Medicare fraud and the - Washington State Office of the Insurance … · 2020-04-14 · Check your Medicare Summary Notice (MSN) • If you know the health care provider or supplier,
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May 2020 continuing education Medicare fraud and the Senior Medicare Patrol (SMP) Created April 7, 2020
Learning objectivesAfter completing the training, you should be able to:
1. Describe ways to determine if Medicare fraud occurred vs a beneficiary’s confused about how Medicare works.
2. Explain what information you need from the client to explore whether fraud has or is occurring.
3. Define the differences between fraud, errors and abuse.
Continued
SHIBA advisor continuing education | May 2020 3
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Presentation Notes
Learning Objectives and SMP resource references SMP resource info: Page 5 in SMP Volunteer Foundations�Note: This is a reminder that a client concern is rarely true fraud, rather it is often some misunderstanding of how Medicare works. SMP resource info: It depends on the case but chapter 4 of SMP Counselor Training Manual helps�Note: You need their name, number, plan, details, and may need documentation. We are teaching volunteers to ask the right questions so you can determine if fraud is occurring and if you need to refer it on to SMP. SMP resource info: Page 37 SMP Volunteer Foundations has definitions
Learning objectives (continued)4. Describe how to get onto the SMP website to take
training on: • SMP Volunteer Foundations• SMP counselor training• SMP complex interactions• SMP group outreach
5. Describe COVID fraud in WA & across the U.S.
6. In STARS, where do you click to share fraud information with the Senior Medicare Patrol database
SHIBA advisor continuing education | May 2020 4
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Learning Objectives and SMP resource references SMP resource info: Email [email protected] and she will email you a link to take the courses this will give access to the SMP resource library the TRAXX section where the training is. �Note: SHIBA wants to introduce all the great resources on the SMP website. SMP resource info: Use ncoa.org 4 tips or anything donna posted on insurance.wa.gov or coronavirus.wa.gov.�Note: We want to come out of the gate and be able to recognize that this is COVID fraud. This is what you need to know including documenting in STARS and clicking on SMP so the SMP program can follow up. Volunteers need to know to enter in STARS and click to send to SMP program. SMP resource info: AT the top of the STARS screen click SMP Other points of discussion and alternate learning objectives Describe how Medicare fraud may be revealed in the course of Medicare counseling. �Note: We want to recognize that not all SHIBA volunteers are fraud experts but we are all in the position of identifying possible Medicare fraud. Describe how you may discover that Medicare fraud is occurring in the course of working on a client case. Describe ways to collect different types of data in STARS and how to best deal with adding data rather than indicating “not collected.” Other Notes: SHIBA also needs to train that there is a specific relationship between reading MSN and EOBs and detecting Medicare Fraud. Take the new training on how to read these on the SMP site. Volunteers should register. Guide them to the booklet.
Learning aidsMedicare & You 2020Partner publication Note: This is the national version.www.medicare.gov/Pubs/pdf/10050-medicare-and-you.pdf
o Volunteer recognition and help paying for Medicare• Review publications from April training
o Medicare & Youo Get help paying for Medicare trifoldo Medicare help rainbow charto Calling the Health Care Authority Medicaid phone
systemo Application for Medicare Saving Programs
• Local topic sharing• Other topics
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Medicare & You How can I protect myself from identity theft?
(M&Y pg. 97)
Instruct clients to:
• Keep your information safe!
• Only give personal information, like your Medicare Number, to doctors, insurers or plans acting on your behalf, or trusted people in the community who work with Medicare like your SHIBA volunteers.
• Don’t share your Medicare number or other personal information with any one who contacts you by phone, email or in person. Medicare or someone representing Medicare will only call you in limited situations.
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Medicare & You
How can I protect myself from fraud and medical identity theft? (M&Y pg. 97)
• Check your Medicare Summary Notice (MSN)
• If you know the health care provider or supplier, call and ask for an itemized statement. They should give this to you within 30 days.
• Visit www.MyMedicare.gov to view your Medicare claims.
Note: A client can visit MyMedicare.gov to view their Medicare claims if they have Original Medicare. They can also call 1-800-MEDICARE.
ContinuedSHIBA advisor continuing education | May 2020 9
How can I protect myself from fraud and medical identity theft? (M&Y pg. 98)
Plans must follow rules
Important! Call 1-800 MEDICARE to report any plans or agents:• Asking for personal information over the phone or email• Calling to enroll you in a plan• Using false information to mislead you
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Knowledge check: M&Y Section 8Q1: What are some ways a client can protect themselves
from fraud and medical identity theft?
Q2: What are examples of the types of questions plans or agents may not ask a client over the phone or via email?
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Q1: What are some ways a client can protect themselves from fraud and medical identity theft? A1: See M&Y page 97- 98. For more information, visit Medicare.gov, or contact your local Senior Medicare Patrol (SMP) Program. For more information about the SMP program, visit smpresource.org or call 1-877-808-2468. Q2: What are examples of the types of questions plans or agents may not ask a client over the phone? A2: See M&Y page 98 Asking for personal information over the phone or email Calling to enroll you in a plan Using false information to mislead you For additional study, volunteers can read Medicare & You Section 8 and review the following questions: Q: List at least five of the rights that people with Medicare have the right to. A: See M&Y page 89 for a list Q: What’s a Medicare appeal? A: See M&Y page 90. An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. Q. What are examples of personal health information that a client has a right to access? A: See M&Y page 94 for a list. Q: If a client believes their privacy rights have been violated, how do they file a privacy complaint? A: See M&Y page 96.
SMP Foundations training
View this presentation to learn more about SMP Foundations training. The goal of this training is to provide you with a foundation of knowledge in three main content areas: • The SMP Program• Medicare Basics• Medicare Fraud and Abuse.
SHIBA advisor continuing education | May 2020
Prevent, detect and reportMedicare fraud
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PowerPoint www.insurance.wa.gov/media/9074PDF of PowerPoint www.insurance.wa.gov/media/9075
This presentation begins on the next slide.
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Presentation Notes
RTC will review training presentation with attendees
This training is a product of the Senior Medicare Patrol (SMP) National Resource Center. It was supported in part by a grant (No. 90MPRC0001) from the 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 ACL or DHHS policy. March 2020
Adapted for WA state and SHIBA volunteer continuing education.Updated March 2020
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Presentation Notes
SMP Foundations Training, PowerPoint Presentation�Updated March 2020 Welcome to SMP Foundations Training! (Presenters: Introduce yourselves.) Tips: Notes that are in italics are meant as notes to the facilitator, not to be read aloud. Notes that are not in italics are meant to be read with the slide. Prior to conducting SMP Foundations Training, familiarize yourself with this PowerPoint (PPT) and all related training materials. See the SMP Foundations Training Kit for the trainer’s guide with additional instructions, the manual, the handouts, answer keys, etc. All content found in this PowerPoint is also in the SMP Foundations Training Manual. The manual also contains additional information that is not included in this PowerPoint. Each participant should be provided with a copy of the manual (including appendices) and handouts. Answer keys may be provided to participants as each activity is completed. For this presentation, you may also want to have the following materials available: either a copy to pass around the room or a copy for each participant. Both are available in the SMP Resource Library: SMP brochure Personal Health Care Journal Several of the photos in this PPT were purchased for SMP Resource Center use only. Please do not copy and paste these photos into your own projects.
SMP = Senior Medicare Patrol
SMP Foundations Training
Goal To provide a foundation of knowledge in three main areas:
• The SMP Program
• Medicare Basics – (not today)
• Medicare Fraud and Abuse
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TOOLS: “Expectations” Flipchart; Flipchart page marked “Parking Lot” Now let’s take a look at what you CAN expect from this training! The goal of SMP Foundations Training is to provide you with a foundation of knowledge in three main content areas: the SMP Program, Medicare Basics, and Medicare Fraud and Abuse. Review the flipchart list of expectations and identify which topics will be addressed in this training, which have not been planned for but can be addressed easily during the training, and which are outside the realm of this training. Please note that although we will reference the SMP Foundations Training Manual throughout today’s training, we will not cover every detail from the manual in training. So, it will still be useful to read the manual on your own if you haven’t already done so. For example, many new terms and acronyms are used, which are explained throughout the manual. Tips: Post the “Expectations” flipchart page to a wall and keep it there throughout the training. At the end of the training, you can revisit this list of participant expectations . Post on the wall a flipchart page marked “Parking Lot Questions.” Also place a Post-it pad on each table. Ask participants, throughout the training, to write their questions on the Post-it notes and place them on the flipchart. The “Parking Lot” can be used for all participant questions, or it can be used for questions that are related to SMP but not directly related to SMP Foundations Training curriculum. Explain to participants how the parking lot will be used in your class and tell them when and how they will be addressed (i.e. questions related to the training may be addressed during training, and other questions will be addressed at the end of training or after training).
SMP Program is within SHIBA in Washington
PreventDetectReport
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We’ll start today’s training with Chapter 1: SMP Program, which describes the SMP mission, the importance of volunteers, and how the public finds their SMP. The SHIBA Program in Washington IS the Washington SMP. So by virtue of you being a SHIBA volunteer you are also actually an SMP volunteer.
Overview
Medicare loses billions of dollars each year due to fraud, errors, and abuse.
The SMP’s unique role is to work at the grassroots level with the people directly affected by Medicare fraud, errors, and abuse.
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Medicare loses billions of dollars each year due to fraud, errors, and abuse. Estimates place these losses at approximately $60 billion annually, though the exact figure is impossible to measure. The SMP program’s unique role is to work at the grassroots level with the people directly affected by Medicare fraud, errors, and abuse.
The SMP mission is to empower and assist
Medicare beneficiaries, their families, and caregivers
to prevent, detect, and report health care fraud, errors, and abuse
through outreach, counseling, and education.
The SMP Mission
PreventDetectReport
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SMPs increase public awareness about the resulting economic and health-related consequences. Education and prevention are at the core of the Senior Medicare Patrol program, as demonstrated by its mission: (Read the slide.)
Prevent
Treat your Medicare card and number like you would a credit card.
Although Medicare cards and numbers no longer contain Social Security numbers, Medicare numbers are valuable to thieves who want to steal money from Medicare.
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SMPs prevent health care fraud through education. SMPs educate Medicare beneficiaries, their families, and caregivers to prevent health care fraud by protecting their medical identification cards and numbers, and cautioning beneficiaries to: Treat their Medicare cards and numbers like they would a credit card. Although Medicare cards and numbers no longer contain Social Security numbers (as of 2019), Medicare numbers are valuable to thieves who want to steal money from Medicare. Only share Medicare and other health care identification cards and numbers with trusted sources who need that information to serve them, such as their health care providers. Rely on their doctors for medical advice and prescriptions, not advice or offers of medical services from unknown persons who call, visit, or approach them in public. Never sign a blank medical or insurance form.
Detect
1) Keep records. 2) File copies of bills.3) Save your MSNs and EOBs
and review them for accuracy.
4) Ask questions of your provider, Medicare plan, or 1-800-Medicare.
Prevention alone cannot stop all fraud, errors, and abuse. SMPs teach beneficiaries, their family members, and their caregivers to detect potential problems by taking the following steps: Keep records of health care visits, services or equipment received, test results, etc. File copies of bills received from doctors, hospitals, pharmacists, suppliers, or other health care providers. Save Medicare Summary Notices (MSNs) and Explanations of Benefits (EOBs) and review them for accuracy. Ask questions of the provider, Medicare plan, or 1-800-Medicare when: The beneficiary doesn’t understand the charges billed The beneficiary doesn’t think they received the service The beneficiary feels the service was unnecessary The beneficiary was charged for the same thing twice
The Personal Health Care Journal (PHCJ):An Important SMP Tool!
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A Personal Health Care Journal is a resource commonly used by SMPs. This guide helps Medicare beneficiaries, their caregivers, and family document important information about doctor visits, medical diagnoses, equipment received, and more. When kept up to date, the journal can be used later to cross-check services outlined on MSNs and EOBs. Note: Plans are in the works for this journal to be updated this year, so stay tuned for more information later this year about a new version of the PHCJ.
Report
1) Call the health care provider.
2) Call the company that issued the bill.
3) Contact the SMP which is the SHIBA number:
1-800-562-6900
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SMPs educate beneficiaries to report suspected fraud, errors, or abuse immediately! Here are steps SMPs recommend beneficiaries take to report their concerns: 1. Call the health care provider or supplier first to question the charge. If it was a mistake, ask them to correct it. 2. If the provider or supplier can’t answer the question, contact the company that issued the bill. Their contact information can be found on the MSN (Medicare Summary Notice) or EOB (Explanation of Benefits). 3. Contact the SMP. If not satisfied with the response from a provider, supplier, or billing company, contact the local SMP. The SMP helps beneficiaries understand the difference between suspected fraud, errors, or abuse. SMPs also assist beneficiaries in addressing suspected errors. If fraud or abuse is suspected, SMPs refer cases to the proper authorities for further investigation.
1995• SMP seeds
planted
1997• SMP program
born
2003• SMP program
nationwide
Today• 54 SMP
programs!
SMP is a National Program
SMPs = Senior Medicare PatrolsHHS = U.S. Department of Health and Human Services ACL = U.S. Administration for Community Living
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Now, let’s talk about SMP as a national program. The Senior Medicare Patrols, or SMPs, are grant-funded projects of the federal U.S. Department of Health and Human Services (HHS), U.S. Administration for Community Living (ACL). All SMP grantees have a shared national identity through a national program name and logo. The seeds of the SMP program we know today can be traced back to 1995, when the U.S. Administration on Aging funded five small initiatives to address Medicare fraud. Through the 1997 Omnibus Consolidated Appropriations Act – legislation that formally supported enlisting seniors in the fight against Medicare fraud – the SMP program was born. Since its inception in 1997, the SMP program has evolved from 12 regional demonstration projects to a nationwide program. The number of grantees increased over time. Since 2003, the SMP program scope has been national. Currently, an SMP grantee serves every state, as well as Puerto Rico, Guam, the U.S. Virgin Islands, and Washington D.C., for a total of 54 SMP programs nationwide.
Funding Source
ACL awards grants to SMPs. The Health Care Fraud and Abuse Control (HCFAC) Program funds:
SMP grantsNational
administration, SMP data reporting
system, and supportive services
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The SMP program is funded by ACL, which issues requests for proposals for the SMP program and then competitively awards grants to a selected project in each of the 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. As of June 1, 2016, SMP grants are funded by the Health Care Fraud and Abuse Control (HCFAC) Program as discretionary projects. This means funding is provided at the discretion of HHS operating divisions. ACL is an operating division headed by the Administrator and Assistant Secretary for Aging, who is appointed by the President and serves under the U.S. Secretary for Health and Human Services. ACL uses HCFAC funds to support the SMP program nationally. HCFAC funds are used to administer the program, maintain a national SMP data reporting system, and provide supportive services to SMPs nationally. Through HCFAC, ACL funds a national SMP Resource Center and occasionally funds other nationally beneficial initiatives, as funding allows.
Program Accountability
The SMP program is accountable to:
• The federal government• ACL • OIG
• Taxpayers
ACL = U.S. Administration for Community Living OIG = Office of Inspector General12
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As a government-funded program, the SMP program is accountable to the federal government and, ultimately, to taxpayers. SMPs must meet ACL requirements for reporting their activities and outcomes in the SMP Information and Reporting System (SIRS). SMP is unique in that annual SMP program outcomes are analyzed and published by the U.S. Department of Health and Human Services Office of Inspector General (OIG) Office of Evaluation and Inspections, which is responsible for performing audits and inspections of HHS programs. The OIG usually performs this activity for federal agencies, not federal grantees. The OIG’s annual report of SMP performance outcomes is the result of the 1997 Omnibus Consolidated Appropriations Act and a formal agreement with ACL.
The OIG Report
Team member time and effort
Outreach and
education activities
Complaints of suspected health care
fraud, errors, or abuse
ACL = U.S. Administration for Community Living CMS = Centers for Medicare & Medicaid Services HHS = U.S. Department of Health and Human ServicesOIG = Office of Inspector General13
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The annual OIG report of SMP performance outcomes data is presented to ACL and is made available to the general public through the OIG’s website. The results are cited by HHS and the federal agencies within HHS, such as ACL and the Centers for Medicare & Medicaid Services (CMS), by organizations interested in SMP, and also by the media. The OIG Report includes data about SMP activity in three major areas: Team member time and effort, which includes the number of active team members as well as the number of team member work and training hours. Team members include SMP volunteers, partners, and staff. Outreach and education activities: Includes such things as the number of group presentations, community events, and individual interactions, as well as the number of people served through these activities. Complaints of suspected health care fraud, errors, or abuse: When Medicare beneficiaries, caregivers, and family members bring their complaints to the SMP, the SMP makes a determination about whether or not fraud, errors, or abuse are suspected. These are called “complex interactions” by SMPs. The SMP helps resolve the errors by working with beneficiaries and providers. Suspected fraud and abuse are referred to the appropriate state and federal agencies for further investigation.
The Importance of SMP Volunteers
The SMP program reaches approximately 2 million beneficiaries each year. This would not be possible without the help of thousands of volunteers!
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Now, let’s talk about the importance of SMP volunteers! As a grassroots education program, SMP work requires significant face-to-face contact with Medicare beneficiaries, their caregivers, and family members to be effective. The SMP program reaches approximately 2 million beneficiaries each year. This would not be possible without the help of thousands of volunteers. The SMP program mission offers volunteers and other team members an opportunity to make an important difference in their communities. Protecting older persons’ health, finances, and medical identity while saving precious Medicare dollars is a cause that attracts civic-minded Americans. Many SMP volunteers are also Medicare beneficiaries and thus well-positioned to assist their peers. Even volunteers who aren’t Medicare beneficiaries take pride in working to ensure that the Medicare program will be protected for future generations.
What SMP Volunteers Do:Six Common “Volunteer Roles”
Administrative support
Information distributor
Exhibitor
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Counselor
Complex interactions specialist15
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Just like the work you do as a SHIBA volunteer, there are some states where the SMP programs works separately from their state SHIP. They have volunteers and other team members to match their skills and interests to the needs of the SMP program. As a result, SMP team members may serve Medicare beneficiaries, their families, and caregivers in many creative ways. However, there are six types of activities most commonly conducted by SMP volunteers nationwide, called “volunteer roles.” Those six volunteer roles are (read the bullets on the slide).
SMP outreach and education efforts!
The Medicare & You handbook: • Available online at
www.Medicare.gov
SMP Resource Center• Toll-free number (877-808-2468)• National SMP website:
www.smpresource.org• Facebook page:
www.facebook.com/SMPNationalResourceCenter
ACL’s website• www.acl.gov
How Does the Public Find their SMP?
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Now let’s take a look at our last topic in Chapter 1… How does the public find their SMP? Information about the SMP program is shared with Medicare beneficiaries, their families, caregivers, and the general public in several ways: SMP Outreach: Most members of the public learn about how to find the SMP in their area through their SMP’s outreach and education efforts. The Medicare & You handbook: The Centers for Medicare & Medicaid Services (CMS) provides information about the SMP program in the Medicare & You handbook. This official U.S. government handbook is provided to Medicare beneficiaries by CMS each year and is available online at www.Medicare.gov. The Medicare & You handbook directs readers seeking their SMP program to the national SMP Resource Center. SMP Resource Center: The SMP Resource Center operates a toll-free number (877-808-2468), a national SMP website (www.smpresource.org), and a national Facebook page (www.facebook.com/SMPNationalResourceCenter). The SMP Resource Center’s website, toll-free number, and Facebook page provide individuals with contact information for the SMP program serving their geographic area. See Appendix A for a list of SMP resources at www.smpresource.org. ACL’s Website: The Administration for Community Living provides information about the national SMP program on their website: www.acl.gov.
Now that you’ve learned all about the SMP program, typically SMP volunteers learn all about Medicare including their ABC’s and D’s and Medigap, but since you are well-versed in this we will skip this part today.
Enrolling in Medicare
2018 Beneficiary Enrollment64% in Original Medicare
36% in Medicare Advantage
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Medicare offers several different time frames for enrolling in the various parts of Medicare. Beneficiaries who receive Social Security benefits or Railroad Retirement Board benefits are automatically enrolled in Part A and Part B effective the month they turn 65. Regardless of whether a beneficiary chooses to enroll in Original Medicare or elects a Medicare Advantage plan, enrollment periods are the time frames in which people become Medicare beneficiaries. As of 2018, 64% of beneficiaries were enrolled in Original Medicare and 36% were enrolled in Medicare Advantage. We’ll move on as we cover this content many times in the year.
Medicare Cards and Numbers
When individuals are enrolled in Medicare, they get their original red, white, and blue Medicare card in
the mail.
The Medicare card shows that a beneficiary has
Medicare health insurance, whether they have Part A, Part B, or both, and the
date their coverage starts.
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When individuals are enrolled in Medicare, they get their original red, white, and blue Medicare card in the mail. If they are automatically enrolled, their card is mailed three months before their 65th birthday or their 25th month of getting disability benefits. The Medicare card shows that a beneficiary has Medicare health insurance. It shows whether they have Part A (Hospital Insurance), Part B (Medical Insurance) or both, and it shows the date their coverage starts.
Medicare Statements
MSNs
•Original Medicare statements are called Medicare Summary Notices, or MSNs.
•MSNs are mailed every three months if there is a Medicare claim filed during that time period.
•MSN design is standard, since all MSNs come directly from Medicare.
EOBs
•Statements from Medicare Advantage plans and Medicare Prescription Drug Plans are called Explanations of Benefits, or EOBs.
•Medicare Advantage and Part D plans may send EOBs for each month in which enrollees received benefits.
•EOB design varies from plan to plan; however, CMS issues requirements about the type of information EOBs must include.
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Medicare statements outline coverage decisions and payments made on a beneficiary’s behalf for Medicare-covered services. Several types of Medicare statements are sent to beneficiaries depending on whether they are enrolled in Original Medicare, a Medicare Advantage plan (Part C), or a Medicare Prescription Drug Plan (Part D). (Read slide.)
MSNs and EOBs explain…
• What the health care provider or pharmacy billed for
• The amount approved by Medicare for payment
• How much Medicare paid• What the beneficiary may be
billed for
Medicare Statements, continued
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There is a whole wonderful training on the SMP Resource Center website on Understanding your MSNs and EOBs. That is a great course to take and you have easy access to it by simply emailing me or [email protected] to get access to trainings and assessments.
Medicare Fraud, Errors, and Abuse
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Now that you’ve learned about the Medicare program, including coverage and enrollment basics, let’s take a look at Medicare fraud, errors, and abuse, which are described in Chapter 4 of the SMP Foundations Training Manual.
Waste in Medicare
Waste in the Medicare program involves the entire continuum of fraud, errors, and abuse.
Errors Abuse Fraud
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Waste in the Medicare program involves the entire continuum of fraud, errors, and abuse. First on the continuum is the possibility of a billing error. As explained throughout this manual, Medicare is complex. This complexity lends itself to innocent human errors that, if not caught, create losses to the Medicare program and to beneficiaries’ own personal finances. Next on the continuum is suspected abuse. Errors that become institutionally entrenched are one form of abuse in the Medicare program. At the end of the continuum is Medicare fraud. Fraud is intentional and the types of fraud schemes are complex, sometimes even including the involvement of organized crime.
Medicare Fraud and Abuse
Fraud vs. Abuse The main difference between Medicare fraud and abuse is
intent. Was the improper behavior intentional and conducted knowingly?
A final determination can only be made after an
investigation by the authorities.
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The main difference between Medicare fraud and abuse is intent. Was the improper behavior intentional and conducted knowingly? Only the authorities will be able to make a final determination, not SMPs. It is still important to know the differences in the definitions of fraud and abuse. Both terms are commonly used. The actions authorities will take depend upon whether they suspect abuse or whether they suspect fraud. Inappropriate practices that start as abuse can evolve into fraud. A final determination can only be made after an investigation by the authorities.
Definition of Abuse
Medicare Abuse
Payment for items or services when there is no legal entitlement to that
payment and the provider has not knowingly and
intentionally misrepresented the facts
to obtain payment.
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Medicare abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and intentionally misrepresented the facts to obtain payment. Medicare abuse is further defined as incidents or practices by providers that are inconsistent with accepted sound medical, business, or fiscal practices. These practices may directly or indirectly result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care or that are medically unnecessary. CMS includes in this definition “billing Medicare for services that are not covered or are not correctly coded.”
Definition of Fraud
Medicare Fraud Knowingly and willfully executing, or
attempting to execute, a scheme or ploy to defraud the Medicare program or obtaining
information by means of false pretenses, deception, or misrepresentation in order to
receive inappropriate payment from the Medicare program.
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Fraud assumes “criminal intent.” Medicare fraud is defined as knowingly and willfully executing, or attempting to execute, a scheme or ploy to defraud the Medicare program or obtaining information by means of false pretenses, deception, or misrepresentation in order to receive inappropriate payment from the Medicare program. CMS further defines fraud as “the intentional deception or misrepresentation that the individual knows to be false or does not believe to be true” and that is made “knowing that the deception could result in some unauthorized benefit to himself or herself or some other person.”
Common Examples of Suspected Medicare Fraud or Abuse
Billing for services or supplies not provided
Providing unsolicited supplies Misrepresentation
Prescribing or providing excessive or unnecessary tests and
services
Violating the participating provider
agreement
Offering or receiving a kickback (bribe) in
exchange for a beneficiary’s Medicare
number
Requesting Medicare numbers at an
educational presentation or in an
unsolicited phone call
Routinely waiving coinsurance or
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Let’s look at some common examples of suspected Medicare fraud or abuse: Billing for services or supplies that were not provided Providing unsolicited supplies to beneficiaries Misrepresenting a diagnosis, a beneficiary’s identity, the service provided, or other facts to justify payment Prescribing or providing excessive or unnecessary tests and services Violating the participating provider agreement with Medicare by refusing to bill Medicare for covered services or items and billing the beneficiary instead Offering or receiving a kickback (bribe) in exchange for a beneficiary’s Medicare number Requesting Medicare numbers at an educational presentation or in an unsolicited phone call Routinely waiving coinsurance or deductibles Waivers are only allowed on a case-by-case basis where there is financial hardship, not as an incentive to attract business See Appendix A of the SMP Foundations Training Manual for information about how to find examples of current fraud schemes at www.smpresource.org.
Medicare Errors and Other Situations That May Not Be Fraud
Because of Medicare’s complexities, human error in the billing process or beneficiary misunderstandings may occur, such as:
Beneficiary claims to have not received a service or does not
recognize a provider name
High or duplicate charges on a
hospital inpatient bill
Medicare didn’t pay for skilled nursing
care
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The majority of health care providers are ethical, striving to provide quality care and to submit proper claims for payment. Billing Medicare for health care services involves following complicated rules and procedures, however, which can lead to human error in the billing process. It is important to not immediately jump to the conclusion of fraud if something doesn’t look right on an MSN or EOB. Because of Medicare’s complexity, beneficiaries may have trouble understanding their Medicare statements and bills from providers or they may be suspicious of a charge or service that is actually legitimate. That’s why SMPs encourage beneficiaries to contact their providers with questions as a typical first step in addressing suspected fraud, errors, and abuse. Here are some common examples of suspected errors or misunderstandings: Beneficiary claims to have not received a service or does not recognize a provider name A billing or processing error may have occurred, or the service could legitimately have been provided by a provider the beneficiary did not see in person High or duplicate charges on hospital inpatient bill Medicare didn’t pay for skilled nursing care See Chapter 4 for more details about any or all of these examples. If contacting the provider doesn’t clarify whether or not an error occurred or whether the billing practice was consistent with Medicare rules, then Medicare fraud or abuse may be suspected. A pattern of error by a particular provider increases the likelihood of fraud or abuse and is considered a red flag.
The Impact of Medicare Fraud, Errors, and Abuse
Economic impact on taxpayers
Solvency of the Medicare Trust Fund
Economic and health impact to individual Medicare beneficiaries29
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Reasons for addressing the problem of waste in Medicare include the economic impact on taxpayers and the solvency of the Medicare Trust Fund as well as the economic and health impacts to individual Medicare beneficiaries who are victims of Medicare fraud, errors, and abuse.
Medicare Trust Fund Losses
$60 Billion Lost
Annually
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Medicare loses billions of dollars each year due to fraud, errors, and abuse. In 2014 testimony before the Senate Special Committee on Aging, the National Health Care Anti-Fraud Association placed these losses at approximately $60 billion annually, though the exact figure is impossible to measure. The most commonly cited range for all health care fraud estimates is 3 to 10% of annual health care expenditures. 2018 Medicare expenditures were over $740 billion and are expected to rise as the baby boomer population ages. Although the exact amount of Medicare funds lost due to fraud each year is not known, the more the U.S. Department of Health and Human Services spends to prevent and detect fraud the more it finds. What is clear is that the problem exists and efforts to address it through beneficiary and provider education, as well as law enforcement actions, produce results. With legitimate Medicare costs expected to rise, reducing loss due to fraud, errors, and abuse remains vital.
Consequences to Beneficiaries
Medical identity theft
Health impact
Personal financial losses
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In addition to harming the Medicare program, Medicare fraud, errors, and abuse can result in serious personal consequences for Medicare beneficiaries, such as medical identity theft, negative health impacts, and personal financial losses. Medical Identity Theft: Medical identity theft can disrupt a Medicare beneficiary’s medical care and waste taxpayer dollars. Medical identity theft occurs when a beneficiary’s personal information (such as their name, Social Security number, or Medicare number) is misused or stolen – by a provider, a supplier, or by someone posing as the real beneficiary. Scam artists solicit Medicare numbers because they can be used to submit false claims to Medicare. When Medicare beneficiaries fall prey to scams aimed at obtaining Medicare numbers, they will need to contact their local SMP for assistance! Health Impact: Receiving health care from a fraudulent provider can mean the quality of the care is poor, the intervention is not medically necessary, or, worse, the intervention is actually harmful. A beneficiary may later receive improper medical treatment from legitimate providers as a result of inaccurate medical records. Additionally, because of inaccurate or fraudulent claims to Medicare, beneficiaries may be denied needed Medicare benefits. For example, some products and services have limits. If Medicare thinks such products or services were already provided, they will deny payment. Personal Financial Losses: Medicare fraud, errors, and abuse can all result in higher out-of-pocket costs for beneficiaries, such as copayments for health care services that were never provided, were excessive, or were medically unnecessary. Beneficiaries may also find themselves stuck with bills for services from providers who should have billed Medicare but instead billed them for the entire cost of that service.
How SMPs Help
SMPs educate beneficiaries on how to
prevent, detect, and report health care fraud.
When suspicious behaviors or charges are detected, SMPs
educate beneficiaries about how to report their
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SMPs play a unique role in the fight against fraud and abuse. SMP volunteers and staff serve as “eyes and ears” in their communities, educating beneficiaries to be the first line of defense against Medicare fraud and abuse. SMPs educate beneficiaries on how to prevent, detect, and report health care fraud. Prevention and detection efforts include educating beneficiaries, their family members, and caregivers on the importance of protecting personal information, safeguarding Medicare numbers, and reviewing MSNs and EOBs for accuracy. When suspicious behaviors or charges are detected, SMPs educate beneficiaries about how to report their complaints. To find out about scams related to the SMP mission and actions taken by federal agencies to crack down on Medicare fraud, errors and abuse, visit the national SMP website: www.smpresource.org (described in Appendix A).
Wrap-Up: Are You Ready?
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We’ve made it through all four chapters of SMP Foundations Training! Now let’s wrap up with a quick review of resources and answers to your questions. Please keep in mind that you can use the SMP Foundations Training Manual as a reference tool as you do your SMP work. The appendices provide information about related resources and key terms for SMPs.
A word about STARS and SIRSWhen you enter data into STARS be sure to check off send to SMP. Staff in Tumwater will enter more
details into SIRS if there is suspected fraud.
See page 46.
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Read the question or statement on the slide and share the answer as appropriate for your SMP.
Please complete assessmentTo complete the assessment on this basic version of SMP Volunteer Foundations, email:
Volunteers play a vital role in the SMP mission. Your participation in SMP Foundations Training will help you prevent, detect, and report Medicare fraud, errors, and abuse!!!
Thank You!
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TOOLS: Evaluation (if applicable) Thank you for participating in today’s training and thank you for your interest in being an SMP volunteer! (Read the slide.) Tips: Administer the course wrap-up (final review, assessment, and evaluation) or explain when it will be administered. Tell participants what to expect next – now that their SMP Foundations Training is completed.
Fraud and scamsShare these instructions with clients to alert them about giving out personal information over the phone.www.insurance.wa.gov/sites/default/files/2019-06/scam-calls-fraud.pdf
See the next slide for a larger version.
SHIBA advisor continuing education | May 2020
Note: Clients can notify Medicare if their number becomes compromised and get a new one if needed.
2. Discuss the differences between fraud, abuse, and errors. What should you tell a client to look for and how to follow up?
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Discussion notes: Question 1: What are some examples of fraud and abuse? Billing for services, supplies or equipment that were not provided. Billing for excessive medical supplies. Obtaining or giving a Medicare number for “free” services. Improper coding to obtain a higher payment. Unneeded or excessive x-rays and lab tests. Claims for services that are not medically necessary. Using another person’s Medicare number, or letting someone else use your number, to obtain medical care, supplies or equipment. Question 2: Discuss the difference between fraud, errors and abuse. What should you tell a client to look for and how to follow up? Health care services and billing are complicated, which can lead to errors. Tell clients to review their Medicare Summary Notices (MSNs) and other statements for: Services they didn’t receive Double billing Services not ordered by their doctor See Question 1 above for examples of fraud and errors. Only a review and investigation of the issue will determine if it’s an error, fraud or abuse.
STARS reporting
STARS Beneficiary Contacts SMP instructions Any SHIBA volunteer can help with fraud reporting. If you follow the instructions on this job aid, you will help cases get flagged for review and possible action by the SHIBA Complaints Resolution Coordinator.
• Scammers may use COVID-19 as an opportunity to steal a client’s identity and commit Medicare fraud.
• In some cases, a scammer might tell a client they'll send them a Coronavirus test, masks, or other items in exchange for their Medicare number or personal information.
• Instruct clients to be wary of unsolicited requests for their Medicare number or other personal information.
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Protecting clients from fraud (continued)• It's important to always guard a Medicare card like a
credit card and check Medicare claims summary forms for errors.
• Clients should only give their Medicare number to participating Medicare pharmacists, primary and specialty care doctors or people they trust to work with Medicare on their behalf.
• Remember, Medicare will never call someone to ask for or check their Medicare number.
For more information visit Medicare.gov/fraud. SHIBA advisor continuing education | May 2020 57
Your trainer will discuss other fraud examples and provide details. Spend time discussing and asking questions to clarify understanding of each different type of fraud. What are otherexamples? • Price gouging and extortion.• Sales of goods and services for more than 15% above the
pre-emergency prices.• Supply misrepresentation and mislabeling items, such as N95
masks and hand sanitizers. • Counterfeit products.• Pamphlet drops in neighborhoods with incorrect or false
information.Continued
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Other COVID-19 fraud examples
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Price gouging and extortion During state emergencies there are triggers price-gouging statute prohibits sales of goods and services for more than 15% above the pre-emergency prices. Supply misrepresentation – advertisements for N95 masks, hand sanitizers – clickbait – N95 masks will be coffee filters with rubber bands, mislabeled products, counterfeit products Pamphlet drops in neighborhoods saying COVID-19 is in their neighborhood and then people come to the door with WHO logo selling masks, coming door to door with Red Cross outfits and people coming door to door asking if they can come into the home to talk about emergency measures. FRAUD! DANGER! Handmade/harmful sanitizers being sold door to door. Also hawking protective gear. Cyber crime. The minute the public health crisis began were investment scams. “we will have a run on N95 masks” – Feb 4 the FTC issued a fraud alert.
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• Door-to-door sales from people who claim to be with the Red Cross.
• Cyber crime. • Home delivery fraud.• Email phishing and malware.• Robocalls. • Telehealth fraud. • Genetic testing fraud.• TRICARE compounding and genetic testing fraud. • Compounding pain cream fraud.
Source: Jennifer Trussell from Administration for Community LivingFor more details go to the SMP resource center, which offers good news on Medicare fraud busts.
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Other examples of COVID-19 fraud (cont.)
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Grocery stores offering home delivery can be a big risk to older folks. Email phishing with CDC logos is very misleading and downloads malware. Robocalls – so many people are teleworking that service providers are having trouble keeping up. Robocallers calling about upgrades to your service. Rollout of much needed tele-health services – telehealth fraud including misrepresenting themselves as bonified providers, telehealth billing. Genetic testing to diagnose coronavirus – genetic testers are up to it again. Tricare compounding and genetic testing fraud – fraud-scheme migration and family-based fraud (mother and son). Scheme will migrate to other geographic areas. Compounding pain cream fraud: hit V.A. and TRICARE pharmacies. More than $2 billion of fraudulent payments. 6 people sentenced to prison including a physician and people in Texas, Virginia; one sentenced to over 8 years for committing the recruiting and conspiracy with the lab and individuals who ordered the cream.
Known SMP COVID-19 fraud complaints:
• Residents of senior housing and assisted livingfacilities are being approached by non-government entities/people about opportunities for COVID-19 testing.
• Beneficiaries are receiving robocalls about “special virus kits” and being asked for their Medicare number to send a “free” test.
• Health care agencies are receiving emails offering COVID-19 testing services that can be ordered through a telehealth provider.
CMS has set up a webpage with information for Medicare beneficiaries related to the Coronavirus at: www.medicare.gov/medicare-coronavirus
“See It, Snap It, Send It." Share a photo or screenshot when you file a complaint with the state Attorney General's Office.
File a complaint here: https://fortress.wa.gov/atg/formhandler/ago/ComplaintForm.aspx
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Filing COVID-19 scam complaints
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From the OAG website: The Washington State Office of the Attorney General can only process complaints that involve either Washington state residents or businesses located in Washington state. � UPDATE OR ADD TO AN EXISTING COMPLAINT HERE. DO NOT file a new complaint if you are providing additional information to an existing complaint. Filing a new complaint will delay processing of your complaint.
When it comes to fraud, what do you need to know to help you with your work as a SHIBA advisor?
How can SMP training help?
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Knowledge check: Learning aidsQ1: What is the goal of SMP Foundations training?
Q2: Which publication could you refer a client to if they have a question about scam calls? What phone number should a client call if their Medicare number has been compromised?
Q3: Which job aid will help you to make sure a complaint is reported to SMP. What is the specific instruction?
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Knowledge check questions and answers. Q1: With regard to today’s training, what is the primary purpose of SMP Foundations training? �A1: T provide a foundation of knowledge in three main areas: 1. The SMP program 2. Medicare basics 3. Medicare fraud and abuse. Q2: Which publication could you refer to if a client has a question about scam calls?�A2: Watch out for scam calls! Call 1-800-MEDICARE. Q3: Which job aid will help you with making sure a complaint is reported to SMP. What is the specific instruction? A3: STARS beneficiary contact SMP instructions. Be sure to mark “Yes” when prompted for “Send to SMP.”
ResourcesMedicare and Coronavirus
Check the OIC website regularly for information and updates. www.insurance.wa.gov/medicare-and-coronavirus
Coronavirus information on the website includes:• What Medicare covers• Early prescription refills• Medicare telehealth coverage• Prepare for your health care needs• Tips to keep yourself healthy• Other resource links
Resources (continued)COVID-19 resourcesThe SMP National Resource Center created resources related to COVID-19 fraud that are now available on the website and in the SMP Resource Library. Use keyword search “COVID-19.”• SMP Consumer Fraud Alert: COVID-19: This SMP Consumer Fraud Alert is
available to the public and to SMPs on the SMP Resource Center website to warn about COVID-19 fraud. www.smpresource.org/Handler.ashx?Item_ID=F27C608F-711D-4FF4-A87B-EBE61FE52890
• COVID-19 Consumer Tip Sheet: This tip sheet includes tips to protect consumers and Medicare from COVID-19 fraud.www.smpresource.org/Handler.ashx?Item_ID=81DF9DD9-7385-4E55-8BF8-457B71521BEB
• COVID-19 Fraud Infographic: SHIBA sponsors can share this infographic on social media or in print to use as a handout.www.smpresource.org/Handler.ashx?Item_ID=E632EFEB-BE9C-4474-BDC7-1A3D23D014CC Tip: If you have a problem opening, try a different browser.
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FTC Webinar: Helping Seniors Avoid Robocall ScamsSMP Resource Library www.smpresource.org/login.aspxLogin RequiredThe recording and related resources from this webinar are available in the SMP Resource Library. Tip: Search using the keyword "FTC.“
