The SMP Program: Protect Yourself from Health Care Fraud

Slide 1: The SMP Program: Protect Yourself from Health Care Fraud

Slide 2:Presented By:

Erin Weir Healthcare Consumer Protection Coordinator AgeOptions

Slide 3:What We Will Cover Today

The SMP Program What is Healthcare Fraud? Examples of Healthcare Fraud The SMP Message: Protect, Detect, Report!

Slide 4:How much do you think is lost every year to health care fraud and abuse? A) $5-10 million B) $25-125 million C) $10-20 billion D) $75-250 billion

How Much is Lost? BILLIONS of dollars every year! Fraud and Abuse estimates: $75-250 billion/year (FBI) ? between 3% and 10% of everything spent on health care is lost to fraud (Medicare, Medicaid, and private insurance companies) $68 billion in 2008 � National Health Care Anti-Fraud Association (organization of about 100 private insurers and public agencies) Waste estimates: $98 billion in �improper� health care payments (waste) in fiscal year 2009 � Peter Orszag, director of White House Office of Management and Budget (OMB) BILLIONS of dollars every year! Fraud and Abuse estimates: $75-250 billion/year (FBI) ? between 3% and 10% of everything spent on health care is lost to fraud (Medicare, Medicaid, and private insurance companies) $68 billion in 2008 � National Health Care Anti-Fraud Association (organization of about 100 private insurers and public agencies) Waste estimates: $98 billion in �improper� health care payments (waste) in fiscal year 2009 � Peter Orszag, director of White House Office of Management and Budget (OMB)

Slide 5:How much do you think is lost every year to health care fraud and abuse? A) $5-10 million B) $25-125 million C) $10-20 billion D) $75-250 billion

How Much is Lost? BILLIONS of dollars every year! Fraud and Abuse estimates: $75-250 billion/year (FBI) ? between 3% and 10% of everything spent on health care is lost to fraud (Medicare, Medicaid, and private insurance companies) $68 billion in 2008 � National Health Care Anti-Fraud Association (organization of about 100 private insurers and public agencies) Waste estimates: $98 billion in �improper� health care payments (waste) in fiscal year 2009 � Peter Orszag, director of White House Office of Management and Budget (OMB) BILLIONS of dollars every year! Fraud and Abuse estimates: $75-250 billion/year (FBI) ? between 3% and 10% of everything spent on health care is lost to fraud (Medicare, Medicaid, and private insurance companies) $68 billion in 2008 � National Health Care Anti-Fraud Association (organization of about 100 private insurers and public agencies) Waste estimates: $98 billion in �improper� health care payments (waste) in fiscal year 2009 � Peter Orszag, director of White House Office of Management and Budget (OMB)

Slide 6:Medicare & Medicaid Beneficiaries loss of benefits higher premiums identity theft Taxpayers Medicare is paid for by taxes Billions of taxpayer dollars wasted The Medicare Program Running out of money!

Fraud affects:

Slide 8:The SMP Program www.illinoissmp.org

Slide 9:The SMP Program

Senior Medicare Patrol National Program SMP Programs in all 50 states, Washington, D.C., Puerto Rico, Guam, Virgin Islands Goals of program: Recruit volunteers to provide outreach Educate consumers about health care fraud and abuse

Slide 10:SMP Staff and Volunteers�

Give presentations to groups (like this one!) share information and materials at health fairs or other events Help people with questions about billing mistakes or fraud issues Help report fraud to investigators

Slide 11:Illinois SMP Program Partners

Illinois Area Agencies on Aging Local Agencies in Chicago & suburbs: South Suburban Senior Services of Catholic Charities Catholic Charities Northwest Catholic Charities Lake County Senior Service Associates Coalition of Limited English Speaking Elderly Illinois Network of Centers for Independent Living Illinois Attorney General�s Office

Slide 12:What is Health Care Fraud?

Slide 13:What is Health Care Fraud?

Billing for services or supplies not provided Billing for services or supplies that are different than what was actually provided Changing forms to get a higher payment Billing multiple times for the same service or item

Slide 14:What is Health Care Fraud?

Using someone else�s provider number (some people will even use dead doctors� numbers!) Selling or sharing someone�s Medicare number Offering gifts or money for Medicare numbers

Slide 15:Health Care Abuse/Errors

Abuse: Providing unnecessary services Providing services that don�t meet Medicare or Medicaid�s quality standards Errors: Accidentally billing a service twice Typos or mistakes in billing codes

Slide 16:Fraud may be discovered when�

Beneficiaries report complaints or Medicare contractors review medical claims for inappropriate billing

Slide 17:Examples of Health Care Fraud

Slide 18:Examples of Fraud � Nursing Facilities

A nursing home provides physical therapy to large groups of residents at one time, but bills Medicare as if the therapy was provided individually. Another nursing home provides social activities for the residents and bills Medicare for psychotherapy.

Slide 19:Examples of Fraud � Home Health

A representative from a home health agency in Springfield visited a woman in her home and told her that her doctor wanted the home health agency to check her blood pressure once a week. A nurse came once a week, took her blood pressure, and left. The home health agency billed Medicare for skilled nursing services.

Slide 20:Examples of Fraud � Durable Medical Equipment (DME)

A man in Chicago had a stroke and needed an electric wheelchair. When his equipment company tried to bill Medicare for the wheelchair, the claim was rejected because another equipment company had billed Medicare for a wheelchair that they said they gave to him in 2004.

Slide 21:Examples of Fraud � Physician Services

A podiatrist in Oak Park trimmed the toenails of multiple residents in a senior building. He then billed Medicare as if he had provided an office visit and foot surgery for each of the residents.

Slide 22:Examples of Fraud � Hospital Services

A southern Illinois hospital billed a patient for multiple tests that she did not receive, adding up to over $16,000. Some hospitals inappropriately hold patients in �observation status,� rather than admit the person as a hospital inpatient, to get a higher payment.

Slide 23:Examples of Fraud � Mental Health Services

A group of �therapists� picked people up in a van, drove them to a location where they played Bingo and ate lunch, and then dropped everyone back off at home. The �therapists� billed Medicare as if they provided individual psychotherapy to all of the people that participated.

Slide 24:Examples of Fraud � Prescription Drugs

A major pharmacy chain made millions of dollars in profit by switching pills. Instead of providing the brand-name drug that was prescribed, the pharmacy substituted a generic. However, the pharmacy still billed Medicare and the consumers involved as if they provided the brand-name drug.

Slide 25:Examples of Fraud � Medicare Advantage Plan Marketing

A Medicare Advantage plan agent set up a table at a Chicago food pantry and told people that he could give them �free� health coverage. One of the people decided to enroll in the �free� plan. He later found out that the plan was NOT free (he had to pay a monthly premium) and the plan would not cover his doctor.

Slide 26:The SMP Message:

Protect! Detect! Report!

Slide 27:PROTECT Yourself From Fraud!

Slide 28:PROTECT Yourself From Fraud!

Do NOT give your Medicare number to people you do not know! On the phone At the door At a presentation, exercise class, screening, etc. ? FREE services do NOT require your Medicare number!

Slide 29:PROTECT Yourself from Fraud!

Don�t carry your Social Security, Medicare, or Medicaid cards in your wallet! Hand out Tip Sheet on how to Protect Yourself Sometimes, people will call you and say they are from Medicare, asking you for your personal information. This usually isn�t the case (sometimes Medicare contracts with companies that will call.) If you are uncomfortable or uncertain about the caller, hang up the phone and call Medicare yourself. Hand out Tip Sheet on how to Protect Yourself Sometimes, people will call you and say they are from Medicare, asking you for your personal information. This usually isn�t the case (sometimes Medicare contracts with companies that will call.) If you are uncomfortable or uncertain about the caller, hang up the phone and call Medicare yourself.

Slide 30:PROTECT Yourself from Fraud!

Don�t carry your Social Security, Medicare, or Medicaid cards in your wallet! You don�t need them in an emergency � the hospital will treat you, and you can send them your insurance information later If you really want to carry something, make a photocopy and black out the last 4 digits of your ID number Hand out Tip Sheet on how to Protect Yourself Sometimes, people will call you and say they are from Medicare, asking you for your personal information. This usually isn�t the case (sometimes Medicare contracts with companies that will call.) If you are uncomfortable or uncertain about the caller, hang up the phone and call Medicare yourself. Hand out Tip Sheet on how to Protect Yourself Sometimes, people will call you and say they are from Medicare, asking you for your personal information. This usually isn�t the case (sometimes Medicare contracts with companies that will call.) If you are uncomfortable or uncertain about the caller, hang up the phone and call Medicare yourself.

Slide 31:PROTECT Yourself from Fraud!

Shred documents with your personal information on them BEFORE you throw them away! Take the mail out of your mailbox. Hand out Tip Sheet on how to Protect Yourself Sometimes, people will call you and say they are from Medicare, asking you for your personal information. This usually isn�t the case (sometimes Medicare contracts with companies that will call.) If you are uncomfortable or uncertain about the caller, hang up the phone and call Medicare yourself. Hand out Tip Sheet on how to Protect Yourself Sometimes, people will call you and say they are from Medicare, asking you for your personal information. This usually isn�t the case (sometimes Medicare contracts with companies that will call.) If you are uncomfortable or uncertain about the caller, hang up the phone and call Medicare yourself.

Slide 32:PROTECT Yourself From Fraud!

Do NOT accept services from someone who calls or visits you unexpectedly, even if they say that your doctor sent them!

Slide 33:PROTECT Yourself From Fraud!

Do NOT �sign up� for services at a presentation or event. Do NOT sign timesheets or other forms without reading them. Do NOT sign blank forms!

Slide 34:PROTECT Yourself From Fraud!

Insurance plans CANNOT: Enroll you in a plan without your permission Lie to you about a plan to get you to enroll Sign you up for a plan on the phone unless you call them Contact you without your permission Give you gifts worth more than $15

Slide 35:DETECT Fraud!

Slide 36:DETECT Fraud!

Keep track of the health care services you receive in a journal or on a calendar. If you receive home health, hospice, or hospital services, ask for an itemized list of the services that you have received. Check the list for errors.

Slide 37:DETECT Fraud!

Read your Medicare Summary Notice or Explanation of Benefits from your insurance company! Watch for: Services that you did not get Services that were not ordered by your doctor Billing for the same thing twice Other billing errors

Slide 38:DETECT Fraud!

Medicare Summary Notices are sent quarterly (once every three months). You can always request a Medicare Summary Notice by calling 1-800-Medicare. You can also view your claims and Medicare information online at: www.MyMedicare.gov.

Slide 39:REPORT Fraud!

Slide 40:Why Report Fraud?

Healthcare fraud puts you at risk for identity theft! IT�S YOUR MONEY! Taxpayer dollars Higher premiums Saving the Medicare Program! People who commit fraud are STEALING from you, not helping you! IT�S YOUR MONEY: All Taxpayers: Part A is funded mostly (90%) through payroll taxes (FICA) �1.45% is withheld directly from the employee Beneficiaries: Part B is funded in part through beneficiary premiums (23%) ? increased Part B spending increases the Part B premium Misaligned payments can also cause beneficiaries to pay more in coinsurance IT�S YOUR MONEY: All Taxpayers: Part A is funded mostly (90%) through payroll taxes (FICA) �1.45% is withheld directly from the employee Beneficiaries: Part B is funded in part through beneficiary premiums (23%) ? increased Part B spending increases the Part B premium Misaligned payments can also cause beneficiaries to pay more in coinsurance

Slide 41:Why Report Fraud?

Your Medicare account may be flagged: �Do Not Pay!� When things aren�t ordered by your doctor, they may not fit or work properly. When someone gives you something that you don�t need: Your health may get worse Your Medicare benefits may be �used up� You can also �use up� your benefit if Medicare thinks you are getting services that you aren�t. If a doctor trims your toenails and takes your Medicare number, he may be billing Medicare for something else, like foot surgery! Medicare will think that you have had that foot surgery and won�t cover products or services that you wouldn�t need if you had that surgery. EX: person given wheelchair and later denied walker.You can also �use up� your benefit if Medicare thinks you are getting services that you aren�t. If a doctor trims your toenails and takes your Medicare number, he may be billing Medicare for something else, like foot surgery! Medicare will think that you have had that foot surgery and won�t cover products or services that you wouldn�t need if you had that surgery. EX: person given wheelchair and later denied walker.

Slide 42:If you notice a mistake: Call the provider. If it is just a mistake, they may be able to fix the problem. If this doesn�t work or you suspect fraud, contact AgeOptions at (800)699-9043.

Report Fraud!

Slide 43:Volunteers are the key to spreading the SMP message!

We need YOUR help!

Slide 44:If you have questions, contact:

Erin Weir Healthcare Consumer Protection Coordinator AgeOptions Phone: (708)383-0258, (800)699-9043 TTY: (708)524-1653 erin.weir@ageoptions.org