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The SMP Program: Empowering Consumers to Prevent Healthcare Fraud. Presented By:. Erin Weir, Healthcare Consumer Protection Coordinator AgeOptions. What We Will Cover Today. The SMP Program What is Healthcare Fraud? Examples of Healthcare Fraud The SMP Message:

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Presented By: Fraud

Erin Weir,

Healthcare Consumer

Protection Coordinator


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What We Will Cover Today Fraud

  • The SMP Program

  • What is Healthcare Fraud?

  • Examples of Healthcare Fraud

  • The SMP Message:

    Protect, Detect, Report!

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Medicare & Medicaid Lose FraudBILLIONS of Dollars every year to fraud, abuse, and errors!

At least $68 BILLION was lost in 2008!(National Health Care Anti-Fraud Association -

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Fraud affects: Fraud

  • Medicare & Medicaid Beneficiaries

    • loss of benefits

    • higher premiums

    • identity theft

  • Taxpayers

    • Medicare is paid for by taxes

    • Billions of taxpayer dollars wasted

  • The Medicare Program

    • Running out of money!

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According to the U.S. Congress… Fraud

“Senior citizens are our best front line defense against these losses.

Yet often they don’t have the information and expertise needed to recognize and accurately report cases of error, fraud, and abuse.”

Source: U.S. Senate Report 104-368

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The SMP Program Fraud

  • Senior Medicare Patrol (SMP)

  • Goal = empower consumers to prevent health care fraud and abuse through outreach and education

  • Recruit volunteers to educate consumers about healthcare fraud and abuse

  • Programs in all 50 states, Washington, D.C., Puerto Rico, Guam, Virgin Islands

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Illinois SMP Program Fraud

  • Illinois Area Agencies on Aging

  • Local Agencies in Chicago & suburbs:

    • South Suburban Senior Services of Catholic Charities

    • Catholic Charities Northwest

    • Catholic Charities Lake County

    • Senior Service Associates

  • Coalition of Limited English Speaking Elderly

  • Illinois Network of Centers for Independent Living

  • IL Attorney General’s Office Senior Outreach Program

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SMP Staff and Volunteers… Fraud

  • Give presentations to groups (like this one!)

  • Give out information and materials at health fairs or other events

  • Help people with questions about billing mistakes or fraud issues

  • Help report fraud to investigators

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In 2008 alone… Fraud

  • Over 4,685 active volunteers served SMP programs

  • Volunteers received close to 42,500 hours of training and contributed over 112,000 hours in support of the SMP program

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What is Healthcare Fraud? Fraud

Fraud occurs when an individual or organization deliberately deceives others to gain unauthorized benefit.

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Fraud may be discovered when: Fraud

  • Beneficiaries report complaints


  • Medicare contractors review medical claims for inappropriate billing

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What is Healthcare Fraud? Fraud

  • Billing for services or supplies not provided

  • Billing for services or supplies that are different than what was actually provided

  • Altering claim forms to obtain a higher payment

  • Billing twice for the same service or item

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What is Healthcare Fraud? Fraud

  • Billing separately for services that should be included in a single service fee

  • Using someone else’s provider number (some people will even use dead doctors’ numbers!)

  • Selling or sharing someone’s Medicare number

  • Offering gifts or money for Medicare numbers

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What is Healthcare Abuse? Fraud

  • Incidents or practices of providers that are inconsistent with accepted sound medical, business, or fiscal practices.

  • These practices may directly or indirectly result in:

    • Unnecessary costs to the program,

    • Improper payment, or

    • Payment for services that fail to meet professionally recognized standards of care or that are medically unnecessary.

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What is Abuse? Fraud

  • Excessive charges for services or supplies

  • Routinely submitting duplicate claims

  • Improper billing practices, such as:

    • Billing Medicare at a higher fee schedule rate than for non-Medicare patients

    • Submitting bills to Medicare when Medicare is not the beneficiary’s primary insurer

    • Collecting more than 20% coinsurance or the deductible on claims filed with Medicare

  • Claims for services not medically necessary

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Healthcare Abuse Involves: Fraud

  • Payment for items or services when there is no legal entitlement to that payment,

  • And the provider has not knowingly and intentionally misrepresented the facts to obtain payment.

  • Note

  • The difference between fraud and abuse is intentionality!

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Remember… Fraud

Inappropriate practices that start as abuse

can evolve into fraud.

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Errors that May Not Be Fraud or Abuse But Should Still Be Reported & Corrected

  • Billing Medicare for cancelled appointments

  • Provider typed wrong Medicare number

  • Accidentally submitting the same charge twice

    These are usually billing errors that can be corrected by the provider (and the SMP program can help!)

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Examples of Healthcare Fraud Reported & Corrected

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Examples of Fraud – Nursing Facilities Reported & Corrected

  • A nursing home provides physical therapy to large groups of residents at one time, but bills Medicare as if the therapy was provided individually.

  • Another nursing home provides social activities for the residents and bills Medicare for psychotherapy.

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Examples of Fraud – Home Health Reported & Corrected

  • A representative from a home health agency in Springfield visited a woman in her home and told her that her doctor wanted the home health agency to check her blood pressure once a week. A nurse came once a week, took her blood pressure, and left. The home health agency billed Medicare for skilled nursing services.

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Examples of Fraud – Durable Medical Equipment (DME) Reported & Corrected

  • A man in Chicago had a stroke and needed an electric wheelchair. When his equipment company tried to bill Medicare for the wheelchair, the claim was rejected because another Durable Medical Equipment company had billed Medicare for a wheelchair on his behalf in 2004. The man could not obtain the wheelchair he needed until a fraud complaint was filed and the claim was corrected.

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Examples of Fraud – Physician Services Reported & Corrected

  • A podiatrist in Oak Park trimmed the toenails of multiple residents in a senior building. He then billed Medicare as if he had provided an office visit and foot surgery for each of the residents.

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Examples of Fraud – Hospital Services Reported & Corrected

  • An Illinois hospital billed a patient for multiple tests that she did not receive, adding up to over $16,000.

  • Some hospitals purposely hold patients in “observation status” for 3-4 days, rather than admitting the person as a hospital inpatient. (The Medicare payment for “observation status” is usually higher than what the hospital would have received if the person is an inpatient.)

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Examples of Fraud – Ambulance Services Reported & Corrected

  • An ambulance company billed Medicare to transport a person to and from dialysis. However, the person is able to walk to and from the ambulance and rode in the front seat. This indicates that the transportation was not “medically necessary” – the person could have taken another form of transportation to dialysis. In cases like this, Medicare will not pay for ambulance transportation.

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Examples of Fraud – Mental Health Services Reported & Corrected

  • A group of ‘therapists’ picked people up in a van, drove them to a location where they played Bingo and ate lunch, and then dropped everyone back off at home. The ‘therapists’ billed Medicare as if they provided individual psychotherapy to all of the people that participated.

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Examples of Fraud – Hospice Care Reported & Corrected

  • A hospice company intentionally enrolled people who were not eligible for hospice and billed Medicare for care they didn’t provide.

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Examples of Fraud – Prescription Drugs Reported & Corrected

  • A major pharmacy chain made millions of dollars in profit by switching pills. Instead of providing the brand-name drug that was prescribed, the pharmacy substituted a generic. However, the pharmacy still billed Medicare and the consumers involved as if they provided the brand-name drug.

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Examples of Fraud – Private Insurance Companies Reported & Corrected

  • A representative from a Medicare Advantage plan set up a table at a Chicago food pantry and told people that he could give them health coverage that would cost less than their Medicare coverage - he told them the coverage was “free.” One of the people decided to enroll in the “free” plan. He later found out that the plan was NOT free (he had to pay a monthly premium) and the plan would not cover his doctor.

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The SMP Message: Reported & Corrected




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PROTECT Yourself From Fraud! Reported & Corrected

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PROTECT Yourself From Fraud! Reported & Corrected

  • Do NOT give your Medicare number to people you do not know!

    • On the phone

    • At the door

    • At a presentation, exercise class, screening, etc.  FREE services do NOT require your Medicare number!

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Protect Yourself! Reported & Corrected

  • Don’t carry your Social Security, Medicare, or Medicaid cards in your wallet!

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Protect Yourself! Reported & Corrected

  • Don’t carry your Social Security, Medicare, or Medicaid cards in your wallet!

    • You don’t need them in an emergency – the hospital will treat you, and you can send them your insurance information later

    • If you really want to carry something, make a photocopy and black out the last 4 digits of your ID number

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Protect Yourself! Reported & Corrected

  • Shred documents with your personal information on them BEFORE you throw them away!

  • Take the mail out of your mailbox.

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PROTECT Yourself From Fraud! Reported & Corrected

  • Do NOT accept services from someone who calls or visits you unexpectedly, even if they say that your doctor sent them!

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PROTECT Yourself From Fraud! Reported & Corrected

  • Do NOT “sign up” for services at a presentation or event.

  • Do NOT sign timesheets or other forms without reading them.

  • Do NOT sign blank forms!

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PROTECT Yourself From Fraud! Reported & Corrected

  • Insurance plans CANNOT:

    • Enroll you in a plan without your permission

    • Lie to you about a plan to get you to enroll

    • Sign you up for a plan on the phone unless you call them

    • Contact you without your permission

    • Give you gifts worth more than $15

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DETECT Fraud! Reported & Corrected

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DETECT Fraud! Reported & Corrected

  • Keep track of the health care services you receive in a journal or on a calendar.

  • If you receive home health, hospice, or hospital services, ask for an itemized list of the services that you have received. Check the list for errors.

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DETECT Fraud! Reported & Corrected

  • Read your Medicare Summary Notice or Explanation of Benefits from your insurance company! Watch for:

    • Services that you did not get

    • Services that were not ordered by your doctor

    • Billing for the same thing twice

    • Other billing errors

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DETECT Fraud! Reported & Corrected

  • Medicare Summary Notices are sent quarterly (once every three months).

  • You can always request a Medicare Summary Notice by calling 1-800-Medicare.

  • You can also view your claims and Medicare information online at:

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REPORT Fraud! Reported & Corrected

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Why Report Fraud? Reported & Corrected

  • Healthcare fraud puts you at risk for identity theft!


    • Taxpayer dollars

    • Higher premiums

  • Saving the Medicare Program!

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Why Report Fraud? Reported & Corrected

People who commit fraud are STEALING from you, not helping you!

  • Your Medicare account may be flagged: “Do Not Pay!”

  • When things aren’t ordered by your doctor, they may not fit or work properly.

  • When someone gives you something that you don’t need:

    • Your health may get worse

    • Your Medicare benefits may be “used up”

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Report Fraud When You Find It! Reported & Corrected

If you notice a mistake:

  • Call the provider or the number on your Medicare Summary Notice. If it is just a mistake, they may be able to fix the problem.

  • If this doesn’t work or you suspect fraud, contact AgeOptions at (800)699-9043.

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Erin Weir Reported & Corrected

Healthcare Consumer Protection Coordinator


Phone: (708)383-0258,


TTY: (708)524-1653

[email protected]

If you have questions, contact: