HEALTHCARE FRAUD & ABUSEPARTNERSHIP & PREVENTION

Presented By:

Linda Chavez, Director

Foothill Communities RSVP

and

Micki Nozaki, Project Director

California Senior Medicare

Patrol

MEDICARE FRAUD

Medicare is a $60 to $90 billion dollar

problem

TOUGHER CRIMINAL PENALTIES

MEDICARE FRAUD

MEDICARE FRAUD

Types of Medicare Fraud

• Identity Theft

• Ambulance Transport

• Dialysis Transport

• Laboratory

• Diagnostic Testing Facilities

• Sleep Studies

• Home Health & Hospice

• Durable Medical Equipment (DME)

MEDICARE FRAUD

• Recent case involving a local physician (Dr. “P”) who operated his own cosmetic health clinic in Beverly Hills, California

• Performed cosmetic surgeries and face lifts

• Billed for surgeries not performed

• Never expected his patients to report him

CASE STUDY

MEDICARE FRAUD

Case Facts

• Submitted a total of $7.5 million in bogus claims

• Services alleged to have provided included

• Revascularization

• Ablation of a bone tumor

• Placement of radiotherapy catheter in breast

• Lacked the equipment to perform these services

FACTS

MEDICARE FRAUD

Bad Guys Cannot Commit Fraud

Without Stealing Someone’s Identity• 300,000 compromised beneficiary ID’s

• In 2014 – 2.3 million victims of ID theft

• One third lost health insurance as a result of the theft

• President Obama signed a bill that requires HHS to issue Medicare cards that do not contain Social Security Numbers.

IDENTITY THEFT

MEDICARE FRAUD

Strike Force Information• Expanded to nine cities

• To date, 2,300 defendants charged with healthcare fraud related crimes

• $7 billion in fraudulently billed claims

HEALTHCARE FRAUD AND ENFORCEMENT ACTION TEAM (HEAT) STRIKE FORCE

Current HEAT Strike Force Cities

Miami Los Angeles Detroit

Houston Brooklyn Tampa Bay

Baton Rouge Chicago Dallas

Couldn’t Get a Wheelchair Taken for a Ride

VICTIMS

MEDICARE FRAUD

MEDICARE FRAUD

• Senior Medicare Patrol (SMP) was established in 1997

• 54 SMP’s in the U.S.

• Fraud prevention education

• Protect

• Detect

• Report

• Refer allegations of fraud to law enforcement

SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD

• Seniors Helping Seniors

• Critical partnership with RSVP

• Recruit, train and manage volunteers

• Fraud prevention education

• Protect

• Detect

• Report

SENIOR MEDICARE PATROL (SMP) AND RSVP

MEDICARE FRAUD

Educating & Empowering Seniors

SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD

Medicare Fraud via Telephone

• Equipment vendor calls beneficiaries

• Sales pitch is done rapidly, usually in a foreign accent

• Masquerades as Social Security Administration or Medicare

• Promises new Medicare care or FREE equipment

• Obtains beneficiary’s personal information

SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD

Insurance Agent Marketing Misconduct

• CMS marketing guidelines prohibit:

• Cold Calling

• Offering prizes for Medicare numbers

• Enrolling beneficiaries without their authorization

• Offering money to enroll in Medicare Advantage plan.

SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD

Protect: Your Medical Identity

• Medicare fraud IS identity theft

• Your Medicare number is the Social Security number.

SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD

Detect: Fraudulent Billing

• Medicare Summary Notice (MSN)

• Parts A and B

• Sent quarterly

• What Medicare covers, paid

• What beneficiary owes

• Part C, D Explanation of Benefits

• myMedicare.gov (daily)

SENIOR MEDICARE PATROL (SMP)

MEDICARE FRAUD

Report: Medicare Fraud and Abuse

• California SMP toll-free hotline

• 855-613-7080• HICAPs (800-434-0222)

• www.cahealthadvocates.org

• www.smpresource.org

Micki Nozaki - mnozaki@cahealthadvocates.org

SENIOR MEDICARE PATROL (SMP)

• Measure H2– Number of clients to whom information on health insurance, health care access and health benefits

programs is delivered

• Definition of key terms: – Health insurance: risk arrangement that assures financial coverage for a defined range of health care

services, known as benefits, only if these are required. Coverage is offered to an individual or group in exchange for regular payments (premiums paid regardless of use of benefits) by a licensed third party (not a health care provider) or entity, usually an insurance company or government agency that pays for medical services but does not receive or provide health care services.

• How to calculate (Measure/Collect Data)– The information may be delivered using methods such as individual level interactions, group-level

interactions, hotlines, clearinghouses, etc.– Count unduplicated new individuals who are provided with information, as a result of the grantee’s

activities. If more than one method of delivery is used (e.g., a group-level interaction followed by an individual-level interaction), count the client only once.

– Grantee reports and logs of interactions with clients.

RSVP BENCHMARKS

HOW SMP FITS