SMP Program: Empowering Seniors to Prevent Health Care Fraud

2. SMP Program:Empowering Seniors to Prevent Health Care Fraud • SMP: Senior Medicare Patrol – Medicare fraud prevention program • 1997: Senator Tom Harkin had an idea… • Today: nationwide program in 50 states, DC, & U.S. territories • Peer education model: SMPs recruit and train senior volunteers to conduct outreach and education to their peers and caregivers about Medicare fraud prevention • Mission: To empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education.

3. SMP Message • Prevent fraud by protecting personal information, knowing how to detect fraud, and knowing where and how to report suspected fraud, errors, and abuse

4. SMP Program:Empowering Seniors to Prevent Healthcare Fraud • Receive complaints of potential healthcare fraud, errors and abuse and either resolve or refer to OIG for investigation. • ScamWire Alerts • Emerging scams throughout PA • Distribute to volunteers and partners • Home delivered meals initiative • Legislative outreach • To join listserv: carmody@carie.org • Outreach and Education • Professional groups • Caregivers • Limited English Proficiency groups

5. SMP Program:Empowering Seniors to Prevent Healthcare Fraud SMP Program since 1997: • 60,000 volunteers trained • Over 104,000 complaints handled • 3.5 million people educated • 94,000 group education sessions • 1.2 million 1-on-1 counseling sessions • Over 1.9 million media airings • Over $106 million in savings • Prevention hard to quantify • Health Care Fraud and Abuse Control Program

6. Take a Guess… How much do you think is lost to Medicare fraud and abuse each year?

7. Why Should We Care About Healthcare Fraud And Abuse? Each year, Medicare loses over $60 billion to fraud, abuse, and errors

8. Why Should We Care About Healthcare Fraud And Abuse? .

9. What Does Healthcare Fraud Look Like? Traditional Medicare Managed Care Capitated payment Incentive for fraud is to enroll beneficiaries into plans and keep capitated payments in-hand rather than spend on patient care. Underutilization of system • Fee-for-service • Incentive for fraud is to bill over and above what was actually provided to get higher reimbursement. • Over bill, up-code, send more supplies • Overutilization of system

10. What Fraud Looks Like: Traditional Medicare • Billing for services or supplies never received • Double-billing: Billing twice for the same service or item • Up-coding: Billing for services different than what was rendered • Sending more medical supplies than ordered or needed • Billing for a service using a deceased person’s Medicare number. • Scammers offering free services or products in exchange for a peek at Medicare number.

11. What Fraud Looks Like: Managed Care • Medicare marketing violations by managed care and Part D plans • Enrollment and disenrollment schemes • Denial of needed medical care • A long delay in providing a service; for example, waiting several months for approval for durable medical equipment • Much harder to identify

12. Case Examples • Patient complained of sore throat • Doctor confirmed and wrote prescription • Doctor billed for laryngoscopy! • Patient called office, they fixed the “error” • R&V Medical Supplies dropping off scooters to seniors in NE Philadelphia • Claimed they had been selected by City of Philadelphia and local AAA to receive scooter • Needed to verify Medicare number • One woman knew better, reported the company, and exposed a fraud ring.

13. Fraud in the News • Brotherly Love Ambulance, Inc. – Owner pleaded guilty for committing $2 million fraud scheme involving submitting false claims and paying kickbacks to patients. • Home Care Hospice – Owner charged with submitting $14.3 million in false claims for patients who were ineligible for hospice. • Dr. Joseph Kubacki– Temple University Opthamologist convicted and sentenced to 7 years in prison for falsifying patient charts and submitting $3 million in false claims.

14. Telephone Scams: Recent Reports from Pennsylvania • New Medicare card scam • Calling from Medicare or Social Security • Verify basic information • Request Medicare or bank account # • Use fear / make threats • $299 Prescription drug scam • Calling from drug company • Promise something too good to be true • Ask for bank account # • Diabetic supply scams • Is someone in the home diabetic? • Promises free supplies delivered to home • No prescription necessary

15. Protect w Detect w Report Prevent fraud by protecting personal information, knowing how to detect fraud, and knowing where and how to report suspected fraud, errors, and abuse

16. How Can Beneficiaries Protect Themselves? • Never give any personal information to unsolicited callers or people who show up at their door. • Remember that Medicare and Social Security will never try to sell a service or product. • Encourage beneficiaries to work directly with their doctor if they need medical supplies or equipment. Don’t accept equipment from people who call or show up at the door. • Do not carry Medicare card on SEPTA • Their Medicare # IS their Social Security # • Never sign blank insurance forms. • Be wary of high pressure sales tactics. Don’t enroll unless you’re sure.

17. How Can Beneficiaries Detect Fraud? • Keep a healthcare journal/calendar • Review & reconcile statements • Dates of services • Provider names • Services or supplies received • If they don’t receive statements, request them. • Track claims in real time: www.mymedicare.gov • If Medicare pays for something medically unnecessary now, it may not pay for something medically necessary in the future. • Be an informed consumer; ask questions.

18. What to do if Beneficiaries Suspect Fraud or Abuse? • Report it! • Call the provider, rule out error. • Call the Pennsylvania SMP: 1-800-356-3606 • We will work with them to resolve case or refer it to OIG. • Their call can help warn others via our ScamWire alerts 

19. So, How Do I Help My Clients? • Understanding how fraud and abuse directly affects the beneficiaries you assist. • Reinforcing the message of protect, detect, report. • Be on the lookout for red flags • Stockpiles of supplies • unsolicited visitors/callers • Encouraging clients to keep healthcare journals. • Helping to create an account on www.mymedicare.gov • Helping to review statements and bills to check for accuracy. • Knowing who to call for help, and calling for help. • Materials distribution – Scam Wire.

20. Contact Us 1-800-356-3606 • Program Manager • Rebecca Nurick –nurick@carie.org • Regional Volunteer Coordinators • Jennifer Carmody – carmody@carie.org • Southeast PA and Central PA/Capital Region • Vanessa Miller – miller@carie.org • Lehigh Valley and Northeast PA • Alisha Nash - nash@carie.org • Southwest PA and Northwest PA

21. Thank You Any Questions?