Medical Identity Theft - Health Insurance and the Affordable Care Act in Wisconsin

Transcription

1 FraudAlert! Helping keep the promise. March 2014 Volume 17, No. 8 Coalition of Wisconsin Aging Groups Elder Law Center From the Project Director Elizabeth Conrad Check out our website at Let s Get Acquainted By Judy Steinke, Wisconsin SMP Volunteer Coordinator Wisconsin SMP (Senior Medicare Patrol) is delighted to introduce Stan Suring of Cedarburg as this month s featured volunteer. Stan heard about the Coalition of Wisconsin Aging Groups and Wisconsin SMP while he was serving on the advisory board of the Aging and Disability Resource Center of Ozaukee County. Upon completion of his term on the advisory board, he attended our SMP Volunteer Foundations Training in the fall of Stan s interest in assisting the senior community began about ten years ago when he completed his training as a Certified Aging in Place Specialist. At that time, his plan was to be selfemployed as a contractor and consultant to home owners who wanted to make their homes safer to live in as they aged. This plan was abandoned when he received an offer from a longtime friend to join his pet product business. Stan assisted with the remodeling of his friend s facility and then assumed the role of product development and the prototyping of new items. Volunteering has always been a part of Stan s life, but upon retirement in September 2013, he began expanding his volunteer activities. He was a project leader for the 4-H for over 20 years, served his church as an elder, and served as an elected member of the school board. He also was an elected leader of the local YMCA and their Indian Guides and Princesses program. Wisconsin SMP In this issue: Let s Get Acquainted with Stan Suring, SMP Volunteer Like Wisconsin SMP on Facebook ACA Deadline Spurs State Agencies to Issue Fraud Warning WI DOJ News Release FTC: Don t Click on Random Text Messages The Financial and Human Costs of Medical Identity Theft Second Doctor Pleads Guilty in Flushing, NY Clinic Fraud Case DHHS News Release SMP Activities Published and distributed by the Coalition of Wisconsin Aging Groups Elder Law Center funded in part by grant #90MP0187 from the Administration on Aging/Administration for Community Living, Department of Health and Human Services. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration on Aging Policy. EDITOR AND PROJECT DIRECTOR Elizabeth Conrad ASSOCIATE EDITOR Kevin Brown This publication may be reproduced ONLY in its entirety. Permission to excerpt portions must be obtained prior to use CWAG. All rights reserved. Continued on page 2 FRAUD ALERT! Coalition of Wisconsin Aging Groups Elder Law Center Dairy Drive Madison, WI econrad@cwag.org

2 Let s Get Acquainted continued Stan and his wife, LaVonne, recently became certified as Master Gardeners and are active with the Ozaukee Master Gardener program. Stan volunteers his time by assisting the teaching staff at a local middle school in demonstrating the benefits and joys of home gardening. In addition, he spends time promoting the value of home food production to adults in the community. Stan and LaVonne were both born and raised in a small town about 50 miles north of Green Bay. They have lived in Cedarburg for over 40 years and have three married children and six grandchildren. Thank you, Stan, for joining the SMP team and for your dedication to improving the lives of Wisconsin s seniors! Like Wisconsin SMP on Facebook By Kevin Brown, Wisconsin SMP Capacity Building Grant Manager/Trainer Facebook, which has transformed how much of the world communicates, turned ten years old last month. According to the company, there were 1.23 billion monthly active users of Facebook at the end of December The average number of daily active Facebook users in December was also huge: 757 million. In June 2012, Wisconsin SMP (Senior Medicare Patrol) launched a Facebook page for our project. We have posted links to more than 130 news items on healthcare and other scams on our page since then, reaching over 1,800 individuals. Dozens of Facebook users have liked our project, and many have liked and shared our posts with their Facebook friends. If you use Facebook and like what we have been doing to empower seniors to prevent healthcare fraud in Wisconsin over the past sixteen years, please go to and like us. Then invite your family members and friends on Facebook, especially older ones, to like us, too. Social media is an excellent way to spread our message of fraud prevention across the state, nation, and world. Please let your online friends know about our Facebook page and encourage them to support Wisconsin SMP s efforts to fight healthcare fraud in our state. ACA Deadline Spurs State Agencies to Issue Fraud Warning As we near the March 31 st deadline for people to sign up for health insurance under the Affordable Care Act (ACA), state agencies are warning consumers to be careful as they search for health insurance especially when they go online. Open registration for the ACA is also open season for fraudsters, especially those operating on the Internet. The Wisconsin Department of Justice, Department of Health Services, the Office of the Commissioner of Insurance (OCI), and the Department of Agriculture, Trade and Consumer Protection (DATCP) issued a rare combined fraud warning earlier this month, urging consumers to pay attention to website addresses and the credentials of those selling health insurance. Since the state does not operate its own health exchange, Wisconsin residents signing up for health insurance under the new government program should go directly to the federal ACA home page or contact state licensed insurance companies, salespeople, and navigators who have been trained and 2

3 certified to sell and explain the program. According to J.P. Wieske of the insurance commissioner s office, there are a number of mirror websites that are not really health exchange websites. The four state agencies recommend the following precautions: Call OCI at to confirm that the insurance agent and company are licensed. Verify the legitimacy of websites. Officials recommend typing the name of the site into your browser, rather than searching for information about the ACA. The official website address for the ACA is Be suspicious if you are asked to transact business in an unusual way. For example, if you are asked to use a money order or to buy a money card to pay for the insurance, you should stop, call, and confirm. Threats, limited-time offers, or misinformation about Medicare are red flags. If you are on Medicare, you do not need to enroll in the ACA or reapply for Medicare. Source: Wisconsin State Journal (March 7, 2014) Reprinted with permission of the Wisconsin Department of Justice February 26, 2014 Attorney General J.B. Van Hollen Announces Settlement with Endo Pharmaceuticals to Resolve Off-Label Marketing Allegations MADISON Attorney General J.B. Van Hollen announced today that Wisconsin has joined with other states and the federal government in a global settlement with Endo Pharmaceuticals, a wholly owned subsidiary of Endo Health Solutions (Endo), a manufacturer of pharmaceutical products. The settlement resolves civil allegations of unlawful marketing practices aimed at promoting the drug Lidoderm for conditions not approved by the Food and Drug Administration (FDA). According to the qui tam, or whistleblower lawsuit, Endo unlawfully marketed Lidoderm for use in connection with lower back pain or chronic pain. The FDA approved Lidoderm only for the treatment of pain associated with post-herpetic neuralgia, more commonly known as shingles. Under the terms of the civil settlement, Endo will pay the state $405,760 as part of a total $1,310,940 attributable to Wisconsin Medicaid. The state and federal governments jointly fund Medicaid a medical insurance program for the needy and disabled. That amount is part of a total $472,916,967 to the states and federal governments. Endo also will pay a $20.8 million criminal fine, and enter into a Deferred Prosecution Agreement with the Northern District of New York and a Corporate Integrity Agreement with the Department of Health and Human Service s Office of the Inspector General. The lawsuit was filed in the Eastern District of Pennsylvania under the provisions of the federal False Claims Act and analogous state false claims statutes, including Wisconsin s. Between March 1999 and December 2007, Endo knowingly promoted the sale and use of Lidoderm for uses that were not medically accepted indications and not covered by Wisconsin Medicaid, causing false and/or fraudulent claims to be submitted and paid. 3

4 FTC: Don t Click on Random Text Messages The Federal Trade Commission (FTC) is warning consumers to be wary of any text messages from unknown entities, especially ones that claim you have won a terrific prize. Don t click on any links that are included in these messages, and don t reply to them either. They are probably scams. The FTC recently settled charges with a group of marketers that participated in a scheme that sent millions of unsolicited spam text messages promoting supposedly free merchandise like $1,000 gift cards for Wal-Mart and Best Buy. Consumers who clicked the links in the messages did not get the promised prizes and were taken to websites that asked them to give personal information and sign up for multiple offers, often involving purchases or paid subscriptions. What can you do about unwanted text messages? Delete unwanted text messages that ask you to enter a special code, or to confirm or provide personal information. Legitimate companies won t send you a text asking for sensitive information. Don t click on links in the text message. Links can take you to spoof sites that look real but will steal your personal information. Report spam texts to your carrier. If you are an AT&T, T-Mobile, Verizon, or Sprint subscriber, copy the original message and forward it to 7726 (SPAM) free of charge. Source: Federal Trade Commission Blog Post (February 28, 2014) The Financial and Human Costs of Medical Identity Theft Medical identity theft occurs when someone uses an individual s name and sometimes other parts of their identity such as insurance information without the person s knowledge or consent to obtain medical services or goods, or uses the individual s identity to make false claims for medical services or goods. It is different from traditional financial identity theft in that medical identity theft can cause human harm, as well as financial harm to the victim. Financial Harm The financial harm is obvious. According to the Ponemon Institute, a privacy and security firm that has been studying the medical identity theft problem for several years, as many as 1.8 million people may have been affected by this harmful, time-consuming, and expensive crime in The company interviewed 757 people in 2012 who said they or a family member had been a victim of medical identity theft. The average cost to each victim was $22,346, up from $20,663 in Six percent of the survey respondents reported paying more than $100,000 to resolve their cases. In addition to fees for lawyers and credit monitoring services, 41% of survey respondents reported that their insurance coverage was terminated as a result of the medical identity theft, forcing them to pay their personal medical expenses out of pocket. Resolving a medical identity theft case can take twelve months on average, so some people even paid for the medical services of the thief just to make the problem go away more quickly. 4

5 Human Harm The human harm is not so obvious and is more difficult to track and correct. The human harm results from incorrect information being placed in the victim s medical records. Medical identity thieves often change patient medical information in order to perpetrate their crimes. This false information may unwittingly be used by the victim s physician, leading to an erroneous diagnosis or an incorrect course of treatment, which can result in physical harm, even death. It is vitally important that a victim of medical identity theft review all their medical records and correct any errors to prevent misdiagnosis and mistreatment. Unfortunately, this can be a very timeconsuming and frustrating process. The federal Health Insurance Portability and Accountability Act (HIPPA) provides some rights to patients to seek corrections to their medical records. However, those rights do have limitations. In practice, when patients challenge the accuracy of their medical records, insurance companies and physicians are hesitant to delete any information. They are concerned the information might be useful at a later date. When someone else s medical history is mixed with the victim s, health care providers are not sure which person has the right to see the records, so they often refuse to give the record to the victim. The victim needs to be persistent. If the provider refuses access to the records, the victim can file a complaint with the U.S. Department of Health and Human Services. What can you do to prevent medical identity theft? Protect your Medicare number and other medical insurance information. Do not give this information to anyone you do not know and trust. Carefully review all medical bills, Medicare Summary Notices, and Explanation of Benefits statements for any charges that don t make sense, and check them out with the provider. What should you do if you become a victim of medical identity theft? File a police report. In addition to reporting the crime to law enforcement authorities for their action, a copy of the report will be useful to you as you go through the process of correcting your medical records. File a complaint with the Wisconsin Department of Agriculture, Trade & Consumer Protection and the Federal Trade Commission. Request copies of your medical records from all your medical providers, including doctors, hospitals, pharmacists, labs, and insurance companies. While the medical provider is required to give you copies upon request, they can also charge you for those copies. This can be expensive, so ask about the charges before you place the request. Once you obtain the records, work with the providers to make the necessary corrections. If you are interested in learning more about medical identity theft, or suspect you may be a victim of medical identity theft, the following resources may be helpful: Health Privacy Project at World Privacy Forum at 5

6 Second Doctor Pleads Guilty in Flushing, NY Clinic Fraud Case U.S. attorney Loretta Lynch announced that Chang Ho Lee, a doctor who resides in New Jersey, pleaded guilty to participating in an elaborate Medicare fraud scheme at two Flushing, New York clinics. Lee and two others faced charges of fraudulently billing Medicare for more than $13 million in services they never provided and that were not medically necessary. Lee used the people who benefit from Medicare to take advantage of the system, Lynch s office said. Hoi Yat Kam, a doctor who operated out of the same clinics, was sentenced in January to twelve months and one day in prison for his role in the scam. According to the indictment, the defendants offered seniors free non-medical services so that they could use their Medicare numbers to bill for care that was never provided. The scheme operated with the relentless efficiency of an assembly line, Lynch said. The U.S. attorney said that dozens of seniors came through the clinics doors every day, lured by the promise of free massages, facials, meals, prizes, and social events. Patients were told they needed to see a doctor in order to receive the free services. They were then escorted to see Lee and other doctors, who prescribed unneeded physical therapy that was never administered. According to the indictment, Lee submitted approximately $3.2 million in claims between January 2010 and October 2011 to Medicare. The indictment also said Lee and his co-defendants participated in a kickback scheme in which they paid people for referring Medicare beneficiaries to them. On February 28, Lee pleaded guilty in federal court to health care fraud and agreed to forfeit more than $3.4 million in fraud proceeds. He is scheduled to be sentenced on June 13 and could face up to ten years in prison. Source: Times Ledger (March 4, 2014) Reprinted with permission of the U.S. Department of Health and Human Services February 26, 2014 Departments of Justice and Health and Human Services Announce Record- Breaking Recoveries Resulting from Joint Efforts to Combat Health Care Fraud Government teams recovered $4.3 billion in FY 2013 and $19.2 billion over the last five years Attorney General Eric Holder and HHS Secretary Kathleen Sebelius today released the annual Health Care Fraud and Abuse Control (HCFAC) Program report showing that for every dollar spent on health care-related fraud and abuse investigations through this and other programs in the last three years, the government recovered $8.10. This is the highest three-year average return on investment in the 17- year history of the HCFAC Program. The government s health care fraud prevention and enforcement efforts recovered a record-breaking $4.3 billion in taxpayer dollars in Fiscal Year (FY) 2013, up from $4.2 billion in FY 2012, from individuals and companies who attempted to defraud federal health programs serving seniors or who sought payments from taxpayers to which they were not entitled. Over the last five years, the administration s enforcement efforts have recovered $19.2 billion, up from $9.4 billion over the prior 6

7 five-year period. Since the inception of the program in1997, the HCFAC Program has returned more than $25.9 billion to the Medicare Trust Funds and treasury. These recoveries, released today in the annual HCFAC Program report, demonstrate President Obama s commitment to making the elimination of fraud, waste and abuse, particularly in health care, a top priority for the administration. This is the fifth consecutive year that the program has increased recoveries over the past year, climbing from $2 billion in FY 2008 to over $4 billion every year since FY The success of this joint Department of Justice and HHS effort was made possible in part by the Health Care Fraud Prevention and Enforcement Action Team (HEAT), created in 2009 to prevent fraud, waste and abuse in Medicare and Medicaid and to crack down on individuals and entities that are abusing the system and costing American taxpayers billions of dollars. With these extraordinary recoveries, and the record-high rate of return on investment we ve achieved on our comprehensive health care fraud enforcement efforts, we re sending a strong message to those who would take advantage of their fellow citizens, target vulnerable populations, and commit fraud on federal health care programs, said Attorney General Eric Holder. Thanks to initiatives like HEAT, our work to combat fraud has never been more cooperative or more effective. And our unprecedented commitment to holding criminals accountable, and securing remarkable results for American taxpayers, is paying dividends. These impressive recoveries for the American taxpayer are just one aspect of the comprehensive antifraud strategy we have implemented since the passage of the Affordable Care Act, said HHS Secretary Sebelius. We ve cracked down on tens of thousands health care providers suspected of Medicare fraud. New enrollment screening techniques are proving effective in preventing high risk providers from getting into the system, and the new computer analytics system that detects and stops fraudulent billing before money ever goes out the door is accomplishing positive results all of which are adding to savings for the Medicare Trust Fund. The new authorities under the Affordable Care Act granted to HHS and the Centers for Medicare & Medicaid Services (CMS) were instrumental in clamping down on fraudulent activity in health care. In FY 2013, CMS announced the first use of its temporary moratoria authority granted by the Affordable Care Act. The action stopped enrollment of new home health or ambulance enrollments in three fraud hot spots around the country, allowing CMS and its law enforcement partners to remove bad actors from the program while blocking provider entry or re-entry into these already over-supplied markets. The Justice Department and HHS have improved their coordination through HEAT and are currently operating Medicare Fraud Strike Force teams in nine areas across the country. The strike force teams use advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes as well as chronic fraud by criminals masquerading as health care providers or suppliers. The Justice Department s enforcement of the civil False Claims Act and the Federal Food, Drug and Cosmetic Act has produced similar record-breaking results. These combined efforts coordinated under HEAT have expanded local partnerships and helped educate Medicare beneficiaries about how to protect themselves against fraud. In Fiscal Year 2013, the strike force secured records in the number of cases filed (137), individuals charged (345), guilty pleas secured (234) and jury trial convictions (46). Beyond these remarkable 7

8 results, the defendants who were charged and sentenced are facing significant time in prison an average of 52 months in prison for those sentenced in FY 2013, and an average of 47 months in prison for those sentenced since In FY 2013, the Justice Department opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants, and a total of 718 defendants were convicted of health care fraud-related crimes during the year. The department also opened 1,083 new civil health care fraud investigations. The strike force coordinated a takedown in May 2013 that resulted in charges by eight strike force cities against 89 individuals, including doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $223 million in false billings. As a part of the May 2013 takedown, HHS also suspended or took other administrative action against 18 providers using authority under the health care law to suspend payments until an investigation is complete. In FY 2013, the strike force secured records in the number of cases filed (137), individuals charged (345), guilty pleas secured (234) and jury trial convictions (48). Beyond these remarkable results, the defendants who were charged and sentenced are facing significant time in prison an average of 52 months in prison for those sentenced in FY 2013, and an average of 47 months in prison for those sentenced since In March 2011, CMS began an ambitious project to revalidate all 1.5 million Medicare enrolled providers and suppliers under the Affordable Care Act screening requirements. As of September 2013, more than 535,000 providers were subject to the new screening requirements and over 225,000 lost the ability to bill Medicare due to the Affordable Care Act requirements and other proactive initiatives. Since the Affordable Care Act, CMS has also revoked 14,663 providers and suppliers ability to bill the Medicare program. These providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules. HHS and the Justice Department are leading historic efforts with the private sector to bring innovation to the fight against health care fraud. In addition to real-time data and information exchanges with the private sector, CMS Program Integrity Command Center worked with the HHS Office of the Inspector General and the FBI to conduct 93 missions to detect, investigate, and reduce improper payments in FY From May 2013 through August 2013, CMS led an outreach and education campaign targeted to specific communities where Medicare fraud is more prevalent. This multimedia campaign included national television, radio, and print outreach and resulted in an increased awareness of how to detect and report Medicare fraud. To read today s report visit For previous years reports visit For more information on the joint DOJ-HHS Strike Force activities, visit: 8

9 SMP Activities Date Activity County March 4 SMP Presentation-St. Nazianz Nutrition Site Manitowoc March 5 SMP Presentation-Lincoln Villas-Racine Racine March 11 SMP Booth-Women s Health Policy Summit-Milwaukee Milwaukee March 12 SMP Presentation-Valders Nutrition Site Manitowoc March 13 SMP Booth-Solving the Dementia Puzzle Conf.-Evansville Rock March 17 SMP Presentation-Manitou Manor Nutrition Site Manitowoc March 18 SMP Booth-UWEC Senior Americans Day-Eau Claire Eau Claire March 19 SMP Presentation-Cleveland Nutrition Site Manitowoc March 20 SMP Presentation-Burlington Senior Center Racine March 20 SMP Presentation-Berkshire Senior Living-Greendale Milwaukee March 22 SMP Booth-Wellness & Energy Fair-Waunakee Dane March 25 SMP Booth-Colonial Club Health Fair-Sun Prairie Dane March 28 SMP Presentation-Racine County ADRC Racine April 1 SMP Presentation-St. Nazianz Nutrition Site Manitowoc April 2 SMP Volunteer Foundations Training-Stevens Point Portage April 8 SMP Presentation-Racine County Elderly Services Network Racine April 9 SMP Presentation-Valders Nutrition Site Manitowoc April 9 SMP Presentation-First Lutheran Church-Beaver Dam Dodge April 11 SMP Booth-Parish Nurse Day of Enrichment-La Crosse La Crosse April 16 SMP Presentation-Cleveland Nutrition Site Manitowoc April 21 SMP Presentation-Manitou Manor Nutrition Site Manitowoc April 23 SMP Presentation-Lake Oaks Nutrition Site Racine April 24 SMP Presentation-Wausau Retired Educators Marathon April 24 SMP Booth-Senior Living Show-Neenah Winnebago April 25 SMP Presentation-Racine County ADRC Racine April 27 SMP Booth-Cedar Mall 50+ Fair-Rice Lake Barron May 1-2 WVCA Conference-Rothschild Marathon May 6 SMP Presentation-St. Nazianz Nutrition Site Manitowoc May 6 SMP Volunteer Foundations Training-Bristol Kenosha May 8 SMP Booth-Senior Living Show-Rothschild Marathon May 9 SMP Booth-Multi-Cultural Senior Health Fair-Madison Dane May 14 SMP Presentation-Valders Nutrition Site Manitowoc May 19 SMP Booth-Wisconsin Alzheimer s Conference-Wis. Dells Sauk May 19 SMP Presentation-Manitou Manor Nutrition Site Manitowoc May 21 SMP Presentation-Cleveland Nutrition Site Manitowoc May 21 SMP Presentation-Lincoln Villas North Nutrition Site Racine May 30 SMP Presentation-Racine County ADRC Racine We are always looking for opportunities to support our colleagues in the aging network. Please contact Wisconsin SMP and let us know about upcoming events in your area. 9

10 Wisconsin SMP Coalition of WI Aging Groups 2850 Dairy Drive Ste. 100 Madison WI ATTENTION: All of You with In an effort to save paper, postage and be volunteer friendly, we will issues of the Fraud Alert! to those who have . Please contact Kevin Brown at and give him your address to add to our list. Thank you! For more information, contact: Elizabeth Conrad, SMP Project Director Coalition of Wisconsin Aging Groups Elder Law Center 2850 Dairy Drive Suite 100 Madison, WI Phone: 800/ / You can also access our publication by visiting our web site Or you can visit the Coalition of Wisconsin Aging Groups web site Click on Publications then click on Wisconsin Senior Medicare Patrol (SMP) and scroll down and click on the edition you wish to view.