1 medicare and skilled nursing facility care: protect yourself from fraud! updated august 2014
TRANSCRIPT
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Medicare and Skilled Nursing Facility Care: Protect Yourself
from Fraud!
Updated August 2014
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What We Will Cover Today
• The SMP Program
• Medicare and Skilled Nursing Facility (SNF) Care
• Skilled Nursing Facilities and Fraud
• Protect, Detect, Report!
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How much do you think is lost every year to health care fraud and abuse?
A) $5-10 million
B) $25-125 million
C) $10-20 billion
D) $75-250 billion
How Much is Lost?
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How much do you think is lost every year to health care fraud and abuse?
A) $5-10 million
B) $25-125 million
C) $10-20 billion
D) $75-250 billion
How Much is Lost?
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• Medicare & Medicaid Beneficiaries– Loss of benefits– Higher premiums– Identity theft
• Taxpayers– Medicare is paid for by taxes– Billions of taxpayer dollars wasted
Fraud affects:
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Why Report Fraud?• Health care fraud puts you at risk for
identity theft.• IT’S YOUR MONEY!
• Taxpayer dollars• Higher premiums
• Saving the Medicare Program• People who commit fraud are
STEALING from you, not helping you!
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Why Report Fraud?• 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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The SMP Programwww.illinoissmp.org
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The SMP Program
• Senior Medicare Patrol
• National Program – SMP Programs in all 50 states, Washington,
D.C., Puerto Rico, Guam, Virgin Islands
• Goals of program: – Recruit volunteers to provide outreach– Educate consumers about health care fraud
and abuse
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SMP Staff and Volunteers…• Give presentations to groups (like this one!)
• Share 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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Illinois SMP Program Partners
• Illinois Area Agencies on Aging
• Catholic Charities
• White Crane Wellness Center
• Coalition of Limited English Speaking Elderly
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Medicare & Skilled Nursing Facility (SNF) Care
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What is Skilled Nursing Care?
• Skilled Nursing Care is health care that “requires the involvement of skilled nursing or rehabilitative staff in order to be given safely and effectively”
(CMS Publication No. 10153)
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What is Skilled Nursing Care?
• Skilled nursing staff include: – registered nurses– licensed practical and vocational nurses– physical and occupational therapists– speech language pathologists – audiologists
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What is Skilled Nursing Care?
• Examples of care that may often be considered “skilled” care: – Intravenous injections– Physical therapy– Catheters– Wound care – Ostomy care
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When does Medicare cover Skilled Nursing Facility Care?
• Medicare covers skilled nursing facility care on a short-term basis (if you need skilled care) in order to:
–Help improve your condition
–Maintain your current condition and prevent it from getting worse
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When Does Medicare Cover Skilled Nursing Facility Care?
Medicare Part A covers Skilled Nursing Facility (SNF) care if you meet the following three requirements…
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When Does Medicare Cover Skilled Nursing Facility Care?
1) Your doctor certifies that you need skilled care that can only be provided in a SNF at least 5 days/week, and you get this care in a Medicare-certified SNF
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When Does Medicare Cover Skilled Nursing Facility Care? 2) You had a 3 day inpatient hospital
stay prior to entering the SNF (usually within 30 days).
– The day that you are admitted to the hospital counts
– The day you are discharged does not count
– Time spent in “observation status” does not count. (Ask the hospital if you have been admitted as an “inpatient” or if you are under “observation.”)
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When Does Medicare Cover Skilled Nursing Facility Care? 3) You have SNF days left in your
“benefit period”
Medicare covers up to 100 days of SNF care in a “benefit period.” A benefit period begins the 1st day you are in the hospital and ends when you have received no inpatient care (hospital or SNF) for at least 60 days.
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When Will Medicare NOT Cover Skilled Nursing Care?
• If someone only needs “custodial” care, and does not require “skilled” care, Medicare will not pay for a stay in a skilled nursing facility (SNF).
• “Custodial care” refers to non-medical care that provides assistance with activities of daily living, such as bathing, dressing, eating, etc.
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How Much Does Medicare Pay?
• Medicare will pay for the first 20 days of SNF care in a benefit period in full ($0 copayment).
•If you spent more than 20 days in a SNF, for days 21-100, there is a daily copayment. (In 2011, this copayment is $141.50/day.) Note: some Medicare supplement plans may cover this copayment.
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What Care Does Medicare Cover?• If you qualify for skilled nursing facility (SNF) care, Medicare will cover:
– A semi-private room and meals
– Skilled nursing care
– Physical therapy, occupational therapy, and/or speech-language pathology services
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What Care Does Medicare Cover?• If you qualify for skilled nursing facility (SNF) care, Medicare will cover:
– Medical social services
– Medications
– Medical equipment used while in the facility
– Some medically necessary ambulance transportation
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What if I have a Medicare Advantage Plan?
If you are on a Medicare Advantage plan, the way that your plan covers skilled nursing care may be slightly different. The plan may:
•Cover more days than Original Medicare or waive the 3 day hospital stay requirement
•Require you to use a Skilled Nursing Facility in the plan’s network
•Have a different copayment structure than Original Medicare
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Your Rights in a Skilled Nursing Facility (SNF) - Quality of Care
If you have a question or complaint about the care that you receive in a SNF, you can contact the Illinois Long Term Care Ombudsman program. To find an Ombudsman in your area, contact the Illinois Department on Aging Senior HelpLine at (800)252-8966.
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Your Rights in a Skilled Nursing Facility (SNF) - Quality of Care
The Medicare Quality Improvement Organization (QIO) also takes complaints about quality of care. To file a quality of care complaint with the QIO in Illinois, call IFMC-IL at (800)647-8089.
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Your Rights in a Skilled Nursing Facility (SNF) - Discharge
• If you have Original Medicare, before you are discharged, the SNF must give you a written notice stating: – The date your Medicare coverage will end– Why your stay is no longer going to be covered – The estimated cost of non-covered care if you
choose to stay in the SNF– Your right to request that the SNF submit a claim to
Medicare to obtain an official payment decision from Medicare (called a “demand bill”)
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Your Rights in a Skilled Nursing Facility (SNF) - Discharge
• If you disagree with the SNF’s decision to discharge you, you can request an appeal. To appeal a discharge, contact the Quality Improvement Organization (QIO). In Illinois, this organization is IFMC-IL: (800)647-8089.
• The QIO will respond to your appeal within one day of receiving it.
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Your Rights in a Skilled Nursing Facility (SNF) - Discharge
• If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital.
• If you do this, you will not have to pay for
the services you receive during the appeal (except for charges like copays and deductibles).
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Your Rights in a Skilled Nursing Facility (SNF) - Discharge
• If you do not appeal, but decide to stay in the hospital past your planned discharge date, you may have to pay for any services you receive after that date.
• If you have private insurance or Medicaid, your other insurance may cover your stay even after your Medicare coverage stops.
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Skilled Nursing Facilities
(SNF’s) and Fraud
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SNF’s and Fraud – What is Fraud?
• Billing for services that you never received
• Billing for services that are different than what you received
• Billing for unnecessary services
• Billing for more or more advanced services than you need (“upcoding”)
• “Kickback” arrangements (payments or other inducements for patient referrals)
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SNF’s and Fraud: Physical TherapyA skilled nursing facility provides physical therapy to 10 residents in a group for one hour (all at one time). However, when the facility bills Medicare, they bill as if they provided each of those 10 individuals with 1 hour of individual therapy.
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SNF’s and Fraud: Physical Therapy
• Problems:
– Billing for a different type of service than what was provided (individual therapy instead of group therapy)
– Billing for more hours of therapy than what was actually provided
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SNF’s and Fraud: Mental Health
A skilled nursing facility provides BINGO games for residents on Thursday afternoons. Without the residents’ knowledge, the facility bills Medicare for mental health therapy during these BINGO sessions.
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SNF’s and Fraud: Mental Health
• Problems:– Billing for a service that was never
provided (BINGO does NOT count as mental health therapy!)
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SNF’s and Fraud: Kickbacks• A skilled nursing facility receives “referral
payments” from a local hospice agency in exchange for referring many of their residents to receive services from that hospice agency.
• At another skilled nursing facility, a local home health agency provides the facility with discharge planners in exchange for patient referrals.
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SNF Fraud Schemes: Kickbacks
• Problems:– The federal Anti-Kickback Statute makes
it illegal for health care providers to give or accept any form of payment in exchange for patient referrals. “Payment” includes money, items, or services.
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SNF’s and Fraud: “Upcoding”
• A skilled nursing facility orders their staff to enroll patients into physical therapy when the patients do not need (and do not qualify for) physical therapy.
• Another skilled nursing facility falsifies documentation to make it look like patients need more therapy services than the patients actually need.
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SNF’s and Fraud: “Upcoding”• Problems:
– The SNF is providing unnecessary/ inappropriate services in order to receive higher payments from Medicare than they should receive.
– If someone’s services are “upcoded” now, that person may not be able to get that care later when they need it.
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Protect!Detect!Report!
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PROTECT Yourself From Fraud!
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PROTECT Yourself From Fraud!
• If you need skilled nursing care, contact your doctor. Your doctor must certify you to receive skilled nursing care.
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PROTECT Yourself From Fraud!
• Choose a skilled nursing facility carefully.
• You can find quality information about skilled nursing facilities on www.medicare.gov under “Nursing Home Compare.”
• Visit the SNF and ask questions using Medicare’s SNF checklist.
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PROTECT Yourself From Fraud!
• Do NOT sign any forms or paperwork without reading them first. Never sign blank forms.
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PROTECT Yourself From Fraud!
• Ask questions if you do not understand the care you are receiving.
• Do not accept ‘extra’ services that you do not need - Medicare may be billed fraudulently for those unnecessary services.
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DETECT Fraud!
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DETECT Fraud!
• Ask the SNF for an itemized statement of all of the services you receive while in the SNF.
• Check that statement for errors, such as services you did not receive, or services that are different than what you received.
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DETECT Fraud!• Read your Medicare Summary Notice
or Explanation of Benefits from your insurance company. Watch for:– Services or supplies that you did not get– Services or supplies that were not ordered by
your doctor– Billing for the same thing twice– Other billing errors
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REPORT Fraud!
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REPORT Fraud!• If you have questions about services that
you did receive, contact the SNF first and ask for an explanation.
• If this does not work or you suspect fraud (for example, you see a claim on your Medicare Summary Notice for a service that you never received), call the Illinois SMP program at:
(800)699-9043
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Volunteers are the key to spreading the SMP message!
We need YOUR help!
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Thank you!
If you have questions, contact:
AgeOptions
(800)699-9043
This presentation was supported in part by a grant (No. 90MP0163 and 90SP0061) from the Administration on Aging
(AoA), Administration for Community Living (ACL), U.S. Department of Health and Human Services (DHHS). Grantees carrying out projects under government
sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions do not
necessarily represent official AoA, ACL, or DHHS policy.