1. Arkansas SMP Empowering Seniors to Prevent Healthcare Fraud
Sponsored by the Division of Aging and Adult Services
Funded by grant No. 90AM2931 from the Administration on Aging

2. Arkansas SMP Mission Established in 1995 to:
RECRUIT & TRAIN VOLUNTEERS
over 480,000 beneficiaries in Arkansas
over 44 million beneficiaries in the US
EMPOWER SENIORS
Medicare/Medicaid beneficiaries
people with disabilities
nursing home residents & their families
caregivers to:
PREVENT HEALTHCARE FRAUD
Protect – personal information
Detect - monitor health care costs, read Medicare Summary Notices (MSN) and E.O.B.’s, and become informed, concerned, & active consumers (itemized bills)
Report – 1st call plan provider if there are questions,
then a local volunteer or the SMP Hotline:

3. Healthcare Fraud
What is it?

4. Fraud
Medicare fraud is intentionally billing Medicare for services you never got/provided.
A fraud scheme can be carried out by individuals, companies o
r groups of individuals

5. TYPES of FRAUD (Intentional* misrepresentation)
Provider Billing
Double billing
Billing multiple times for the same service/same bene.
Phantom billing
Billing for services that were not performed
Billing for services that were not medically necessary
Up Coding
Billing for more expensive Medicare covered service
Unbundling
Billing related services separately at a higher cost
False cost reporting
Billing old items like new, overcharging, unrelated costs
Falsification of records
Changing records to support improper billing
Over utilization
Unnecessary services, like blood tests, every visit
*Intent is often hard to prove

6. TYPES of FRAUD (Intentional misrepresentation)
Home Healthcare Fraud
Unnecessary Medical Services or supplies
Misrepresentation of medical professionals
“We can help you…
Kickbacks
>Fees to physicians for referrals
>Disguising fees as salaries for services not rendered
>Free services to benies for switching
>Providing hospitals with discharge planners
>Free services to retirement homes in exchange for referrals
>Subcontracting with retirement homes to induce referrals

7. TYPES of FRAUD (Intentional misrepresentation)
Durable Medical Equipment
Pay money or offer a “free” wheelchair or scooter if you give them your Medicare number
Forge a doctor’s signature or offer to pay doctors to write fake prescriptions
Steal Medicare papers out of your mailbox
Call and say your Medicare benefits will be cut
off if you don’t give them your Medicare number
Charge Medicare for the most expensive chair
but send you a cheaper one (or sometimes
none at all)
Bill the same chair over and over

8. TYPES of FRAUD (Intentional misrepresentation)
Deceptive Marketing Practices
Cold calling
Telephone soliciting
Misrepresenting or withholding information
Will not affect Medicare (It’s a supplement)
”I’m from Medicare
“Sure, your doctor accepts the plan…”
Pressure tactics; etc.
You must decide TODAY!
All I need is your Medicare number
You need this coverage…

9. …watch for the companies or agents who:
Present themselves as “Medicare Approved” with offers that are too good to be true
try to sell you healthcare services you have not asked for
Use high pressure techniques
ask for your Medicare # or other personal information
“Cold call” or drop by without an appointment

10. Read your MSN!
Take a careful look at your MSN and ask yourself three questions…
Did I receive the product or service that Medicare paid for?
Did my doctor order it?
Was it relevant to what I was being treated for?

11. $ How bad is it? $
Would
You
Believe . . .

12. Overview of the Extent of Medicare Fraud
2008 estimate: $40-$60 billion lost to fraud, error, and abuse last year…That’s
($109 - $164 million a day)
More than 1 billion annual total claims processed nationwide through Medicare
At least $1 out of every $10 of Medicare costs are attributed to fraud, waste and abuse; can vary dramatically from 10% to more than 30%, depending on location
Fraudulent claims skyrocketing out of control

13. Medicare fraud is not self-revealing:
Base Problem…
Medicare fraud is not self-revealing:
With credit cards:
Itemized statement
Customer pays with his/her funds
If there is a discrepancy, it is in the customer’s self-interest to protest the charge
With Medicare:
the customer/patient never sees the bill before it is paid by the government
Only rarely will patient catch fraudulent charges on own statement after the fact

14. Public Opinion Does Not Help
To make matters worse:
2 in 3 Americans tolerate insurance fraud to varying degrees
2 in 5 Americans want little or no punishment for insurance cheats; they blame the insurance industry because they “believe insurers are unfair.”
Fraud and waste not always perceived to personally affect patients or taxpayers
So, what’s the answer?

15. “The only thing necessary for the triumph of evil is for good men to do nothing…”
-- Edmund Burke,

16. Prevention Strategies: Change the Mindset
…Recognize that…
Prevention of Medicare fraud is significantly more cost effective than fighting it through law enforcement and criminal prosecution

17. Prevention Strategies: Change the Mindset
Embrace new paradigm that massive abuse is NOT just the cost of doing business… we may need a realistic compromise

18. Prevention Strategies: Change the Mindset
Prevent Medicare fraud together through partnerships and cooperation at multiple levels:
Physicians and other providers
Hospitals, clinics, pharmacies, and other agencies
Equipment, drug, and service suppliers
Patients, caregivers and their families
All working together to
Protect…Detect…Report

19. Arkansas SMP Call Toll-free 1-866-726-2916 for: Training Speakers
Materials
Reporting for suspected fraud/abuse
Volunteers to assist seniors
Web Site: