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Medicare and Durable Medical Equipment: Protect Yourself

from Fraud!

Updated August 2014

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What We Will Cover Today

• The SMP Program

• Medicare and Durable Medical Equipment (DME)

• DME and Fraud

• Protect, Detect, Report!

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How much do you think is lost every year to health care fraud and abuse?

A) $5-10 million

B) $25-125 million

C) $10-20 billion

D) $75-250 billion

How Much is Lost?

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How much do you think is lost every year to health care fraud and abuse?

A) $5-10 million

B) $25-125 million

C) $10-20 billion

D) $75-250 billion

How Much is Lost?

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• Medicare & Medicaid Beneficiaries– Loss of benefits– Higher premiums– Identity theft

• Taxpayers– Medicare is paid for by taxes– Billions of taxpayer dollars wasted

Fraud affects:

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Why Report Fraud?• Health care fraud puts you at risk for

identity theft.• IT’S YOUR MONEY!

• Taxpayer dollars• Higher premiums

• Saving the Medicare Program• People who commit fraud are

STEALING from you, not helping you!

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Why Report Fraud?• Your Medicare account may be

flagged: “Do Not Pay!”• When things aren’t ordered by your

doctor, they may not fit or work properly.

• When someone gives you something that you don’t need:• Your health may get worse• Your Medicare benefits may be “used up”

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The SMP Programwww.illinoissmp.org

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The SMP Program

• Senior Medicare Patrol

• National Program – SMP Programs in all 50 states, Washington,

D.C., Puerto Rico, Guam, Virgin Islands

• Goals of program: – Recruit volunteers to provide outreach– Educate consumers about health care fraud

and abuse

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SMP Staff and Volunteers…• Give presentations to groups (like this one!)

• Share information and materials at health fairs or other events

• Help people with questions about billing mistakes or fraud issues

• Help report fraud to investigators

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Illinois SMP Program Partners

• Illinois Area Agencies on Aging

• Catholic Charities

• White Crane Wellness Center

• Coalition of Limited English Speaking Elderly

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Medicare & Durable Medical Equipment (DME)

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What is DME?

• Durable Medical Equipment (DME) is reusable medical equipment, such as:– Wheelchairs– Walkers– Oxygen Equipment– Hospital Beds – Canes– Crutches

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What is DME?

• Medicare also covers many Prosthetics, Orthotics, and Supplies, such as:– Arm, leg, back, and neck braces– Artificial limbs and eyes– Diabetic supplies– Therapeutic shoes or inserts for people

with diabetes who have severe diabetic foot disesase

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When is DME Covered? • Durable Medical Equipment is covered by

Medicare when it is medically necessary - a doctor must prescribe it for you.

• Medicare Part B covers Durable Medical Equipment when you are going to use it in your home. If you are in a hospital or skilled nursing facility, the hospital or nursing facility should provide you with the equipment you need while you are there.

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When is DME Covered? Medicare will only cover DME if it is provided by a Medicare approved DME supplier. To find a Medicare approved supplier in your area:

• Call 1-800-MEDICARE (1-800-633-4227)

OR

• Go to Medicare’s website: www.medicare.gov. Click on “Find Suppliers of Medical Equipment in Your Area.”

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Power Wheelchairs and Scooters• Medicare will cover power wheelchairs

and scooters when they are necessary for your medical condition.

• Medicare will NOT cover a power wheelchair or scooter if it is only needed/used outside of the home – these devices are meant to be used mostly inside the home.

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How Much Does DME Cost?

• If you have Original Medicare and the DME supplier “accepts Medicare assignment,” Medicare will usually pay 80% of the cost of medically necessary DME. You will usually pay the remaining 20%, after you have paid your Part B deductible for the year. (Note: If you have a Medigap or other supplement plan, that plan may cover this 20%.)

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How Much Does DME Cost?

• If you have Original Medicare and the DME supplier does NOT “accept assignment,” there is no limit to what the supplier can charge you!

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How Much Does DME Cost?

• If you are on a Medicare Advantage plan, the plan must cover the same items and services as Original Medicare. However, the costs will depend on the plan.

• Call your plan to find out if your DME will be covered and what it will cost.

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Buying vs. Renting DME• Medicare has rules about when DME will be

rented and when it may be purchased. In general, certain types of equipment are usually rented (for example, oxygen equipment), but other types of equipment may be bought (canes, walkers, etc.). To find out if a particular piece of equipment will be rented or bought, ask the DME supplier or call 1-800-MEDICARE (1-800-633-4227).

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How Do I Get DME If I Need It?

• If you think you may need medical equipment, talk to your doctor. S/he will write a prescription, and if necessary, complete a “Certificate of Medical Necessity” – a form that your doctor sends to Medicare to get approval for certain kinds of equipment.

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How Do I Get DME If I Need It? • Before ordering equipment, ask the

supplier if they accept Medicare “assignment.” If a supplier is enrolled in Medicare, but does not accept “assignment,” they can charge you whatever they want.

• If a supplier is not enrolled in Medicare, Medicare will not pay for the supplies.

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Durable Medical Equipment (DME) and Fraud

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DME and Fraud – Medicare Rules

• NO unsolicited telemarketing– DME suppliers may only contact you if:

• 1) you have given the supplier written permission to contact you

• 2) the contact is about an item that the company already provided to you, OR

• 3) the supplier has provided you with at least 1 item in the last 15 months

– This rule also applies to solicitations through email, instant messages, in-person contact, or internet advertising.

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DME and Fraud – Medicare Rules

• DME suppliers must maintain a physical facility that is open and accessible to the public.– In most cases, the supplier must be open to the

public at least 30 hours a week– The facility must be staffed and accessible

during posted hours of operation• DME suppliers must have a primary business

telephone number – cell phones may NOT be used as primary business numbers.

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DME and Fraud – What is Fraud?

• Billing for equipment that you never received

• Billing for equipment that is different than what you received

• Billing for more advanced equipment than what you need

• Giving false or misleading information, such as offering of “free” equipment when they are going to bill Medicare

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DME Fraud Schemes: Scooter Scam

• A DME salesman visits a senior center and offers everyone at the senior center a “free” scooter. The salesman asks each person for his/her Medicare number. The company then bills Medicare as if they provided each person with an electric wheelchair. As a result, when one of these people needs an electric wheelchair two years later, Medicare will not pay for it.

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DME Fraud Schemes: Scooter Scam

• Problems:– Billing for a more expensive item than what was

provided (wheelchair instead of scooter) – Equipment given was not medically necessary

– scooters were given to everyone at the senior center, regardless of medical necessity

– Salesperson offers scooters as “free” and waives copayments – false and misleading information

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DME Fraud Schemes: Diabetic Shoe Scam

• A DME supplier sets up a table in the lobby of a senior building with a sign that says “Free shoes for Medicare beneficiaries!” When senior residents approach the table, they are given a pair of shoes from a local convenience store, in exchange for their Medicare numbers. The supplier then bills Medicare for “medically necessary” diabetic shoes for each person.

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DME Fraud Schemes: Diabetic Shoe Scam

• Problems: – False/misleading advertising – “free” shoes– Lack of medical necessity – shoes are being

given to anyone with Medicare coverage, regardless of whether they have diabetes and actually need the shoes

– Billing for diabetic shoes while providing cheaper, non-medical shoes

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DME Fraud Schemes: Arthritis Kit Scam

• One Saturday morning, Joe receives a visit from a man who asks if he has arthritis. When Joe answers, “yes,” the man tells Joe that he is going to give him a great new product – an “arthritis kit” – for free! All he needs is Joe’s Medicare number. Joe gives it to him, and the man gives Joe a package containing a lamp, a knee brace, and a box of gloves. Two months later, Joe receives his Medicare Summary Notice, which shows charges for thousands of dollars worth of orthotic braces!

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DME Fraud Schemes: Arthritis Kit Scam

• Problems:– No such thing as an “arthritis kit” – this is

always a scam!– Unsolicited door-to-door marketing, asking for

Medicare number– No prescription or certificate of medical

necessity by a doctor– Billing for products different than what was

given

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DME Fraud Schemes: Telemarketing of Diabetic Supplies

• While watching TV one afternoon, Sonia receives a phone call. When she answers, a robotic voice asks her to press “1” if she has diabetes. Sonia presses 1 and speaks to someone who offers to send her free diabetic supplies. Sonia gives the caller her Medicare number, but she never receives any supplies. Now, Sonia is concerned about identity theft because she realizes that her Medicare number is the same as her Social Security number.

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DME Fraud Schemes: Telemarketing of Diabetic Supplies• Problems:

– Unsolicited telemarketing, asking for Medicare number over the phone

– Possible billing for supplies never provided (if the company is billing for the supplies that have never been given to Sonia)

– Possible identity theft – the caller could be using Sonia’s Social Security number to gain access to other information and accounts.

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Protect!Detect!Report!

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PROTECT Yourself From Fraud!

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PROTECT Yourself From Fraud!

• If you need durable medical equipment, prosthetics, orthotics, or supplies, contact your doctor.

• Do NOT accept services from DME suppliers who:– Ask you to use their doctor– Contact you without your permission– Tell you that their equipment is “free”

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PROTECT Yourself From Fraud!

• Do NOT give your Medicare number to people you do not know!– On the phone– At the door– At a presentation, exercise class, “free”

screening, etc. (“Free” services do not require a Medicare number!)

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PROTECT Yourself From Fraud!

• Do NOT accept services from someone who calls or visits you unexpectedly, even if they say that your doctor sent them!

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PROTECT Yourself From Fraud!

• When you order DME, prosthetics, orthotics, or supplies, ask for a copy of all documentation for the equipment or supplies.

• Do NOT sign any forms or paperwork without reading them first. Never sign blank forms.

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DETECT Fraud!

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DETECT Fraud!• Read your Medicare Summary Notice

or Explanation of Benefits from your insurance company. Watch for:

– Services or supplies that you did not get

– Services or supplies that were not ordered by your doctor

– Billing for the same thing twice– Other billing errors

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REPORT Fraud!

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REPORT Fraud!• If you have questions about services that

you did receive, contact your doctor or the DME supplier first.

• If this does not work or you suspect fraud (for example, you see a claim on your Medicare Summary Notice for a service that you never received), call the Illinois SMP program at:

(800)699-9043

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Volunteers are the key to spreading the SMP message!

We need YOUR help!

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Thank you!

If you have questions, contact:

AgeOptions

(800)699-9043

This presentation was supported in part by a grant (No. 90MP0163 and 90SP0061) from the Administration on Aging

(AoA), Administration for Community Living (ACL), U.S. Department of Health and Human Services (DHHS). Grantees carrying out projects under government

sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions do not

necessarily represent official AoA, ACL, or DHHS policy.