Medicare Fraud & ID Theft Prevention

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1 Medicare Fraud & ID Theft Prevention 2013 SMP National Training Meeting Washington, D.C. August 5, 2013 Margaret Peggy Sparr, Director Program Integrity Enforcement Group (PIEG) Center for Program Integrity, CMS Medicare Parts A, B, C & D Part A Hospital Insurance Trust Fund: inpatient hospital, skilled nursing facility (SNF) & some home health & hospice svcs Part B Supplementary Medical Insurance (SMI) Trust Fund: outpatient hospital; lab; IDTF & diagnostic tests; ambulance services; physician services; PT/OT/ST; Durable Medical Equipment (DME); CMHC; CORF/ORF Part C Medicare Advantage Program (Managed Care Organizations) Part D Medicare Prescription Drug Coverage 2

2 Medicare Expenditures Per 2012 CMS Office of Actuary report: Since FY 2006, Medicare expenditures rose from $408 billion for 43.2 million beneficiaries to $550 billion for 50.2 million beneficiaries in FY 2012 Every 8 seconds, someone becomes Medicare eligible, so expenditures will continue to rise. 3 Medicare Fraud Examples Kickbacks Physician Fraud Home Health Care Fraud Ambulance Rides Power Mobility Device Scams Arthritis Kit Scams Free Tests and Screenings Diabetic Supplies 4

3 Beneficiary Fraud Professional patients rent use of Medicare ID # ( no show patient) Solicit kickbacks to participate in fraud receive unnecessary service (surgery/tests) accept free transport, sign logs for services not received Obtain physician orders for unnecessary diagnostic tests, drugs, treatments Re-sell drugs back to pharmacy after dispensing Recruit friends for finder s fee 5 Beneficiary Fraud ACA Sec 6402(a) Administrative Remedy for Knowing Participation by Beneficiary in Health Care Fraud Scheme Effective upon enactment, this provision requires Secretary to impose an administrative penalty on a Medicare, Medicaid, or CHIPeligible individual, commensurate with the offense or conspiracy, for knowing participation by individual in a Federal health care fraud offense or conspiracy to commit such an offense. This is in addition to any existing remedies available to Secretary. 6

4 Medical Identity Theft Medical identity theft is the misuse of another individual s personal information to obtain or bill for medical goods or services. Such theft creates both patient safety risks and financial burdens for those affected. Use of compromised numbers can lead to erroneous entries in beneficiaries medical histories and even the wrong medical treatment. Medical identity theft not only harms beneficiaries and providers, it causes significant financial losses for the Medicare Trust Funds and taxpayers. 7 Guard Your Card * Recent Complaint Feedback 66% of unsolicited phone calls were for diabetic supplies 26% were for orthotics & other supplies 8% were for unspecified types of medical supplies or equipment 61% of companies reportedly offered items for free or no charge 13% of companies told beneficiaries they were calling on behalf of Medicare or SSA 39% of beneficiaries provided their Medicare numbers to callers before calling MEDICARE 5% of beneficiaries stated the supplier already had their Medicare number 8

5 May 14, 2013 Medicare Fraud strike force charges 89 individuals for approximately $223 million in false billing 8 of 9 Strike Force cities involved 89 individuals, including doctors, nurses and other licensed medical professionals Miami, Baton Rouge, Houston, LA, Detroit, Tampa, Chicago, Brooklyn Kickbacks, False billing, unqualified personnel DME, Home health, Mental Health, Physical Therapy, psychotherapy, infusion therapy. 9 New York (Part B and DME) by Zip Code 10

6 National Medicare ID Theft Case Arrests October 13, 2010: OIG & FBI arrested 73 individuals in 5 states directly linked to 2,500 stolen NY Medicare HICNs DOJ indicted 73 in NY (44), CA (10), OH (6), GA (6) & NM (7) in the largest Medicare fraud scheme ever perpetrated by single criminal enterprise Organized crime enterprise throughout US & Armenia perpetrated large-scale, nationwide Medicare scam $163 M in fraudulent Medicare billing for unnecessary medical treatment in 118 false front clinics in 25 states May 20, 2011: Rafik Terdjanian pled guilty to 1 count conspiracy to commit bank fraud in SDNY Rafik assisted son Robert with managing bank accounts for $35 M Medicare fraud scheme ( ) 11 How Numbers Become Compromised At the current time (July 1, 2013), CMS is aware of about 1,807 compromised Medicare provider numbers, 555 compromised Medicare Part D provider numbers and 12

7 Map of Compromised Beneficiary Numbers PSC / ZPIC / PDAC (Part B and DME) 13 Map of Compromised Beneficiary Numbers MEDIC (Part C and D) 14

8 Florida (Hialeah/Miami area) by Zip Code PSC/ZPIC/PDAC (Part B and DME) Beneficiaries 15 Florida (Hialeah/Miami area) by Zip Code MEDIC (Part C and D) Beneficiaries 16

9 Zip Code Distribution of PSC/ZPIC/PDAC (Part B and DME) Beneficiaries from Puerto Rico 17 California ( Los Angeles Area) (Part B and DME) by Zip Code 18

10 Texas ( Houston Area) (Part B and DME) by Zip Code 19 New Mexico (Part B and DME) by Zip Code 20

11 Actions CMS Take After a Medicare contractor verifies that a provider or beneficiary number is compromised, the number may be placed on prepayment edit. When claims are submitted using that number, they may be subject to medical review or automatically denied. When CMS contractors provide reliable evidence of fraud, overpayment or willful misrepresentation associated with a provider number, with CMS approval, the contractor can impose a suspension of payment for future claims. Medicare contractors develop cases, open investigations, and make referrals to Law Enforcement for prosecution. 21 Anti-Fraud Results To Date $4.9 billion recovered in settlements and judgments in civil cases involving fraud against the government in the fiscal year in FY ending Sept. 30, 2012 $13.3 billion total recoveries under the False Claims Act since January which is the largest four-year total in the Justice Department s history and more than a third of total recoveries since the act was amended 26 years ago in Strike Force operations in nine locations have charged more than 1,500 defendants who collectively have falsely billed the Medicare program for more than $5 billion. 22

12 Anti-Fraud Results To Date $4.9 billion recovered in settlements and judgments in civil cases involving fraud against the government in the fiscal year in FY ending Sept. 30, 2012 $13.3 billion total recoveries under the False Claims Act since January 2009 to which is the largest four-year total in the Justice Department s history and more than a third of total recoveries since the act was amended 26 years ago in Strike Force operations in nine locations have charged more than 1,500 defendants who collectively have falsely billed the Medicare program for more than $5 billion. 23 Anti-Fraud Results To Date Qui tam- provisions, which allow private citizens to file suits alleging false claims on behalf of the government. If the United States prevails in the action, the whistleblower, known as a relator, receives up to 30 percent of the recovery. DOJ saw a record 647 qui tam suits filed last fiscal year and recovered a record $3.3 billion in suits filed by whistleblowers during the same period. DOJ s 2012 efforts also included record recoveries for health care fraud, where recoveries topped $3 billion for the first time in a single fiscal year, thereby besting the previous record which had been set in fiscal year

13 What can YOU do? As a Medicare beneficiary, caregiver, SMP volunteer or community representative, protect yourself and/or other beneficiaries by: -knowing and sharing all anti-fraud resources available to give to yourself, beneficiaries and their families. Go to for materials - Be aware of current fraud schemes to watch out for scams like questionable DME suppliers, nonemergency ambulance companies or home health agencies offering free services in exchange for your Medicare number. - Know your SMP and Administration for Community Living (ACL) contacts. 25 Ways to Report Fraud Medicare OIG Hotline: HHS-TIPs Medicare Ombudsman CMS periodic communications on the MSN or the occasional inserts SMP volunteers To find an SMP in your area,: FTC ID Theft Hotline: ( ID- THEFT) Much of this information is on the Medicare.gov website. 26

14 Medicare Fraud.gov 27 Contact Information Telephone: (410) USEFUL WEBSITES: Notices, alerts, bulletins, on-line education Strike Force & HEAT & prosecution info, press releases, indictments -- by state 28

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