medicare telephone fraud scheme national compliance, ethics & integrity office (nco), national...
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Medicare Telephone Fraud Scheme
National Compliance, Ethics & Integrity Office (NCO), National Special Investigations Unit (NSIU)Investigations and Compliance Manager Rick Germroth
Agenda
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Brief Introduction to Kaiser Permanente (KP)
Telemarketing Fraud Definition/Victim Statistics
Investigative Steps and Case Studies
Internal Fraud Alert
Return Session to Facilitator for General Discussion
Founded in 1945, Kaiser Permanente is one of the nation’s largest not-for-profit health plans, serving more than 9 million members.
Membership as of Dec 31, 2012
Kaiser Permanente by the NumbersTotal membership 8.9 million
Hospitals 37Medical offices 611
Physicians Approximate - representing all specialties.
17,157
Employees Approximate - representing technical, administrative, clerical employees and caregivers (includes 45,270 nurses).
175,668
Doctor office visits (annually) >37 millionPrescriptions filled (annually) 135 millionNumber of outpatient pharmacies 400
Data as of Dec 31, 2012
2012-$50.6B; 2011-$47.9B; 2010-$44.2B; 2009-$42.1B; 2008-$40.3B
National Compliance, Ethics & Integrity Office
NSIU and Hotline Operations Org Chart
Rick GermrothInvestigations Manager
Colorado, Georgia, Ohio, Mid-Atlantic States
Sr. Medical Investigator
Senior Investigator
Senior Investigator (Sacramento)
Senior Investigator
Senior Investigator
Senior Investigator
Senior Investigator
Investigations Manager
SCAL, Northwest NCAL, Hawaii, Program Office
National Director of Fraud Control & NSIU
NSIU Compliance Consultant
Senior Manager Compliance Hotline
Operations
NSIU Director
Senior Investigator Senior Investigator
Senior Investigator
Compliance Consultants
Compliance Consultants
Manager Compliance Hotline
Training & Policy Administration
Administrative Specialist
Investigations Manager
NSIU Investigative Focus Areas
Pharmacy Theft/Drug Diversion Embezzlement Member Fraud Identity Theft Cash/Check Fraud Health Care Claims Fraud Vendor Fraud Kickbacks Privacy/Computer Fraud Support Major Crime Investigations
Telemarketing Fraud Definitions
Federal Bureau of Investigation (FBI) – Telemarking fraud refers to money sent or personal/financial information released to an unsolicited/unknown caller. Tips to avoid becoming a victim are on the FBI’s website.
Cornell Law – Telemarketing fraud refers to any type of scheme in which a criminal communicates with the potential victim via the telephone.
IT Law Wiki – Telemarketing fraud refers to any scheme to defraud in which the person(s) carrying out the scheme use(s) the telephone as the primary means of communication with the intent to persuade prospective victims to send money to the scheme.
Statistics
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medicare Beneficiaries.
165 Kaiser Permanente Medicare members enterprise-wide who
have been identified as victims to the unsolicited telephone calls.
Multiple Kaiser Permanente service areas impacted.
Victim Information
Kaiser Permanente Service Areas Impacted
| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Northern California
Southern California
OhioOregon
Colorado
Virginia
Maryland
MEDIC Referrals from Kaiser Permanente
2011 MEDIC Reports Submitted 27 (not separated by allegation
type)
2012 MEDIC Reports Submitted 124– 96 phone scam reports related to Senior Advantage members.
– 28 reports relating to other matters (family/care giver diversion, members selling their drugs, employee diversion).
2013 (to date) MEDIC Reports Submitted 86– 69 phone scam reports related to Senior Advantage members.
– 17 reports relating to other matters (family/care giver diversion, members selling their drugs, employee diversion).
Investigative Steps Contact member to obtain details of the incident.
– Determine the Who, What, When, Where, Why & How factors. – Determine whether personal information, financial and/or health, has been given
out.– If financial information has been released, advise the member to take action to
protect finances, i.e. contact the bank immediately.– Collect details concerning the caller
» Does member have caller identification?» Identifiable voice pattern?» Any hint as to where the caller is calling from?
Verify member’s health plan. Pursue leads developed from conversation with member. Make appropriate notifications.
Internal. MEDIC. Law enforcement.
Chapter 9 – Fraud ReportingCMS Prescription Drug Benefit Manual
Section 50.2.6.4• Plan sponsors are required to cooperate with the MEDICs relating to
any request for information or complaint investigation.• Responses are required within 30 days from the date of request.
Section 50.2.8.2• Recommendation to notify the MEDIC of potential FWA and the
MEDIC will refer to law enforcement as necessary.• If the plan sponsor should determine through an investigation that
FWA has occurred, he or she should refer to the MEDIC within 60 days of the activity being identified.
Common Observations/Threads
Caller has the member’s address and goes over what he or she has with the victim.
Caller offers to send the member a new coverage card offering extra plan benefits.
Caller says he or she is from Kaiser Permanente or the member assumes the caller is a Kaiser Permanente representative.
Caller is seeking bank information.– “Where do you send your Social Security check to?”
– “Let me verify your bank routing number.” (The first numbers in the bank routing sequence can be obtained from the internet). Caller reads the first numbers and then asks the member to finish out the numeric sequence.
Common Observations/Threads (continued)
Caller becomes more aggressive if the member is reluctant to release information.
– “If you don’t give me the information I need, then you won’t get a new card!”
Caller routes the member to his or her “supervisor” if financial information is given out and the “supervisor” confirms the information.
Caller routes the member to his or her “supervisor” if no information is given and the “supervisor” starts the pitch all over again
Caller rarely ever discusses the prescription benefit plan. Caller calls from an unidentifiable number or number is blocked. Caller calls from a “call center.”
Common Observations/Threads (continued) Fewer than 10% of members actually release financial information or
person health information. If the member did release sensitive information, he or she generally
realizes something is wrong and typically takes action to notify the bank of potential compromise of account information.
One victim reported seeing (866) 468-9419 on the caller ID.
– Our investigator called that number which was answered by Your Services Medical (YSM) located in Atlanta, GA.
– When asked about the call received, the investigator was told the calling activity was outsourced to a company located in the Philippines.
– Social analytics data mining was initiated by our investigator to determine whether there were links between our victim members with none found.
Actual MEDIC Referral (1) - Complaint Details A Senior Advantage member reported receiving a telephone call
around 4:30pm on 5/11/2012, from an unidentified individual claiming to be with Kaiser Permanente.
The caller told her that in return for her bank checking account and routing numbers, she would receive a new identification card.
The member ended the call once the caller asked for her bank account information and no financial information was provided to the caller.
On 5/14/2012, the member was contacted by a representative from Kaiser Permanente’s Colorado Regional Compliance Office (RCO).
Colorado RCO was advised that the individual who called her was male and spoke with a heavy accent, possibly Hispanic.
He did not provide a name, address or phone number and she has not been contacted since the initial event.
Actual MEDIC Referral (2) - Complaint Details On June 11, 2013, a Kaiser Permanente Medicare Cost Plus
(KPMCP) member in our Ohio region reported she received a suspicious telephone from an unidentified caller who said he was going to send her a new ID card from Kaiser Permanente.
– The unidentified caller subsequently asked her for the name of her bank.
– The member’s caller ID read “PROMTN MTR WCA (786) 358-6691. The number is out of Miami, but the investigator was unable to
contact anyone at that number. A Google search of the number revealed multiple sites with
over three dozen victims from across the United States reporting that they had received similar telephone calls.
| © Kaiser Permanente 2010-2011. All Rights Reserved.
Actual MEDIC Referral (2) - Complaint Details (continued)
The investigator contacted the member who stated the unidentified male caller had a foreign accent and asked for her by first and last name.
The caller did not disclose his name or the name of the company he was representing.
He asked her for the name of her bank, “To verify if you are the right person,” he said.
He did not mention her Medicare prescription drug plan. The member hung up on the caller.
| © Kaiser Permanente 2010-2011. All Rights Reserved.
Actual MEDIC Referral (3) - Complaint Details On May 10, 2013, a Kaiser Permanente Senior Advantage (KPSA)
member in California reported receiving a phone call from an unidentified male caller who stated he was calling from Kaiser Permanente.
The unidentified male caller had an East Indian accent and asked for the numbers on the bottom of the member’s check because the caller “Needed to confirm certain things,” he said.
The member was told he would receive a new Kaiser Permanente medical card.
The caller then told the member he had won $500,000 dollars and had to pay $440.00 in prize taxes.
As a final attempt, the caller told the member he wanted to sell medical insurance to the member’s wife.
The member did not release any financial or personal information to the caller. | © Kaiser Permanente 2010-2011. All Rights Reserved.
FRAUD ALERT DETAILS ON SOURCE
Date Sent: 05/30/2012 Position/Region:
Regional or Medical Center Compliance Office in coordination with the NCO National Special Investigations Unit
Sender Name: Barbara E. Naimark, Director, NSIU & FWA Training Source: Member Services Call Center
FRAUD CONTROL ALERT DETAILS
The Kaiser Permanente (KP) National Special Investigations Unit (NSIU) has learned of a potential telephone fraud scheme targeting KP Medicare members. KP Medicare members have reported to KP Membership Services that they have received unsolicited telephone calls from an unknown telephone number at all hours of the day and night. The following information is what is known to the NSIU as of the date of this fraud alert:
Unidentified callers are males and females with either East Indian, Asian, or Spanish accents.
Unidentified callers are using blocked numbers and may be calling from a call center somewhere.
Unidentified callers may claim to be calling from “Kaiser.”
KP Medicare members are being told they’ll receive a new “Senior Advantage card” or new “Membership card.”
Unidentified callers know the Medicare member’s home address and will verbally confirm with the member that their address is correct for shipment of the new card.
Unidentified callers will verbally provide the member with a nine-digit number claiming to be the member’s bank routing number and will ask the member to confirm that this is their correct bank routing number. NOTE: At this point the caller is phishing for information from the member and attempting to have the member verbally disclose his/her actual bank routing number and checking account number over the telephone.
This Medicare fraud telephone scam has targeted KP Medicare members in the KP’s Northern California, Southern California, and Colorado regions as of the date of this fraud alert.
Assessment: Risks include:
Kaiser Permanente or other health care professionals could be billed for inappropriate supplies or services.
Members and patients can become victims of identity theft and bank fraud. If personal health information is provided to an unauthorized entity, it could be a violation of the
Health Insurance Portability and Accountability Act (HIPAA). Recommendations:
Alert appropriate departments, managers, physicians, and employees. If a KP Membership Services Representative (MSR) receives a complaint matching this
information, please have the MSR advise the member that both KP and the Centers for Medicare and Medicaid Services (CMS) are both aware of telephone fraud scams of this nature. It is recommended that the MSR refer the member to the CMS Stop Medicare Fraud website address, http://www.stopmedicarefraud.gov/, which contains information about ways Medicare beneficiaries can help prevent Medicare fraud and protect their personal information.
NEXT STEPS Contact Information
If you have questions or need assistance — Contact your local compliance officer. To report suspected cases of this type of fraud — Contact either your local or regional compliance
officers or Barbara Naimark,E-mail [email protected] Office (626)381-5809 Tie 8-331-5809 Mobile (626)484-2581.
Communications Guidance Distribution — For internal distribution only / Not for external distribution. Employees and physicians — Can forward by e-mail and inform in person. Posting — Can be posted in employee-only areas, such as break and supply rooms and not in
cafeterias or hallways where members or the public might see them. Newsletters and U.S. mail — Do not post in internal newsletters or through U.S. Mail. Member Services — Notify local or regional compliance if member complaints are received.
I
Statement of Issue/Investigative FindingsThe KP NSIU has learned of a potential telephone fraud scheme targeting KP Medicare members. KP Medicare members have reported to KP Membership Services that they have received unsolicited telephone calls from an unknown telephone number at all hours of the day and night. The following information is what is known to the NSIU as of the date of this fraud alert:
Common Observations Listed in the Fraud AlertUnidentified callers are males and females with either East Indian, Asian, or Spanish accents.Unidentified callers are use blocked numbers and call from a call center.Unidentified callers claim to be calling from KP.KP Medicare members are being told they’ll receive a new Senior Advantage card or new membership card.
Common Observations Listed in the Fraud Alert (continued)
Unidentified callers know the Medicare member’s home address and will verbally confirm with the member that their address is correct for shipment of the new card.
Unidentified callers will provide the member with a nine-digit number claiming to be the member’s bank routing number and will ask the member to confirm that this is their correct bank routing number. NOTE: At this point the caller is phishing for information from the member and attempting to have the member disclose his or her actual bank routing and/or checking account number.
This Medicare fraud telephone scam has targeted KP Medicare members in the KP Northern California, Southern California, Mid-Atlantic and Colorado regions as of the date of this fraud alert.
Assessment: Risks
Kaiser Permanente or other health care professionals could be billed for inappropriate supplies or services.
Members and patients can become victims of identity theft and bank fraud.
If personal health information is provided to an unauthorized entity, it could be a violation of the Health Insurance Portability and Accountability Act (HIPAA).
Recommendations
Alert appropriate departments, managers, physicians, and employees.
When a KP Membership Services representative receive a complaint matching this information, the representative should advise the member that both KP and the Centers for Medicare and Medicaid Services (CMS) are aware of telephone fraud scams of this nature.
The representative should refer the member to the CMS Stop Medicare Fraud website address, http://www.stopmedicarefraud.gov/, which contains information about ways Medicare beneficiaries can help prevent Medicare fraud and protect their personal information.
