Medicare Fraud Program Training

Agenda

• Basics of Medicare

• Medicare Fraud Program

• What is Fraud?

• Tips & Resources to Combat Fraud

• Areas of Health Care Fraud

Medicare Overview

• Medicare is the federal program administered by the Centers for Medicare and Medicaid Services (CMS)

• Social Security Administration (SSA) is responsible for enrolling people

• Eligibility:– At least 65 years of age– Some people with disabilities– People with End Stage Renal Disease

Medicare Part A

• Hospital Insurance• Inpatient care – hospitals, critical access, hospital

and skilled nursing facilities• Hospice care, some home health, and blood work

Medicare Part B

• Medical Insurance• Helps cover doctor services and outpatient

hospital care• Physical therapy, occupational therapy,

some home health care, ambulance services, durable medical equipment

Facts• 900 million Medicare claims are paid each year and

human eyes NEVER look at them• Scam artists relocate every 90 days• In 1996:

– Our NATION lost $40 billion dollars – ILLINOIS lost $1.3 billion dollars – That’s about $56,000 lost every minute because of

health care fraud and abuse!

What Is Fraud?

Definition: Fraud• Obtaining or attempting to obtain services or payments by

dishonest means with, INTENT, KNOWLEDGE, and WILLINGNESS

• Occurs when a provider bills an item or service which was NOT provided or is different from the service provided

• EXAMPLES:

– A doctor bills for an initial visit but the visit was a follow up– A podiatrist bills for foot surgery but only trimmed toenails– A lab charges for blood tests but no tests were done– A supplier delivers a basic wheelchair but bills for a more

expensive model

Definition: Abuse

• Occurs when a provider bills for medically unnecessary items or services

• Also occurs when the services performed exceed what is needed

• EXAMPLES:– Unnecessary home medical equipment– Excessive diagnostic x-rays and clinical laboratory services

Definition: Waste

• Needless consumption or unnecessary usage

• EXAMPLES:– Mistakes in the processing of claims– Billing errors that go uncorrected

Who commits health care fraud?

• Home Health Care Providers• Durable Medical Equipment suppliers• Pharmacies• Doctors• Nursing Homes• Hospitals

Who can prevent health care fraud?• Home Health Care Providers• Durable Medical Equipment suppliers• Pharmacies• Doctors• Nursing Homes• Hospitals

Remember – most medical and health professionals are honest. Sometimes, a simple billing error has been made

Tips and Resources for Older Persons

What Should You Do If You See A Mistake?

• Phone the medical insurance provider–Listed on the Medicare Summary

Notice• Contact CLESE or AgeOptions

Protect Yourself!

• Keep this information private:– Name, address, date of birth– A provider number– A billing form– A post office box– A Medicare number– A Social Security number

Protect Your Records!

• Don’t carry your social security cards or your Medicare cards

• Carry your Emergency Information Card• Tear or shred personal information• Take the mail out of your mailbox right away

Take a careful look at your Medicare Summary Notice

Ask these 3 questions:

1) Did I receive the service or product that Medicare paid for?

2) Did my doctor order it?

3) Was it relevant to what I was being treated for?

Sample Medicare Summary Notice

Sample Medicare Summary Notice

Medicare Summary Notice1. Date: Date the Notice was sent

2. Customer Service Information: Who to contact with questions about the Notice. Provide your Medicare number (3), the date of the Notice (1), and the date of the service you have a question about (7)

3. Medicare Number: The number on your Medicare card

4. Name and Address: If incorrect, contact the company listed in (2), and the Social Security Administration immediately

5. Be Informed: Messages about ways to protect yourself and Medicare from fraud and abuse

6. Part B Medical Insurance - Assigned Claims: Type of service. See the back of MSN for information about assignment. (Please Note: For unassigned services, this section is called "Part B Medical Insurance - Unassigned Claims.")

7. Dates of Service: Date service or supply was received. You may use these dates to compare with the dates shown on the bill you receive from your doctor

8. Claim Number: Number that identifies this specific claim

9. Services Provided: Brief description of the service or supply received

10. Amount Charged: Amount the provider billed Medicare

11. Medicare Approved: Amount Medicare approves for this service or supply

12. Medicare Paid Provider: Amount Medicare paid to the provider. (Please Note: For unassigned services, this column is called "Medicare Paid You.")

13. You May Be Billed: The total amount the provider may bill you, including deductibles, coinsurance, and non-covered charges. Medicare supplement (Medigap) policies may pay all or part of this amount

14. See Notes Section: If letter appears, refer to (16) for explanation

15. Provider's Name and Address: Doctor (may show clinic, group, and/or referring doctor) or provider's name and billing address. The referring doctor's name may also be shown if the service was ordered or referred by another doctor. The address shown is the billing address, which may be different from where you received the services

12 Tips to Preventing Health Care FraudGo to Trusted Sources:

1. Get medical help only from your personal doctor, hospital or clinic. They are the only ones who should make referrals for special equipment, services or medicine

2. Talk first to your doctor or pharmacist before showing anyone your medical or prescription records

It Is Okay To Be Rude

3. Hang up the phone if someone calls and tries

to pressure you into providing medical information or buying medical equipment

4. Shut the door on anyone who comes to your home and says they are from Medicare or some other health care company

Ask before Buying

5. Check with your health care provider before buying or investing in Internet “cure-all” or “miracle” products or services

Keep Personal Information Safe

6. Collect your mail regularly. Don’t keep mail in your mailbox for more than one day. People steal personal information from your bills and correspondence.

 

7. Rip up or shred your Medicare or other health care papers and other important documents before throwing them away. Thieves go through the trash to steal your identity information!

 

Be careful

8. Treat your Medicare and Social Security Numbers like credit cards. If someone offers to buy your Medicare or Social Security number, don’t do it!

9. Remember that Medicare does not sell anything 

10. Follow your instincts – if it seems to good to be true,

it usually is!

Check Charges for your medical care11. ALWAYS check your Medicare Summary Notice

(MSN) or health care billing statement for accuracy.

Look for three things on your billing statement:– Charges for special equipment, services or medicine

that you did not get – Billing for the same service twice– Services that were not ordered by the Doctor

Take Action

12. If you suspect an error or fraud, gather the facts and report it.

Examples of Health Care Fraud and Abuse

Examples• Home Health & Hospice Services• Clinical Laboratories• Independent Physiological Labs (IPLS)• Hospitals• Ambulance Services• Physicians/Practitioners• Mental Health Services/Providers• Nursing Homes• Durable Medical Equipment (DME) Suppliers• Managed Care Plans (MCPs)

Medicare Part D Rules

• No door-to-door marketing allowed

• You can’t sign up for a plan over the phone unless you call them

• Don’t give out your Social Security number or Medicare number

• Keep track of your mail

Medicare Part D Fraud

• Enrolled in an Medicare Advantage plan instead of a drug plan as requested

• Told drugs were on formulary when they were not

• Pharmacist at a drug store urged beneficiaries to enroll in a certain plan

• Beneficiary called customer service to discuss inappropriate enrollment and was hung up on

Other Examples…

• False advertisement of drug prices• Medicare & Medicaid beneficiaries charged more

than $5 co-pay

• Money offered to enrollees• Beneficiaries paid more than $15 to enroll in a

specific plan

• Beneficiary asked to sell drugs• Drugs sold to other beneficiaries

Summary

Remember:

If a service or item is FREE your Medicare and/or Medicaid number is not needed

Help preserve our health care programs by preventing fraud and abuse

Only your doctor can order medical items and services for you

Who To Call For Help?

• CLESE (312) 461-0812

OR

• AgeOptions

(708) 383-0528

Thank You

For more information contact:Healthcare Access Specialist

AgeOptions

(708)383-0258