SHIBA and the Senior Medicare Patrol (SMP)

1. SHIBA and the Senior Medicare Patrol (SMP) Fraud prevention, detection and reporting Statewide Health Insurance Benefits Advisors (SHIBA ) is a free, unbiased service sponsored by the:

2. 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.

3. Who is affected? All of us! • Medicare and Medicaid clients • How? • Diminished quality of treatment • Less money for needed benefits • Taxpayers • How? • Billions of tax dollars wasted

4. Senior Medicare Patrol:From idea to national program • 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

5. 3 roles of SHIBA & SMP

6. Protect, detect, report • Purpose of SHIBA’s fraud awareness program: • Educate clients (Protect) • Perform 1:1 counseling (Detect) • Refer cases for investigation (Report)

7. 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

8. Identify theft is the door to Medicare fraud SHIBA & The SMP

9. Identify theft • The number on your Medicare card is your Social Security Number • This number is as important to thieves as a credit card

10. Guard your card! Think of your Medicare card as your health care credit card! =

11. 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

12. 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

13. Some of the most wanted fraud fugitives The U.S. Inspector General is searching for these fugitives: Etienne Allonce Alfredo Barcelo Patricia Chisanga Poul Thorsen http://oig.hhs.gov/fraud/fugitives/index.asp

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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!

22. Durable Medical Equipment (DME) Look for: • Unauthorized, unsolicited supplies sent to you Why DME? • Until recently: • No professional licensing requirements • Suppliers could set up shop with very little investment • Huge potential for quick profit

23. 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

24. 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

25. 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

26. Picked up at downtown emergency drop-in center by fraudster Transported to local hospital with questionable diagnosis Homeless Medicare client on Skid Row Moved to skilled nursing facility; promised 90 days of housing paid by Medicare

27. 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

28. 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

29. 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

30. Fraud & pharmacies • 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

31. 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

32. Fraud & hospitals • 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”

33. Complexity = confusion = opportunity for fraud Medicare WA Health Benefits Exchange Affordable Care Act

34. 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

35. 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

36. The Affordable Care Act (ACA) • 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

37. Protect, detect, report • Educate clients (Protect) • Perform 1:1 counseling (Detect) • Refer cases for investigation (Report)

38. 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.

39. 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

40. Example of MSN

41. Report • Collect evidence • Marketing flyers • Business cards • MSNs • Narratives • Ask questions • Seek help • Use written records • Contact SHIBA Report fraud to SHIBA at: 1-800-562-6900

42. 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

43. 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 • Annuities • Health • And more! • Homeowner • Auto • Life