Funded by the U.S. Department of Health & Human Services - - - PowerPoint PPT Presentation
Funded by the U.S. Department of Health & Human Services - Administration on Community Living / Administration on Aging 60 Minute tes Video Clip (click link below to to view on Yo You Tube) http://www.google.com/url?
Funded by the U.S. Department of Health & Human Services - Administration on Community Living / Administration on Aging
(click link below to to view on Yo You Tube)
http://www.google.com/url? sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&cad=rja&ved=0CEMQtwIwAQ&url=http%3A%2F %2Fwww.youtube.com%2Fwatch%3Fv %3DmDvpnRw0NVM&ei=r6zeUqjnAsfuoATd64KoCg&usg=AFQjCNHMd2dSwxK- TbR3Fd7UeqOLPDn89w&bvm=bv.59568121,d.cGU
} Administr
} Th
Di Disseminate te SMP Fraud Preventi tion and Identi tificati tion Informati tion Assist t beneficiaries in in resolv resolvin ing issu issues es and complaints ts Refer suspecte ted cases
te, and abuse to to investi tigati tive enti titi ties
} How much does Medicare pay in claims
} Which state is #1 in losses due to Medicare
} #2, #3, #4 states?
Source: Congressional Business Office (CBO) for 2012
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10.
11.
http ttp://oig.hhs.gov/fraud/fugiti tives/index.asp
} Alte
tering claim forms to to obta tain a higher payment t amount t – – UPCODI DING
Example: A flu shot t billed as a shingles shot t
} Billing tw
twice for th the same service or ite tem
} Billing separate
tely for services th that t should be included in a single service service fee fee -
DLING
Example: A comprehensive blood panel billed as individual te tests ts
} Billing for services not
t rendered or supplies not t provided
stranger offering free medical services and equipment
Medicare numbers
rendered however Medicare paid the provider
} Operated a Health and Beauty Clinic } Performed radiofrequency laser and liposuction } Stole Medicare numbers from patients } Obtained Medicare numbers from others via recruiters } Submitted fraudulent claims for:
} It
Ø Someone used her
Ø Medicare paid the
Ø When she needed a
claiming to be from Medicare.
Medicare.
Advantage plan (HMO) and he was there to help her. The senior was afraid of losing access to her doctor so she gave him her Medicare number, Medi-Cal number and Part D plan information.
access to her doctors.
Ø Stranger called her to
Ø Promised her gloves
Ø Drove her 300 miles
Ø Had her ‘sign’ a form Ø Billed Medicare
Ø Why DM
} Unauthorized, unsolicited
} Doctors receive fax from
} DME providers obtaining
} DME supplier in Southern California } Gained access to skilled nursing facilities and
} 95% of his submitted claims were for power
} Many of the beneficiaries never received the
} Most of the Medicare numbers were provided
} Implemented in many counties in California } Requires competitive bidding and lower
} Forces suppliers to have surety bonds and
} Reduces the number of suppliers } So fraudsters will move to ‘greener pastures’
} Social worker in Colorado } Worked through several home
} Found opportunities to obtain
} Did bookkeeping, cleaned
} Submitted claims for all of
Homeless Homeless Med Medicare icare ben benef eficiary on iciary on S Skid Row kid Row
Picked up at t downto town Em Emergency Dr Drop- in Cente ter by fraudste ter Transporte ted to to a local hospita tal with th questi tionable diagnosis
Moved to to Skilled Nursing Facility ty; promised 90 days days of
hou
ing paid f paid for by Medicare
Ø Why Laborato
} Medically unnecessary
} Providers ‘strongly
} Unbundling (e.g., one
} Tests not ordered, but
Ø Wh
} Beneficiaries who are not
} Hospice agencies
} Beneficiaries who do not
}
Confusion with MA plan members (regular Medicare pays for hospice under Part A)
Ø Wh
} Dramatic increase in the
} They hire independent
} No statements sent to
} Insurance agent’s
} Agents switching to
} Cold calling (if no prior
} New: Medicare Summary
} Part D Prescription Drug Program began 2006
} Most likely fraud cases:
times the national average
} Billing hundreds of Rx for a single beneficiary } Dispensing less than the prescribed amount of pills } Claims for brand name drugs but dispensing generics } Large # of claims for refills, never requested
} 2nd largest drug store chain in the United
} Customers in California and other states have
} In-patient vs. outpatient status } Hospitals charge for significant amount of line items } Typically do not give you an itemized statement upon discharge } One hospital statement could involve tens of people generating a
single patient’s bill
} American Medical Association- “Nearly 20% of claims have errors” } ICD -9 Codes: approximately 15,000 } ICD – 10 Codes: 68,000 new codes
Affordable Care Act Covered California Cal Medi- Connect
} Your Medicare coverage is protected } Medicare isn’t part of the Health Insurance
} No matter how you get Medicare, whether through
} You don’t need to do anything with the
} Adding ability for Department of Health & Human
} Implementing a ‘smart, automated system’ to
} Integrating Medicare and Medi-Cal } Partnering with private insurers and Medicare
} Increasing law enforcement – Office of
\