Helping keep the promise.

Transcription

1 FraudAlert! Helping keep the promise. June 2015 Volume 18, No. 11 Coalition of Wisconsin Aging Groups Elder Law Center From the Project Director Kevin Brown Check out our website at Let s Get Acquainted By Judy Steinke, Wisconsin SMP Volunteer Coordinator Wisconsin SMP (Senior Medicare Patrol) is pleased to introduce Wayne Masnica of Salem as this month s featured volunteer. Wayne met Elizabeth Conrad, former Wisconsin SMP Project Director, when they gave presentations to the Kenosha Senior Citizens group in June He was a dedicated AARP Fraud Fighter then, and both of them spoke at a fraud forum that was arranged by the Kenosha County Elder Benefit Specialist. When the Fraud Fighter program came to an end, Wayne decided to join Wisconsin SMP. He enjoys volunteering because it enables him to share his knowledge to help others. Helping others has been a theme throughout Wayne s life. He served in the U.S. Marine Corps for three years and then completed his BS in Physiology. Wayne began his career as a teacher for the Milwaukee Archdiocese. Later, he obtained two graduate degrees: a MS in Pulmonary Physiology from the University of Wisconsin and a MBA in Marketing Finance from UC-Irvine. Wayne retired as an international marketing executive and then started his own marketing consulting firm in the healthcare industry. Wayne states that he and his wife, Arlene, have been married for 53 fantastic years. They have four children and ten grandchildren. His hobbies include reading, traveling, and fishing. Thank you, Wayne, for your service to our country and for sharing your knowledge and expertise to make life easier for others. Wisconsin SMP is delighted that you joined the project! FRAUD ALERT! Coalition of Wisconsin Aging Groups Elder Law 1 Center Wisconsin SMP In this issue: Let s Get Acquainted with Wayne Masnica, SMP Volunteer CWAG Awarded New Federal Grant for Wisconsin SMP Project Former Pewaukee Neurosurgeon Accused in Counterfeit Implant Scheme CFPB: Reverse Mortgage Ads May Be Misleading Special Issue of Generations Focuses on Medicare at 50 CMS News Release DOJ News Release Register for the 2015 Dane County & State Triad Conference Upcoming Wisconsin SMP Activities Published and distributed by the Coalition of Wisconsin Aging Groups Elder Law Center. This project was supported, in part by grant #90MP0213, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C 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 for Community Living policy. EDITOR AND PROJECT DIRECTOR 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 Dairy Drive Madison, WI kbrown@cwag.org

2 CWAG Awarded New Federal Grant for Wisconsin SMP Project By Kevin Brown, Wisconsin SMP Project Director I am very pleased to report that the U.S. Department of Health and Human Services (HHS) announced earlier this month that the Coalition of Wisconsin Aging Groups (CWAG) has been awarded a new three-year grant to help Wisconsin SMP (Senior Medicare Patrol) continue our efforts to fight Medicare fraud in our state. CWAG was awarded $272,900 for the first year (June 1, 2015-May 31, 2016) of the new three-year grant project period, which began June 1, 2015 and ends on May 31, 2018, and is slated to receive a similar level of funding for the second and third years of the project, which amounts to more than $818,000. Wisconsin SMP is one of 54 SMP projects across the nation that educate Medicare beneficiaries, their family members, and caregivers about how to prevent, detect, and report healthcare fraud, waste, and abuse. The Administration for Community Living operates the SMP program in close partnership with the Centers for Medicare & Medicaid Services and the HHS Office of Inspector General. Since 1997, the Wisconsin SMP program has conducted 190 volunteer training sessions and trained more than 1,700 volunteers throughout the state to educate Medicare beneficiaries, family members, and caregivers about the importance of protecting their personal information, reviewing their Medicare notices to identify billing errors and potentially fraudulent activity, and reporting suspected fraud, waste, and abuse. Wisconsin SMP staff and volunteers have made over 1,100 presentations on healthcare fraud and distributed informational materials at more than 800 community outreach events over the past eighteen years. Wisconsin SMP will continue to work with our excellent partners in the aging network, such as the Aging & Disability Professionals Association of Wisconsin and Wisconsin Association of Nutrition Directors, to empower seniors to prevent healthcare fraud in our state. We will also continue to collaborate with service coordinators, parish nurses, law enforcement officials, media consultants, and our other professional partners to spread our message of fraud prevention across the state. The new grant will allow Wisconsin SMP to expand our volunteer workforce, increase public awareness of healthcare fraud prevention, and educate and serve more Medicare beneficiaries. Thank you to all of the Wisconsin SMP staff members, volunteers, and professional partners who have worked on behalf of our project over the past eighteen years. You have helped Wisconsin SMP make a big difference in the fight against healthcare fraud in our state, and we look forward to working with you in the next three years. Former Pewaukee Neurosurgeon Accused in Counterfeit Implant Scheme Approximately 50 insurance companies, including three in Wisconsin, have filed a lawsuit alleging that dozens of doctors and hospitals nationwide were involved in a massive health care fraud scheme and conspiracy that involved charging patients and their insurance companies full price for counterfeit implants. About a dozen hospitals and 16 doctors were named in the suit, including Cully White, a former neurosurgeon from Pewaukee. White served a six-month sentence in federal prison last year after he pleaded guilty to one count of health care fraud in The lawsuit is seeking recovery of triple the amount billed to the insurance companies for the counterfeit medical parts, which could total more than $100 million. 2

3 The lawsuit alleges that White received kickbacks for implanting counterfeit spinal equipment in patients. The company that manufactured the parts was a machine and tool shop in California. Spinal Solutions, LLC, which sold the fake parts, was owned by Roger Williams and is now closed. Two Wisconsin hospitals Aurora St. Luke s Medical Center and Wheaton Franciscan Healthcare s St. Francis Hospital were also named in the lawsuit as defendants. The counterfeit spinal hardware was delivered to defendant White in Wisconsin by defendant Williams private aircraft, and flight logs confirm that these deliveries originated in California, alleges the lawsuit. White then performed his end of the contract by implanting the counterfeit hardware into unsuspecting patients at St. Francis Hospital and Aurora St. Luke s Medical Center. White introduced the bogus products to the two hospitals. The suit charges all of the hospitals named as defendants with negligence for not properly vetting their surgeons and the implant suppliers. Over two dozen similar lawsuits have been filed in Los Angeles by patients alleging that they have received counterfeit medical implants. However, this is the first suit to designate White as a defendant. This whistle-blower lawsuit was filed in February, but it was not unsealed until May. The named defendants have not yet been served with a complaint. In 2014, the Center for Investigative Reporting revealed that White flew to vacation spots in Mexico and Vail, Colorado, in a Spinal Solutions airplane. This report also noted that White had indicated in surgical reports that he had used Spinal Solutions devices on several occasions. After White served his six-month sentence in a minimum security prison camp, he was released and put under house arrest for up to six months at his Pewaukee Lake home. He had been charged with 14 counts for allegedly scheming to submit fraudulent insurance claims. As part of a plea bargain, White agreed to give up his medical license. A former patient of his received a $2.5 million settlement for a malpractice claim he had filed against White. Source: Milwaukee Journal Sentinel (June 3, 2015) CFPB: Reverse Mortgage Ads May Be Misleading A recent study conducted by the Consumer Financial Protection Bureau (CFPB) found that older homeowners were often given the false impression by reverse mortgages ads. The researchers found that many older homeowners believe reverse mortgages are a government benefit and guarantee consumers can remain in their homes for the rest of their lives. The CFPB stressed that reverse mortgages are loans for consumers 62 and older and must be repaid with interest. As is the case with all loans, there are certain risks. It is possible that seniors with reverse mortgages will lose their homes. In fact, approximately ten percent of consumers with reverse mortgages end up defaulting on their loans, which is nearly double the rate of default for traditional home mortgages. Reverse mortgages enable borrowers to receive cash or a line of credit by tapping into the accumulated equity in their homes. Reverse mortgages are often taken out to help pay bills or remodel portions of a home. However, the loan is not due in monthly increments. Instead, the loan balance increases and is due when the borrower dies, moves, or sells the home, or defaults on other financial obligations. 3

4 Most reverse mortgages are insured by the Federal Housing Administration, but they are not risk-free government benefits, despite advertising that might attempt to create this false impression. The CFPB found that most of the 97 different TV, radio, print, and online ads they reviewed failed to disclose the risks of reverse mortgages. Or, if they did, they were so buried in the fine print that consumers did not pick up on key aspects of the loan, CFPB Director Richard Cordray said. Indeed, many reverse mortgage ads did not even mention anything about interest rates, repayment terms or other crucial requirements of the loan. Cordray said he is particularly concerned because reverse mortgages are complex and sold to older adults, a demographic known to be vulnerable to deceptive advertising and misleading sales pitches. The CFPB interviewed approximately 60 homeowners aged 62 and older in focus groups and in individual interviews in Chicago, Los Angeles, and Washington, D.C. in its study. The trade group that represents reverse mortgage lenders, the National Reverse Mortgages Lenders Association, stated that they have a code of ethics and specific guidance for ethical advertising for its members. We share viewers concerns that any advertising should be accurate, said Peter Bell, the president of the association. As an association we are committed to educating consumers about the pros and cons of reverse mortgages, training lenders to be sensitive to clients needs and enforcing our code of ethics and professional responsibility. Source: Wisconsin State Journal (June 14, 2015) Special Issue of Generations Focuses on Medicare at 50 July 30 will be the 50 th anniversary of the Medicare program. Currently, 55 million people, or one in six Americans, are enrolled in Medicare, which accounts for 14 percent of the federal budget. Clearly, Medicare is a firmly entrenched American institution, but is there a bright future for the program? The American Society on Aging examines that topic in a special issue of Generations, its quarterly journal, entitled Medicare at 50. The Medicare program affects everyone, directly or indirectly, said Generations Guest Editor John Rother, who is the president and CEO of the National Coalition on Health Care. It s the single most important social program, along with Social Security, that sustains dignity in later years. It faces major challenges going forward... but it s so central to our society that we can t imagine life without it. Tricia Neuman, the other Guest Editor of the issue, agrees. It s hard to imagine a future without Medicare. Policy makers face real challenges moving forward finding ways to finance care for an aging population, building on Medicare to leverage better quality care for its beneficiaries, and balancing the need to keep Medicare affordable for the nation and for seniors. Neuman is the senior vice president of the Kaiser Family Foundation and the director of the Foundations Program on Medicare Policy and its Project on Medicare s Future. The entire issue of Medicare at 50 is available online at Source: American Society on Aging AgeBlog (June 3, 2015) 4

5 Reprinted with permission of the Centers for Medicare & Medicaid Services June 10, 2015 Medicare and Medicaid 50 th Anniversary Count Down Washington, D.C. This summer will mark the 50th anniversary of the enactment of Amendments to the Social Security Act that established the Medicare and Medicaid programs. Over the next 50 days, the Centers for Medicare & Medicaid Services will recognize the impact these two programs have had in transforming our nation s health care system. By sharing daily facts and posts on Twitter (@cmsgov) and Medicaid.gov, CMS will highlight people, places, and progress that represent the Medicare and Medicaid programs as we know today. The 50th anniversary of Medicare and Medicaid provides an important opportunity for us to reflect on the critical role these programs have played in protecting the health and well-being of millions of families, said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services. Today, Medicare and Medicaid are creating a health care system that is better, smarter, and healthier setting standards for how care is delivered. As we take a moment to reflect on the past five decades, we must also look to the future and explore ways to strengthen and improve health care for future generations. On July 30, 1965, President Johnson signed legislation to establish Medicare for the elderly and Medicaid for low-income adults, children, pregnant women, and people with disabilities. Though Medicare and Medicaid started as basic health coverage programs for Americans, the programs have evolved over the years to provide more Americans with improved access to quality and affordable health care coverage. These programs have transformed the delivery of health care in the United States. To commemorate this anniversary, CMS will engage in conversations with beneficiaries, providers, and health experts. We invite the public to participate in this celebration by sharing stories of how Medicare and Medicaid have made a difference. Stories can be shared at In late July, regional CMS offices will host public events in addition to a national event in Washington, D.C. Reprinted with permission of the U.S. Department of Justice June 18, 2015 National Medicare Fraud Takedown Results in Charges Against 243 Individuals for Approximately $712 Million in False Billing Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell announced today a nationwide sweep led by the Medicare Fraud Strike Force in 17 districts, resulting in charges against 243 individuals, including 46 doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $712 million in false billings. In addition, the Centers for Medicare & Medicaid Services (CMS) also suspended a number of providers using its suspension authority as provided in the Affordable Care Act. This coordinated takedown is the largest in Strike Force history, both in terms of the number of defendants charged and loss amount. 5

6 Attorney General Lynch and Secretary Burwell were joined in the announcement by FBI Director James B. Comey, Assistant Attorney General Leslie R. Caldwell of the Justice Department s Criminal Division, Inspector General Daniel R. Levinson of the HHS Office of Inspector General (HHS-OIG) and Deputy Administrator and Director of CMS Center for Program Integrity Shantanu Agrawal, M.D. The defendants are charged with various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering and aggravated identity theft. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, including home health care, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and pharmacy fraud. More than 44 of the defendants arrested are charged with fraud related to the Medicare prescription drug benefit program known as Part D, which is the fastest-growing component of the Medicare program overall. This action represents the largest criminal health care fraud takedown in the history of the Department of Justice, and it adds to an already remarkable record of enforcement, said Attorney General Lynch. The defendants charged include doctors, patient recruiters, home health care providers, pharmacy owners, and others. They billed for equipment that wasn t provided, for care that wasn t needed, and for services that weren t rendered. In the days ahead, the Department of Justice will continue our focus on preventing wrongdoing and prosecuting those whose criminal activity drives up medical costs and jeopardizes a system that our citizens trust with their lives. We are prepared and I am personally determined to continue working with our federal, state, and local partners to bring about the vital progress that all Americans deserve. This Administration is committed to fighting fraud and protecting taxpayer dollars in Medicare and Medicaid, said Secretary Burwell. This takedown adds to the hundreds of millions we have saved through fraud prevention since the Affordable Care Act was passed. With increased resources that have allowed the Strike Force to expand and new tools, like enhanced screening and enrollment requirements, tough new rules and sentences for criminals, and advanced predictive modeling technology, we have managed to better find and fight fraud as well as stop it before it starts. According to court documents, the defendants participated in alleged schemes to submit claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided. In many cases, patient recruiters, Medicare beneficiaries and other co-conspirators allegedly were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare for services that were medically unnecessary or never performed. Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $712 million in fraudulent billing. The people charged in this case targeted the system each of us depends on in our most vulnerable moments, said Director James Comey. Health care fraud is a crime that hurts all of us and each dollar taken from programs that help the sick and the suffering is one dollar too many. Every day, the Criminal Division is more strategic in our approach to prosecuting Medicare Fraud, said Assistant Attorney General Caldwell. We obtain and analyze billing data in real-time. We target hot spots areas of the country and the types of health care services where the billing data shows the potential for a high volume of fraud and we are speeding up our investigations. By doing this, we are increasingly able to stop schemes at the developmental stage, and to prevent them from spreading to other parts of the country. 6

7 Health care fraud drives up health care costs, wastes taxpayer money, undermines the Medicare and Medicaid programs, and endangers program beneficiaries, said Inspector General Levinson. Today s takedown includes perpetrators of prescription drug fraud, home health care fraud, and personal care services fraud, three particularly harmful types of fraud plaguing our health care system. This record-setting takedown sends a message to would-be perpetrators that health care fraud is a risky way to line your pockets. Our agents and our law enforcement partners stand ready to protect these vital programs and ensure that those who would steal from federal health care programs ultimately pay for their crimes. The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. Since their inception in March 2007, Strike Force operations in nine locations have charged over 2,300 defendants who collectively have falsely billed the Medicare program for over $7 billion. Including today s enforcement actions, nearly 900 individuals have been charged in national takedown operations, which have involved more than $2.5 billion in fraudulent billings. Today s announcement marks the first time that districts outside of Strike Force locations participated in a national takedown, and they accounted for 82 defendants charged in this takedown. In Miami, a total of 73 defendants were charged with offenses relating to their participation in various fraud schemes involving approximately $263 million in false billings for home health care, mental health services and pharmacy fraud. In one case, administrators in a mental health center billed close to $64 million between 2006 and 2012 for purported intensive mental health treatment to beneficiaries and allegedly paid kickbacks to patient recruiters and assisted living facility owners throughout the Southern District of Florida. Medicare paid approximately half of the claimed amount. In Houston and McAllen, Texas, 22 individuals were charged in cases involving over $38 million in alleged fraud. One of these defendants allegedly coached beneficiaries on what to tell doctors to make them appear eligible for Medicare services and treatments and then received payment for those who qualified. The company that paid the defendant for patients submitted close to $16 million in claims to Medicare, over $4 million of which was paid. In Dallas, seven people were charged in connection with home health care schemes. In one scheme, six owners and operators of a physician house call company submitted nearly $43 million in billings under the name of a single doctor, regardless of who actually provided the service. The company also significantly exaggerated the length of physician visits, often times billing for 90 minutes or more for an appointment that lasted only 15 or 20 minutes. In Los Angeles, eight defendants were charged for their roles in schemes to defraud Medicare of approximately $66 million. In one case, a doctor is charged with causing almost $23 million in losses to Medicare through his own fraudulent billing and referrals for DME, including over 1000 expensive power wheelchairs and home health services that were not medically necessary and often not provided. In Detroit, 16 defendants face charges for their alleged roles in fraud, kickback and money laundering schemes involving approximately $122 million in false claims for services that were medically unnecessary or never rendered, including home health care, physician visits, and psychotherapy, as 7

8 well as pharmaceuticals that were billed but not dispensed. Among these are three owners of a hospice service who allegedly paid kickbacks for referrals made by two doctors who defrauded Medicare Part D by issuing medically unnecessary prescriptions. In Tampa, five individuals were charged with participating in a variety of schemes, ranging from fraudulent physical therapy billings to a scheme involving millions in physician services and tests that never occurred. In one case, a licensed pain management physician sought reimbursement for nerve conduction studies and other services that he allegedly never performed. Medicare paid the defendant over $1 million for these purported services. In Brooklyn, N.Y., nine individuals were charged in two separate criminal schemes involving physical and occupational therapy. In one case, three individuals face charges for their roles in a previously charged $50 million physical therapy scheme. In the second case, six defendants were charged for their roles in a $8 million physical and occupational therapy scheme. In New Orleans, 11 people were charged in connection with $110 million in home health care and psychotherapy schemes. In one case, four individuals who operated two companies one in Louisiana and one in California that mass-marketed talking glucose monitors (TGMs) across the country allegedly sent TGMs to Medicare beneficiaries regardless of whether they were needed or requested. The companies billed Medicare approximately $38 million for the devices and Medicare paid the companies over $22 million. The cases announced today are being prosecuted and investigated by Medicare Fraud Strike Force teams from the Fraud Section of the Justice Department s Criminal Division and from the U.S. Attorney s Offices of the Southern District of Florida, Eastern District of Michigan, Eastern District of New York, Southern District of Texas, Central District of California, Eastern District of Louisiana, Northern District of Texas, Northern District of Illinois and the Middle District of Florida; and agents from the FBI, HHS-OIG and state Medicaid Fraud Control Units. In addition to the Strike Force, today s enforcement actions include cases brought by the U.S. Attorney s Offices of the Southern District of California, Southern District of Illinois, Northern District of Ohio, Western District of Kentucky, District of Maryland, District of Connecticut, District of Alaska and the Southern District of Georgia. A complaint or indictment is merely a charge, and defendants are presumed innocent until proven guilty. The court documents for each case will posted online, as they become available, here: The Affordable Care Act has provided new tools and resources to fight fraud in federal health care programs. The law provides an additional $350 million for health care fraud prevention and enforcement efforts, which has allowed the Justice Department to hire more prosecutors and the Strike Force to expand from two cities to nine. It also toughens sentencing for criminal activity, enhances provider and supplier screenings and enrollment requirements, and encourages increased sharing of data across government. 8

9 In addition to providing new tools and resources to fight fraud, the Affordable Care Act clarified that for sentencing purposes, the loss is determined by the amount billed to Medicare and increased the sentencing guidelines for the billed amounts, which has provided a strong deterrent effect due to increased prison time, particularly in the most egregious cases. Register for the 2015 Dane County & State Triad Conference On September 18, the 2014 Dane County & State Triad Crime Prevention and Safety Conference & Expo will be held at the American Family Insurance Training Center in Madison. This event will provide valuable information to seniors to help keep them safe in their homes and communities. Workshop topics will include: brain health; identity theft; older adult bullying; 2015 drug threats; domestic violence in later life; guarding financial health; safe driving; and hoarding/decluttering. Seniors, law enforcement, human service professionals, and the general public are invited to attend the conference. The registration fee is $25.00 ($20.00 early bird), which includes a continental breakfast, lunch and materials. To register for the conference, go to For more information, contact Mary Stamstad, RSVP of Dane County Program Coordinator, at or mstamstad@rsvp.org. Upcoming Wisconsin SMP Activities Date Activity County July 11 SMP Presentation-Post-Polio Support Group-Monona Dane July 22 SMP Volunteer Update Training-Madison Dane July 25 SMP Booth-Wellness Fest 2015-La Crosse La Crosse July 28 SMP Presentation-Creekside Senior Center-Evansville Rock July SMP/SHIP National Training Meeting-Arlington, VA July 29 SMP Presentation-Grafton Senior Center Ozaukee August 4 SMP Booth-National Night Out Event-Greenville Outagamie August 5 SMP Booth-National Night Out Event-Brookfield Waukesha August 5 SMP Presentation-Port Washington Senior Center Ozaukee August 6 SMP Booth-2015 Healthy Aging Summit-Stevens Point Portage August 11 SMP Presentation-Rosewood Villas-Madison Dane August 12 SMP Volunteer Foundations Training-Wausau Marathon August 13 SMP Volunteer Update Training-Tomahawk Lincoln August 17 SMP Presentation-Columbus Area Senior Center Columbia August 18 SMP Presentation-Fitchburg Senior Center Dane August 19 SMP Presentation-Forum 55+ Group-Marshfield Wood August SMP Booth-Wisconsin Farm Technology Days-Sun Prairie Dane 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: Kevin Brown, 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.