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SHIBA and theSenior Medicare Patrol (SMP)
Statewide Health Insurance Benefits Advisors (SHIBA )is a free, unbiased service sponsored by the:
Fraud prevention, detection and reporting
8/26/2014
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SHIBA mission
SHIBA provides free, unbiased information about health care coverage and access to help
improve the lives of all Washington state residents. We cultivate community
commitment through partnership, service and volunteering.
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Medicare and Medicaid clients
How?
Diminished quality of treatment
Less money for needed benefits
Taxpayers
How?
Billions of tax dollars wasted
Who is affected?All of us!
Senior Medicare Patrol:From idea to national program
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Through public law 104-208 (est. 1997) Administration on Aging established 12
demonstration projects
• To recruit & train retired professionals to detect & report potential error, fraud & abuse
Today we have 54 SMP projects in all states, Wash. DC, Puerto Rico, Guam & U.S. Virgin Islands
Washington state SHIBA program sponsors SMP in our state
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3 roles of SHIBA & SMP
1.Distribute fraud prevention and identification information
2.Assist clients in resolving issues & complaints
3.Refer suspected cases of fraud, waste & abuse to investigative entities
Protect, detect, report
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Purpose of SHIBA’s fraud awareness program: Educate clients (Protect)
Perform 1:1 counseling (Detect)
Refer cases for investigation (Report)
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Little quiz
How much does Medicare pay in claims every year?Answer: About $500 billion
Which state is #1 in losses due to Medicare & Medicaid fraud & abuse?Answer: Florida
#2, #3, #4 states?Answer: California, New York and Texas
SHIBA & The SMP 8
Identify theft is the door to Medicare fraud
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Identify theft
The number on your Medicare card is your Social Security Number
This number is as important to thieves as a credit card
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Guard your card!
Think of your Medicare card as your health care credit card!
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Every Medicare benefit can be a potential fraud area
Ambulance services Clinical lab/independent physiology labs 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
Who commits Medicare fraud & abuse?
People or providers who bill Medicare OR benefit from Medicare getting billed
Doctors & health care providers Durable Medical Equipment (DME suppliers) Employees of doctors or suppliers Home health agencies, hospice Medicare clients
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Some of the most wanted fraud fugitives
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EtienneAllonce
AlfredoBarcelo
PatriciaChisanga
PoulThorsen
http://oig.hhs.gov/fraud/fugitives/index.asp
The U.S. Inspector General is searching for these fugitives:
Examples of fraud Altering claim forms to get a higher payment amount
(called “upcoding”)• Example: Flu shot billed as a Shingles shot
Billing twice for same service or item Billing separately for services that should be included
in a single service fee (“unbundling”)• Example: Comprehensive blood panel billed as
individual tests Billing for services not rendered or supplies not
provided
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Beware of providers who advertise free services
Two Medicare clients – a husband & wife – get a visit at home by a stranger offering free medical services & equipment
Stranger drives them to clinic where they were asked for their Medicare card numbers
They were sent home with a box of Ensure Their Medicare Summary Notices (MSNs) showed
claims for services not rendered, however, Medicare paid the provider
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Example of fraud conviction
LA doctor convicted of multi-million dollar Medicare fraud case: Operated a health & beauty clinic Performed radiofrequency laser & liposuction Stole Medicare numbers from patients Got Medicare numbers from others via recruiters Submitted fraudulent claims for:• Revascularization• Ablation of a bone tumor• Placement of radiotherapy catheter in breast
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What can happen if you become a Medicare victim
Stolen Medicare numbers can lead to false claims Medicare may note your file as a problem and as
a result, your:• Benefits may stop • Medicare number may be flagged as a
“Compromised Number” A Stolen Social Security Number can lead to theft
of your banking information
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Compromised Medicarenumber Someone used her Medicare
number to submit fraudulent claims for a wheelchair
Medicare paid the claims to the fraudster
When she really needed a wheelchair, Medicare denied her legitimate claim
It happened to her
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Beware of strangers pretending to be from Medicare
Phone scam case followed by a home visit from “Medicare:” Senior receives a phone call from a woman claiming to be from
Medicare. The woman says she is going to “visit the senior at her home.” The next day, the senior gets a visit from a man named Richard who
says he’s from Medicare. He tells the senior a new state law requires her to enroll in a
Medicare Advantage plan and he’s there to help her. Afraid of losing access to her doctor, the senior gives Robert her Medicare number and Part D plan information.
Senior was enrolled in a health plan, which raised her premium and she lost access to her doctors.
SMP referred the case for investigation.
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Fooled by a criminal
Stranger called her to verify her Medicare number
Promised her gloves for her arthritis
Drove her 300 miles for an “exam”
Had her “sign” a form Billed Medicare $1,000 for
tests
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Telemarketing/phone scams
Fraudster calls consumers in the early morning Gives a rapid sales pitch, usually with a foreign accent Deliberately confuses consumers into believing he/she
represents Social Security or Medicare Promises a new Medicare card or medical card – OR
offers free medical alert equipment Purpose: To get your checking
account and credit card information!
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Durable Medical Equipment (DME)
Why DME? Until recently:• No professional
licensing requirements• Suppliers could set up
shop with very little investment• Huge potential for
quick profit
Look for: Unauthorized, unsolicited
supplies sent to you
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DME fraud example
DME supplier: Gained access to skilled nursing facilities & board &
care homes 95% of his submitted claims were for power
wheelchairs Many clients never received the equipment or
didn’t need it Most of the Medicare numbers were provided by
patient recruiters who received kickbacks
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DMEPOS aims to slow down DME fraud
Implemented in 2 Washington state regions in 2013
Requires competitive bidding & lower prices from equipment suppliers
Forces suppliers to have surety bonds & legit places of business
Reduces the number of suppliers
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The face of home health fraud
Social worker employed in several home health agencies
Found opportunities to obtain more Medicare funds
Did bookkeeping, cleaned cabinets, played cards
Submitted claims for all these activities to Medicare but coded as Medicare – covered services
Homeless Medicare client on Skid Row
Picked up at downtown emergency drop-in center by fraudster
Transported to local hospital with questionable diagnosis
Moved to skilled nursing facility; promised 90 days of housing paid by Medicare
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Fraud & lab services
Why Lab services? Doctors don’t see what’s
billed to Medicare Labs aren’t required to
submit diagnosis information to support the need for the services
What to look for: Medically unnecessary
services billed Providers “strongly urging”
patients to go to a specific clinic
Unbundling (e.g., one blood panel listed by individual test)
Tests not ordered, but performed & billed
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Fraud & hospice care
Why hospice care? End of life issues
extremely vulnerable situation
Clients & families are usually unaware of items billed to Medicare
What to look for: Clients who are not
terminally ill enrolled in hospice
Hospice agencies promising “all the oxygen you need”
Clients who don’t understand how hospice is covered
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Fraud & Medicare Advantage (MA) plans
Why MA plans? Major increase in
number of managed care plans
They hire independent agents
No statements sent to members (except EOBs for Part D plans)
What to look for: Insurance agent marketing
violations• Agents switching to their plan
without client consent or knowledge
• Cold calling (if no prior relationship)
NEW: Effective October 2014, Medicare Summary Notices must be sent
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Part D prescription drug program started in 2006• $50+ billion dollar program
Most likely fraud cases:• Billing hundreds of Rx for a single client• Dispensing less than the
prescribed amount of pills• Claims for brand name drugs
but dispensing generics• Large amount of claims for
refills, but never requested
Fraud & pharmacies
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2013 CVS Caremark Corp. fraud investigation
Second largest drug store chain in the U.S.
Customers have been surprised to find that CVS renewed their prescriptions & billed their insurance without their consent
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In-patient vs. outpatient status Hospitals charge for a significant amount of
line items Typically don’t give you an itemized statement
when you’re discharged One hospital statement could involve multiple
people generating a single patient’s bill American Medical Association – “Nearly 20%
of claims have errors”
Fraud & hospitals
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Complexity = confusion = opportunity for fraud
Medicare
WA Health
Benefits Exchange
Affordable Care Act
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If you have Medicare…
Your Medicare coverage is protected Medicare isn’t part of the Health Exchange so
you don’t have to replace your Medicare coverage with an Exchange plan
No matter how you get Medicare, you still have the same benefits & security
You don’t need to do anything during the Exchange’s open enrollment period
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Example of ACA-related Medicare fraud
Someone contacts Medicare client via phone or email
They tell client they need a new Medicare ID card or plan number due to ACA or “Obama care”
They ask client to confirm personal information, including Social Security number
Client then becomes victim of ID theft
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Adds ability for Dept. of Health & Human Services to disallow provider enrollment
Implements a “smart, automated system” to proactively ID fraudulent claims• Fraud prevention system
Integrates Medicare & Medicaid Partners with private insurers & MA plans Increases law enforcement – Office
of Inspector General
The Affordable Care Act (ACA)
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Protect, detect, report
Educate clients (Protect) Perform 1:1 counseling (Detect) Refer cases for investigation (Report)
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Protect
Treat your Medicare card as your credit card or SSN card
Don’t carry it with you until you need it for visits to the doctor, clinic or pharmacy
Never give your Medicare number to a stranger
Record doctor visits, tests & procedures in a personal health care journal or calendar
Save MSNs and Part D EOBs; shred when you no longer need it
Remember: Medicare does NOT call or visit sell you anything.
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Detect
Review MSNs & Part D Explanation of Benefits (EOBs) for possible mistakes
Access myMedicare.gov account
Compare MSNs & EOBs to personal health care journal and Rx drug receipts to ensure they’re correct
Look on billing statement for:• Charges for item/service
you didn’t receive• Billing for same thing twice• Services your doctor didn’t
order
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Example of MSN
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Report Ask questions Seek help Use written
records Contact SHIBA
Collect evidence• Marketing flyers• Business cards• MSNs• Narratives
Report fraud to SHIBA at:
1-800-562-6900
Volunteer for SHIBA!
Do you want to help explain health care benefits or options to:
Friends? Neighbors? You community? Help people become better informed consumers?
Become a volunteer! Call: 1-800-562-6900
Need help with other insurance questions?
The Office of the Insurance Commissioner can also help you with questions, information, and complaints about all types of insurance, such as:
Call our Insurance Consumer Hotline
1-800-562-6900
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• Homeowner• Auto• Life
• Annuities• Health• And more!
