What Can YOU Do to Help Prevent Healthcare Fraud?
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- Phoebe Richard
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1 What Can YOU Do to Help Prevent Healthcare Fraud? Presented by: Sandra Colon Sponsored by: MAGEC
2 What is the Senior Medicare Patrol? SMPs... 2 Help Medicare and Medicaid beneficiaries prevent, detect and report health care fraud Protect older persons and help preserve the integrity of the Medicare and Medicaid programs Rely on volunteers to help perform SMP work
3 What is Medicare? Federal health insurance program for persons 65 years and older; also for some under 65 Created by Congress in 1965 Administered by the Centers for Medicare and Medicaid Services (CMS) 3 NOT intended to pay 100% of medical bills
4 Parts of Medicare Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Part D: Prescription Drugs 4 Medicare Supplement Insurance (Medigap) is not part of Medicare.
5 Part A: Hospital Insurance Part A provides health care benefits that help cover: Inpatient hospital care Inpatient skilled nursing care Some home health care services Hospice care 5
6 Part B: Medical Insurance 6 Part B provides health care benefits that help cover: Doctor services Durable medical equipment (DME) Some home health care services X-rays, lab services Outpatient services Mental health services Most preventive health care services
7 Part C: Medicare Advantage Part C replaces Original Medicare (Parts A and B) and any supplement insurance (Medigap) when elected. Run by private insurance companies Must cover all Part A and Part B services May offer extra benefits May include prescription drugs 7
8 Part D: Prescription Drugs 8 Part D plans help with prescription drug costs. The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to offer Prescription Drug Plans to people with Medicare. Beneficiaries are encouraged to compare plans!
9 What is Medicare Fraud? 9 Intentionally billing Medicare for services that were not received, or billing for a service at a higher rate than is actually justified
10 What is Medicare Abuse? 10 Providers supply services or products that are not medically necessary or that do not meet professional standards
11 Examples of Fraud & Abuse Billing for services, supplies, or equipment that were not provided Billing for excessive medical supplies Obtaining a Medicare number for free services Improper coding to obtain a higher payment Unneeded or excessive x rays and lab tests Claims for services that are not medically necessary 11 Using another person s Medicare card to obtain medical care, supplies or equipment
12 What about Errors? Health care services and billing are complicated, which can lead to errors. Only a review and investigation of the issue will determine if it is an error, fraud, or abuse. 12
13 Medicare Fraud, Errors, and Everyone Abuse Affect Billions of taxpayer dollars lost to improper claims Medicare trust fund at risk Medicare Beneficiaries Higher premiums Less money for needed benefits Quality of treatment 13
14 Consequences to Beneficiaries like YOU! Fraudulent use of your Medicare number may affect YOUR Medicare benefits! If a Medicare number is stolen, it can t be cancelled or changed by Medicare. Your file may be flagged do not pay. Errors in medical history records can result in benefits being denied later when you need them! 14 Theft of your Medicare number may also lead to theft and misuse of: Your Social Security Number and your identity Your medical identity Your banking and credit information
15 Consequences To Perpetrators It s a federal crime to defraud the U.S. Government or any of its programs! Fraud convictions: 15 Can be criminal and/or civil May result in prison sentences, restitution (repayment of the stolen funds), and/or steep fines Result in mandatory exclusion from the Medicare program for a specific length of time
16 HEAT IN THE SUNSHINE STATE Joint task force: DHHS and DOJ To strike against fraud hot spots in targeted cities New policies and approaches to combat fraud Ca., Fla., NY, Illinois,Louisian,Michigan, Texas Health Care Fraud Prevention and Enforcement Action Team (HEAT) Teams of multi-agency units, federal,
17 Real Life Cases: Medicare Fraud & Abuse in South Florida! 17
18 Three Steps to Prevent Health Care Fraud 1) Protect 2) Detect 3) Report 18
19 Step 1: Protect Yourself from Medicare Fraud and Abuse DO Do treat your Medicare card and number like your credit cards. Do watch out for identity theft. Do be aware that Medicare doesn t call or visit to sell you anything. DON T Don't give out your Medicare number except to your doctor or other Medicare provider. Don t carry your Medicare card unless you will need it. 19
20 Step 2: Detect Medicare Fraud & Abuse Review Medicare Summary Notices (MSNs) and other statements for: 1. Services you didn t receive 2. Double-billing 3. Services not ordered by your doctor 20
21 Step 2: Detect Medicare Fraud & Abuse, continued Access your Medicare information online at 21 View most recent MSNs Check Part B deductible status View eligibility information Track available preventive services Find Medicare health or prescription drug plans
22 Step 2: Detect Medicare Fraud & Abuse, continued Use your Personal Health Care Journal Record doctor visits, tests, and procedures in this journal, and take it with you to your appointments. 22 Ask yourself questions about your health care. Write the answers and other information in your journal. Compare your MSNs and other statements to your journal to make sure they are correct.
23 Step 3: Report Suspected Medicare Fraud and Abuse 23 Call the provider. Gather information and documentation. Contact your SMP. This is a free and confidential service!
24 SMP Volunteers Would you like to: Help other Medicare beneficiaries protect, detect and report? Give presentations? (like this one!) Provide one-on-one counseling? Perform administrative work? 24 Join the SMP program as a volunteer!
25 Contact your State SMP: Area Agency on Aging Pasco Pinellas Visit us online: agingcarefl.org/medicare/flsmp For more information Call Toll-free: To report suspected fraud/abuse For training, speakers, and/or materials 25 To volunteer with the SMP program
26 My contact information Sandra Colon Ferrer, Outreach Consultant or or CMS, Program Integritiy Miami Field Office 7900 Oak Lane, Ste 111 Miami Lakes, Fl Miami-Dade, Monroe and Broward and Palm Beach Counties
27 27 Questions?
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