Arkansas SMP Empowering Seniors to Prevent Healthcare Fraud

1. Arkansas SMPEmpowering Seniors to Prevent Healthcare Fraud Sponsored by the Division of Aging and Adult Services Funded by grant No. 90AM2931 from the Administration on Aging

2. Arkansas SMP Mission Established in 1995 to: RECRUIT & TRAIN VOLUNTEERS • over 480,000 beneficiaries in Arkansas • over 44 million beneficiaries in the US EMPOWER SENIORS • Medicare/Medicaid beneficiaries • people with disabilities • nursing home residents & their families • caregivers to: PREVENT HEALTHCARE FRAUD • Protect– personal information • Detect - monitor health care costs, read Medicare Summary Notices (MSN) and E.O.B.’s, and become informed, concerned, & active consumers (itemized bills) • Report – 1st call plan provider if there are questions, then a local volunteer or the SMP Hotline: 1-866-726-2916

3. Healthcare Fraud What is it?

4. Fraud • Medicare fraud is intentionally billing Medicare for services you never got/provided. • A fraud scheme can be carried out by individuals, companies • o • r groups of individuals

5. TYPES of FRAUD(Intentional* misrepresentation) Provider Billing • Double billing Billing multiple times for the same service/same bene. • Phantom billing Billing for services that were not performed Billing for services that were not medically necessary • Up Coding Billing for more expensive Medicare covered service • Unbundling Billing related services separately at a higher cost • False cost reporting Billing old items like new, overcharging, unrelated costs • Falsification of records Changing records to support improper billing • Over utilization Unnecessary services, like blood tests, every visit *Intent is often hard to prove

6. TYPES of FRAUD(Intentional misrepresentation) Home Healthcare Fraud • Unnecessary Medical Services or supplies • Misrepresentation of medical professionals “We can help you… • Kickbacks >Fees to physicians for referrals >Disguising fees as salaries for services not rendered >Free services to benies for switching >Providing hospitals with discharge planners >Free services to retirement homes in exchange for referrals >Subcontracting with retirement homes to induce referrals

7. TYPES of FRAUD(Intentional misrepresentation) Durable Medical Equipment • Pay money or offer a “free” wheelchair or scooter if you give them your Medicare number • Forge a doctor’s signature or offer to pay doctors to write fake prescriptions • Steal Medicare papers out of your mailbox • Call and say your Medicare benefits will be cut off if you don’t give them your Medicare number • Charge Medicare for the most expensive chair but send you a cheaper one (or sometimes none at all) • Bill the same chair over and over

8. TYPES of FRAUD(Intentional misrepresentation) Deceptive Marketing Practices • Cold calling • Telephone soliciting • Misrepresenting or withholding information Will not affect Medicare (It’s a supplement) ”I’m from Medicare “Sure, your doctor accepts the plan…” • Pressure tactics; etc. You must decide TODAY! All I need is your Medicare number You need this coverage…

9. …watch for the companies or agents who: • Present themselves as “Medicare Approved” with offers that are too good to be true • try to sell you healthcare services you have not asked for • Use high pressure techniques • ask for your Medicare # or other personal information • “Cold call” or drop by without an appointment

10. Readyour MSN! Take a careful look at your MSN and ask yourself three questions… • Did I receive the product or service that Medicare paid for? • Did my doctor order it? • Was it relevant to what I was being treated for?

11. $ How bad is it? $ Would You Believe . . .

12. Overview of the Extent of Medicare Fraud • 2008 estimate: $40-$60 billion lost to fraud, error, and abuse last year…That’s ($109 - $164 million a day) • More than 1 billion annual total claims processed nationwide through Medicare • At least $1 out of every $10 of Medicare costs are attributed to fraud, waste and abuse; can vary dramatically from 10% to more than 30%, depending on location • Fraudulent claims skyrocketing out ofcontrol

13. Base Problem… Medicare fraud is not self-revealing: With credit cards: • Itemized statement • Customer pays with his/her funds • If there is a discrepancy, it is in the customer’s self-interest to protest the charge With Medicare: • the customer/patient never sees the bill before it is paid by the government • Only rarely will patient catch fraudulent charges on own statement after the fact

14. Public Opinion Does Not Help To make matters worse: • 2 in 3 Americans tolerate insurance fraud to varying degrees • 2 in 5 Americans want little or no punishment for insurance cheats; they blame the insurance industry because they “believe insurers are unfair.” • Fraud and waste not always perceived to personally affect patients or taxpayers So, what’s the answer?

15. “The only thing necessary for the triumph of evil is for good men to do nothing…” -- Edmund Burke, 1795--

16. Prevention Strategies: Change the Mindset …Recognize that… Prevention of Medicare fraud is significantly more cost effective than fighting it through law enforcement and criminal prosecution

17. Prevention Strategies: Change the Mindset Embrace new paradigm that massive abuse is NOT just the cost of doing business… we may need a realistic compromise

18. Prevention Strategies: Change the Mindset Prevent Medicare fraud together through partnerships and cooperation at multiple levels: • Physicians and other providers • Hospitals, clinics, pharmacies, and other agencies • Equipment, drug, and service suppliers • Patients, caregivers and their families All working together to Protect…Detect…Report

19. Arkansas SMP Call Toll-free 1-866-726-2916 for: • Training • Speakers • Materials • Reporting for suspected fraud/abuse • Volunteers to assist seniors • Web Site:www.arkansas.gov/dhhs/aging/asmp.html