© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Fraud and Abuse in Medicare-What You Need To Know Presented to The American Academy of Professional Coders Woodland Hills, California Christopher Gagnon, Fraud Investigator/ September 19, 2013

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Agenda SGS Overview Fraud and Abuse –Definitions and Effects SGS Investigations Areas of Concern What to Do If You Suspect Fraud Q & A

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 3 SafeGuard Services, LLC Overview SGS has served as the incumbent Program Safeguard Contractor (PSC) for: Medicare-Medicaid for California since 2001 Medicare Part B in California since 2002 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for Jurisdiction D encompassing seventeen states, including California, Nevada, and Hawaii since March 2006 Zone Program Integrity Contractor (ZPIC) Zone 1 operations, integrating Parts A, B, and DME, Hospice and Home Health claim types for fraud detection and prevention in California, Nevada, American Samoa, Guam, Hawaii, the Northern Mariana Islands, Palau, Marshall Islands, and the Federated States of Micronesia since December 2010

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 4 CMS Definitions Medicare Fraud When someone intentionally falsifies information or deceives Medicare. Medicare Abuse When health care providers or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren't medically necessary.

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 5 Effects Of Medicare Fraud & Abuse $60 Billion Estimated Annual Loss Increased Costs of Healthcare – Throughout the Industry Affects Everyone – Taxpayers – Beneficiaries – Providers / Suppliers – Insurers Increased Scrutiny of All Claims Greater Burden for Beneficiaries & Providers Restrictions of Access to Care for Beneficiaries Unfair Competitive Advantage Over Legitimate Providers Damaged Reputation for Healthcare Industry

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 6 SGS Investigations What We Investigate Allegations of Fraud, Waste and Abuse related to Medicare-Enrolled Providers/Suppliers Who We Investigate Hospitals, Home Health Agencies, Hospice Care (Part A) Physicians, Clinics, Testing Facilities, Labs (Part B) DME Suppliers (DME) What We Do Not Investigate Billing Errors Disputes Over Quality Of Service Issues

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 7 SGS Investigations External Referrals Fraud Prevention System (FPS) Medicare Administrative Contractor Beneficiaries Providers Centers for Medicare & Medicaid Services Senior Medicare Patrol OIG Hotline Database Medi-Cal Law Enforcement Internally Data Team Investigators Where Do our Leads Come From?

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 8 SGS Investigations Schemes And Scams Beneficiary Sharing Use of Cappers and other Illegal Marketing Soliciting, Offering or Receiving a Kickback, Bribe or Rebate Provider/Beneficiary Identity Theft Over Utilized Services Providing Unnecessary or Inappropriate Services Billing For Services Not Rendered Up-coding (Provider claim forms which have been altered to obtain a higher payment amount DME’s-IDTF’S-Clinics-Physician Assistants Hit and Run Non-existent Provider Office Locations (i.e., False Fronts, Store Fronts)

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 9 Investigative Steps Review of Claims History Beneficiary Information Provider Information Payment Information Review of Multiple Data Bases Review of Internal Reports/Data Analysis Patients and Hours per day Proximity to Office Peer Comparisons Review of Internet Sites Such as Medical Board Obtain Provider Enrollment Applications

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 10 Investigative Steps Prepayment Review May be Initiated Obtain Sample of Claims Universe Order and Review Medical Records Post Payment Review by our Medical Review Team Perform Beneficiary Validations and/or Interviews Review Existing Complaints Perform Provider Interviews On-sites Telephone

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 11 Outcomes of Investigations Any or All of the Following: – Allegation Not Validated/Closed with No Actions Necessary – Possible Administrative Actions Calculate Overpayment Prepayment Review Deactivation Revocation Payment Suspension – Referral To Law Enforcement

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 12 Examples

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 13 Areas of Concern From a Coders Perspective Egregious Up-coding Suites of Codes Unusual Codes for Specialty Consistent Use of Qualifying Modifiers Pressure from Provider to Change the Codes or Diagnoses

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 14 What To Do If You Suspect Fraud or Abuse Medicare ( ) The OIG Hotline Phone: The Office of Inspector General, HHS website Mail: Office of Inspector General HOTLINE P.O. Box 9778 Arlington, Virginia 22219

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 15 In Closing QUESTIONS?

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 16 ZONE 1 CONTACT INFORMATION Melisa Mulcahy Program Director Beth Romig Benefit Integrity Manager (530) Travis Moore Acting Manager-Task Order 1 (213) Mike Devlin Manager-Task Order 2 (530)

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Thank you