THEY ARE. THE EQUIPMENT OR SERVICE IS FREE; IT WON’T COST YOU ANYTHING.

BE SUSPICIOUS OF PROVIDERS THAT: ROUTINELY WAIVE COPAYMENTS WITHOUT CHECKING ON YOUR ABILITY TO PAY.

ADVERTISE “FREE” CONSULTATIONS TO MEDICARE BENEFICIARIES. CLAIM THEY REPRESENT MEDICARE.

USE PRESSURE OR SCARE TACTICS TO SELL YOU HIGH PRICED MEDICAL SERVICES OR DIAGNOSTIC TESTS.

BILL MEDICARE FOR SERVICES YOU DO NOT RECALL RECEIVING. USE TELEMARKETING AND DOOR-TO-DOOR SELLING AS MARKETING TOOLS.

End of lecture for September 9th, 2009 7th period. Questions?