Medicare Fraud and Scams

1. Medicare Fraud and Scams Funding provided by the Administration for Community Living (Department of Health and Human Services) California Health Advocates (c) 2018

2. Agenda • Who is Senior Medicare Patrol (SMP) • SMP Message: Protect, Detect & Report • CA-SMP Current Trends • Common Fraud Trends • Other Types of Health Care Scams • Non- Health Care Related Scams • How to Stay Connected with SMP

3. California Health Advocates (CHA)Our Focus Providing quality Medicare and related healthcare coverage information, education and policy advocacy • Advocacy – Bring the experiences of Medicare beneficiaries to the public, and especially legislators and their staff at federal and state levels, through media and educational campaigns. • Policy– Conduct public policy research to support recommendations for improving rights and protections for Medicare beneficiaries and their families. • Education – Provide timely and high-quality information on Medicare through our website, fact sheets, policy briefs and educational workshops. California Health Advocates (c) 2018

4. Senior Medicare Patrol (SMP) • SMP is a federally funded project • Established in 1997 • SMPs 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 • 54 SMPs across the country

5. Three Roles of SMPs 1. Provide Medicare fraud prevention education via health fairs, presentations, etc. • Address complaints reported via our SMP State-wide fraud hotline 1-855-613-7080. 3. Refer potential Medicare fraud cases to appropriate investigative entity.

6. SMP Message: • Protect Medical Identity by guarding the Medicare card • Detect Fraudulent Billing by reviewing Medicare Summary Notices and Explanation of Benefits • Report Medicare Fraud by calling SMP at 1-855-613-7080

8. Medicare fraud: It’s fraud associated with these two cards below:

9. Not a victimless crime! 2015: Michigan doctor sentenced to 45 years -Misdiagnosed patients as having cancer, when in fact, they did not. -Gave patients medically unnecessary infusions or injections. Some patients died. -Collected $17.6 million from Medicare.

11. Program Accountability ACL = U.S. Administration for Community Living OIG = Office of Inspector General

12. Why Should We Care? • Theft of Medicare/Medi-Cal numbers leads to false claims • Higher premiums • Billions of tax dollars wasted When it comes to Medicare fraud, everyone loses! It should be in everyone’s best interest to save the integrity of the program for future generations.

13. Current trends: • Durable Medical Equipment (DME)/Brace Scams • Hospice • Allegations of Agent Misconduct & Plan Marketing Violations via TV commercials, mail, telephone or in-person • Billing

14. Beware of Durable Medical Equipment (DME) Brace Scams • Unsolicited phone calls offering free braces covered by Medicare. • TV commercials and newspaper ads offering “free” Medicare approved braces to alleviate pain. • Urgently marked postcards notifying beneficiaries of pending eligibility for free Medicare-covered back and/or knee braces. • Suspicious packages containing braces that were not ordered by your doctor. • Charges on your Medicare Summary Notice statements for braces or other DME that you did not want or were not ordered by your doctor.

16. Beware of Questionable Hospice Enrollment • Beware of hospice companies enrolling patients who do not have a terminal illness with 6 months or less to live. • Don’t get tricked by hospice companies offering free services such as housekeeping, home health, nurse visits, durable medical equipment and/or medications for “free". Medicare does not pay for this! • Report hospice companies who give presentations at senior housing facilities and offer assistance with cooking and cleaning. • Beware of calls or unannounced visits by hospice companies offering additional benefits such as help with cooking and cleaning.

17. 2016:Pasadena Doctor Sentenced to 4 Years in Prison for Falsely Certifying Patients As Terminally Ill -Ordered to pay $1,344,204 in restitution. -Falsely certified that patients were terminally ill. -Sentenced to four years in federal prison.

18. Beware of Agent/Broker Misconduct • An agent enrolled a beneficiary into a plan without their permission. • Agent told the beneficiary that their physician takes the plan. • Agent offers free trips, meals in return for signing up. • Agent misrepresents the plans benefits. • Agent tells beneficiary they have to sign up or they will lose their Medicare.

19. “Betty and the Medicare Health Plan – Making the Right Choice” is now available in electronic format in English/Spanish (one side is in English/one side is in Spanish).

20. DETECT-Review MSNs & EOBs • Keep track of medical appointments -Use journal or calendar • Look for three things on your statements: -Charges for something you didn’t get -Billing for the same services or supplies twice -Services that weren’t ordered by your doctor • Medicare Summary Notice (MSN) Statement that shows what providers and suppliers billed Medicare in a 3-month period Accessible 24/7 via mymedicare.gov • Explanation of Benefits (EOB)

21. Medicare Errors & Other Situations That May Not Be Fraud • Beneficiary does not understand 20% patient responsibility and suspects double billing. • Beneficiary does not recognize name of provider on Medicare statement, but turns out to the provider who read/interpreted results. • Beneficiary forgot about medical appointment and suspected Medicare was billed for something not rendered.

22. Beware of: • Genetic Testing marketing • New Medicare Card related scams

23. Beware of Genetic Testing Schemes • Promise personalized medicine. Free cancer screenings. • Covered by Medicare! • Cheek swab is taken. • Medicare pays thousands of dollars worth of unnecessary genetic testing.

24. New Jersey 2015: Man Charged for Deceiving Seniors Into Unnecessary Genetic Testing: -“ICE CREAM SOCIAL EVENTs” held at low-income senior housing complexes. -Used fear-based tactics to get seniors to participate. -Promised a “personalized medicine.” -DNA swabs taken by non-medical personnel. -Providers recruited via Craigslist advertisements to get tests authorized. -Providers were paid thousands of dollars per month to sign their names. -Billed Medicare more than $1 million!

25. Beware of New Medicare Cards Scams • Caller claims to be from Medicare and offers to send your new Medicare card in exchange for personal information. • Caller offers to activate your new Medicare card. • Caller agrees to send your new Medicare card along with a complimentary back brace. • Caller wants to send you a plastic new Medicare card.

26. PROTECT- Guard Your Card = Treat you Medicare card like a credit card number. • Don’t carry your Medicare card unless you need it. • Only take it to medical appointments, visits to your hospital or clinic, ortrips to the pharmacy. • Never give your Medicare number to a stranger.

27. Common Health Care Scams: • Free Health Screenings – a vendor offers to provide “free” health care screenings, lab tests or other services but asks for a person’s Medicare number. • Counterfeit Prescription Drugs – beneficiaries purchase medication over the Internet to save money, but the drugs they receive are not the right medication or the right dosage. • Insurance Bait & Switch or Cross-selling – licensed agents present information about a Medicare Advantage plan, describing benefits and services that the plan doesn’t actually offer, and then sign people up for a plan that isn’t right for them.

28. SMP Fraud Alerts are available in different languages including: English –Chinese –Spanish –Vietnamese –Korean –Russian –Farsi You may access these fraud alerts by visiting our California Health Advocates website at: https://cahealthadvocates.org/fraud-abuse/medicare-fraud-alerts/

29. Part DFraud • Schemes to Falsely Bill Medicare  • Billing for drugs not prescribed. • Billing for amounts beyond the quantity prescribed. • Billing for brand name drugs but dispensing generic drugs instead. • Billing in excess of a physician’s prescription. • Prescription forged by a provider or supplier. • Prescription written and signed by a physician who has not treated or seen the recipient.

30. Other Types of Health Care Scams

31. Look For: • Falsification of documentation to provide the appearance of medical necessity, when medical necessity did not exist. • Billing for more miles than traveled for transport. • Billing nonemergency trips as emergency trips. • Billing the beneficiary instead of Medicare, if the provider participates in Medicare and the trip met Medicare’s coverage criteria.

32. 21161 SMP case: -Client received $1757.75 ambulance bill -Medicare denied claim because it was coded as non-emergency transport, when it actually was a medically necessary transport Medicare “Gotchas”: Ambulance Transport • Impacts Medicare coverage • Must be emergency • Must be only method of transportation (medically)

33. Home Health Care Services • What to look out for: • The beneficiary is asked to sign forms that verify a nurse or therapist showed up at her home and provided services, when none were provided. • Fraudulent physicians certify that a beneficiary is home bound, when in fact the beneficiary is not. • The beneficiary will be offered cash on a monthly basis or provided a home health aide that only prepares meals or cleans. Medicare does not cover cooking and cleaning! • Tips: • Make sure your physician approves your care plan. • Beware of an agency that offers you free goods and servicesin exchange for your Medicare number • Do not sign blank documents, especially timesheets. • Check your medical statements for services, such as missed visits from agency staff or visits when nothing was done, or equipment that was not necessary or never received.

34. Nursing Homes/Skilled Nursing Facilities What to look our for • A skilled nursing facility provides physical therapy to 10 residents in a group for one hour (all at one time). However, when the facility bills Medicare, they bill as if they provided each of those 10 individuals with 1 hour of individual therapy. • Beneficiary participates in Bingo sessions, but bills Medicare for mental health therapy. • A skilled nursing facility orders their staff to enroll patients into physical therapy when the patients do not need (and do not qualify for) physical therapy. • Tips: • Check your medical statements for accuracy.

35. Mental Health What to look out for: • Mental health providers billing Medicare when patients are non-communicative or can’t benefit from therapy, e.g., the patient who was in a coma for 3 months. • Up-coding: billing for a more complex diagnosis or billing for 50 minute session and only seeing patient for 5 minutes. • Billing group therapy sessions as individual therapy visits.

36. Hospitals Medicare “Gotchas” • Hospital in-patient vs observation status • Impacts Medicare coverage if you move to a SNF • Hospital Discharge • You have the right to an immediate review by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your if you think you are not ready to be discharged from the hospital What to look out for: • Hospitals billing for a more days than days beneficiary was actually in the hospital. • Billing for services and tests not provided.

37. Non-Health Care Related • Scams

38. Grandparent Phone Scam • Masquerades as your grandchild • In trouble – please help! • “Don’t tell my parents!” • “Just send me $$” IRS Phone Scam • If you know or think you owe taxes, call the IRS at 1.800.829.1040. • If you know you don’t owe taxes or have no reason to think that you owe any taxes, then call and report the incident to TIGTA at 1.800.366.4484. • You can file a complaint using the FTC Complaint Assistant; choose “Other” and then “Imposter Scams.” If the complaint involves someone impersonating the IRS, include the words “IRS Telephone Scam” in the notes. SMP does not take reports about non-Medicare related scams, but we do mention them in our outreach to bring awareness

39. National Do Not Call Registry -managed by the FTC -May register by phone at 1-888-382-1222

40. Get connected today! Like & follow our CHA &SMP Facebook pages Subscribe to our e-newsletter www.cahealthadvocates.org To order free materials or schedule a presentation at no-charge, call 1-855-613-7080

41. SMP placemats available in English and Spanish. To place an order, contact Jasmine at jsuo@cahealthadvocates.org

42. FIGHT FRAUD IN YOUR COMMUNITY Tips you can share: • Spread our Protect, Detect and Report Message • Share and post our CA-SMP fraud alerts • To order free materials, schedule a presentation at no-charge, or to report a case, call 1-855-613-7080 THANK YOU!