Protecting Residents from Medicare Fraud Senior Medicare Patrol

Protecting Residents from Medicare Fraud Senior Medicare Patrol LTC Ombudsman Program 2014 -2015 Funded by the U. S. Department of Health & Human Services – Administration on Community Living

Senior Medicare Patrol: From Idea to National Program � Administration on Aging established 12 demonstration projects �recruit and train retired professionals to detect and report potential error, fraud and abuse � There now are SMP projects in all states, Washington DC, Puerto Rico, Guam, and the U. S. Virgin Islands. � Objectives: Protect, Detect, Report 2

Three Roles of SMPs Protect Disseminate SMP Fraud Prevention and Identification Information through media, outreach campaigns, community events Detect Assist beneficiaries in resolving issues and complaints re: Medicare, Medi-Cal and other related health care and consumer issues Report Make referrals of suspected cases of fraud, waste, and abuse to appropriate investigative entities 3

The Problems Older adults residing in assisted living facilities and/or RCFE facilities are oftentimes the targets of Medicare fraud and abuse The Medicare program loses billions of dollars each year as a result of fraud and abuse 4

Why Do We Care? Medicare and Medi-Cal Beneficiaries • Theft of Medicare/Medi-Cal numbers leads to false claims • Beneficiary’s file may be notated as a problem • Benefits may be affected— file may be flagged and not be paid • Diminished quality of treatment • Less money for needed benefits • Theft of SSN often leads to identify theft and theft of financial information Taxpayers • Billions of tax dollars wasted

Common Fraud Areas 1. Ambulance Services 2. Clinical Lab/Independent Physiology Labs 3. 4. 5. 6. 7. 8. 9. 10. 11. Durable Medical Equipment (DME) Suppliers Home Health Agencies Hospice Care Hospital Services Medicare Advantage / Managed Care Plans Medicare Prescription Drug Plans Mental Health Services Nursing Facilities Physician/Practitioner Services & Kickbacks 6

How Fraud Occurs … It is important to note that the number used by Medicare on its insurance cards contains a Social Security Number. This number is as important to thieves as a credit card. 7

Who Perpetrates Medicare Fraud and Abuse? Fraud can be committed by any person or business in a position to bill the Medicare program or to benefit from Medicare being billed 8

Some of OIG’s Most Wanted Fugitives Please stay tuned. More information about these fugitives coming right up. 9

Ombudsman are & • Advocate for residents’ rights and quality care • Educate consumers and providers • Resolve residents' complaints • Provide information to the public • Investigation of Allegations of Abuse and Neglect • Witnessing of AHCD 10

You walk into the door of your facility… What do you see? 11

Some Warning Signs Resident has a medical billing statement or Medicare Summary Notice and says they did not see that provider or did not receive the services billed Resident states s/he has questions about their prescriptions Resident receives an unexpected visit from an insurance agent 12

Some Warning Signs Resident receives calls from strangers claiming they are from Medicare 13

It Happened to Her Ø Ø Ø Someone used her Medicare number Billed Medicare for durable medical equipment including a wheelchair When she needed a wheelchair, Medicare denied the claim 14

Some Warning Signs vs. There is durable medical equipment (DME) that appears to be unnecessary All the residents have the exact same equipment (e. g. , wheelchair, walker) Resident has been enrolled in hospice but is not terminal 15

MEDICAL EQUIPMENT FRAUD • Owner of fraudulent durable medical equipment supplier • Allegedly posed as employee of a legitimate supplier who contracts with numerous nursing homes • Gained access to several nursing homes under false pretenses • Accessed medical charts for residents who require specialized wound care • Billed Medicare for wound care supplies that were never ordered or provided • Stole medical information from medical charts to manufacture charts in an effort to legitimize their billing 16

Fraud by Home Health, Hospice ◦ Recruiting persons to obtain their Medicare numbers for fraudulent billing ◦ Billing for persons not eligible for home health ◦ Misrepresenting facts in order to deny or grant benefits ◦ Enrolling patients in hospice who are not terminal • Unfamiliar face in building, kind of going door-to-door • Notice resident is receiving service that he/she may not need • notice resident complains about needed benefits/services • notice resident is receiving service that he/she may not need 17

The face of Home Health Fraud Social worker in Colorado Worked through several home health agencies Found opportunities to obtain more Medicare funds Did bookkeeping, cleaned cabinets, played cards Submitted claims for all of these activities to Medicare but coded as Medicarecovered services 18

Example: Home Health Agency Fraud Owner targeted elderly Korean beneficiaries Paid kickbacks to doctors and ‘marketers’ Signed up patients that did not qualify for home health care Submitted ‘up-coded’ claims to Medicare Created false medical records for the claims Billed Medicare for home doctor visits conducted by unlicensed persons or were never conducted at all 19

Hospice Fraud Largest for-profit hospice chain in the U. S. May 2013 Department Of Justice lawsuit Filed by whistleblowers / insiders Hospice care paid by Medicare: ◦ Palliative care (medical care provided by physicians, nurses and social workers that specializes in the relief of the pain, symptoms and stress of serious illness) ◦ Continuous Home Care (crisis care for patients experiencing acute medical symptoms requiring skilled nursing services on a short term basis) Crisis care is the most expensive hospice benefit provided by Medicare 20

Hospice Fraud continued Fraud involved: ◦ Knowingly submitted false claims for crisis care services that were not necessary, not actually provided or not performed in accordance with Medicare requirements Billing Medicare for one ‘crisis care’ patient whose medical records indicated that she was playing bingo at the time Billing Medicare for one ‘crisis care’ patient who was noted to be ‘very healthy given her age’ 21

Other forms of Fraud ◦ Billing for unnecessary care ◦ Upcoding (billing for more expensive service) ◦ Incorrect coding/billing practices ◦ Fraudulent diagnoses ◦ Billing for services not rendered ◦ Kickbacks/solicitations ◦ Unbundling (e. g. , billing for individual lab tests) 22

Some Warning Signs “Skilling” patients who do not require or cannot benefit from therapy • Ran a rehabilitation center • Paid residents to sign for unneeded outpatient therapy and speech therapy • Submitted claims for therapy that was not given to residents 23

Some Warning Signs Podiatrist comes out to the home/facility and trims everyone's toenails ◦ A diabetic needs a skilled podiatrist to trim nails to prevent infections ◦ Most people do NOT need a skilled podiatrist to trim nails ◦ Medicare is billed for a higher end service such as debridement of a nail ◦ Patient gets the pedicure so may be unlikely to report 24

Consequences to Beneficiaries Theft of Medicare/Medi-Cal numbers leads to false claims Beneficiary’s file may be notated as a problem Benefits may be affected— file may be flagged (CNC) DO NOT PAY Theft of SSN often leads to identify theft and theft of banking information 25

As an Ombudsman You have the Power to Stop Fraud Report beneficiaries/your suspicions ◦ IF it just doesn’t feel right Assist Reading Medicare Summary Notice (MSN) and Explanation of Benefits (EOB) ◦ This is not a bill 26

Actual cases referred to SMP by an ombudsman SMP case 20650 July 2013 -Long Term Care Ombudsman from Glendale, CA filled out complaint form on behalf of beneficiary. Beneficiary's Medicare Summary Notices shows Medicare has been billed for a chair that is not in the beneficiary's possession, which prevents her from obtaining a chair that is fitted for her needs. Beneficiary was not given the opportunity to be properly fitted for a chair that met her needs. She never saw the physician's prescription for the new wheelchair because it was sent directly to DME supplier without her knowledge. This case was referred to Medicare fraud investigators that same month. 27

Picked up at downtown Emergency Drop- in Center by fraudster Homeless Medicare beneficiary on Skid Row Transported to a local hospital with questionable diagnosis Moved to Skilled Nursing Facility; promised 90 days of housing paid for by Medicare 28

Complexity = Confusion = Opportunity for Fraud Cal Medi. Connect Covered California Affordable Care Act

If you Medicare have Medicare… If you have Your Medicare coverage is protected. Medicare isn’t part of the Health Insurance Marketplace established by ACA, so you don't have to replace your Medicare coverage with Marketplace coverage. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you’ll still have the same benefits and rights you have now. You don’t need to do anything with the Marketplace during Open Enrollment. FYI, proposed dates for Covered CA Open Enrollment for 2015: start Nov 15 until Feb. 46

The Affordable Care Act Adding ability for Department of Health & Human Services to disallow provider enrollment Implementing a ‘smart, automated system’ to proactively identify fraudulent claims ◦ “Fraud Prevention System” Integrating Medicare and Medi-Cal Partnering with private insurers and Medicare Advantage Plans Increasing law enforcement – Office of Inspector General

REPORT TO US SENIOR MEDICARE PATROL – Our Message PROTECT DETECT REPORT 32

Protect üTreat the Medicare card as your credit card üDon’t carry with you until you need it for visits to doctor, clinic or pharmacy üNever give your Medicare number to a stranger üRecord doctor visits, tests and procedures üSave MSNs and Part D Explanation of Benefits Remember: Medicare does not call or visit to sell anything 33

Detect üReview MSNs and Part D Explanation of Benefits (EOB) for possible mistakes üAccess my. Medicare. gov account üCompare MSNs and EOBs to personal health care journal and prescription drug receipts to ensure they are correct üLook on billing statement for: § Charges for item or service not received § Billing for same thing twice § Services not ordered by doctor 34

Report Ø Ask questions Ø Seek assistance Ø Use written records Ø Contact Senior Medicare Patrol üCall SMP toll free hot line 855 -613 -7080 35

You Make a Difference Again We Thank you for being an advocate for seniors and for being our partner in protecting the Integrity of the Medicare Program so that Medicare can continue to serve future generations. Keep this Medicare Fraud hot line number handy … � 855 -613 -7080 36