The Missouri SMPEmpowering Seniors to Prevent Healthcare Fraud

Department of Health and Human Services

Administration on Aging

SMP’s

Goals of The Missouri SMP

Train SMP Specialists

Educate and counsel older adults, their families and the community on Medicare/Medicaid fraud and abuse

SMP Specialists

Volunteers

2 day training

Provide education, advocacy, and counselling to individuals, their families and the general public

Services Provided by SMP’s - Free of Charge

Screening for possible fraud and abuse of the Medicare/Medicaid programs

Billing assistance and appeals process

Explanation of coverage

Policy Comparisons

Senior Fraud Coalition

Missouri Attorney General’s Office – Consumer Fraud, Elder Abuse and Neglect, Identity Theft, Medicaid Fraud

Partnership

Missouri Alliance of Area Agencies on Aging – Regional

Coordinators– SMP Specialists

Most recent-$60 billion lost annually

($6.8 million/hr)

Estimate of Loss to Fraud and Abuse

Effects of Fraud to Beneficiaries

Diminishes the quality of treatment beneficiaries may receive.

Effects of Fraud to Caregivers

Decreases funding available for important programs

Difficult for honest providers to compete with dishonest providers

Effects of Fraud to Taxpayers

Raises taxes

Raises health insurance premiums

Raises health insurance deductibles

Raises administrative costs

Violators Can Include

•Organized crime

•A doctor or provider

•Durable medical equipment suppliers

•Medicare beneficiaries

•Any individual or business

•Insurance Companies

Fraud

Fraud occurs when an individual or organization deliberately deceives others in order to gain some sort of unauthorized benefit.

Abuse

Abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards.

Abuse Can Lead to Fraud

When a provider continues to abuse regulations after warnings, it can become fraud.

Gang Visits

A provider visits a nursing home, briefly walks through the facility without rendering any definable service to individual patients, but bills Medicare for 20 nursing home visits.

Diagnosis Fixing

This happens when a doctor states that a patient has an illness or condition that he does not have in order to receive payment from Medicare or Medicaid.

Music Therapy

Some music therapy is legitimate although Medicare rarely pays for it.

Playing a boom box in the dining hall of a facility and billing Medicare for individual music therapy sessions is not legitimate.

Non-Provided Services

Most common complaint

A physician pled guilty to charges of Medicare fraud related to submitting false claims for house calls. Claims were submitted for persons who had died before the date of claimed services, persons living in other states, persons who were incarcerated, etc.

Altered Claim Forms

When orders came in to a DME (Durable Medical Equipment) company and the orders were shipped out, the owner would add items to the invoices before billing.

Duplicate Billings

Simply billing twice

for the same service

Kickbacks or Bribes

For example:

Paying a fee to a physician for each patient care plan certified by the physician on behalf of the home health agency.

Use of Another Person’s Card

Some beneficiaries will loan their card to an uninsured person to use or sell the use of the number.

Upcoding

This is a statement that the service provided was more complicated than it really was.

Unnecessary Services

Medicare will only pay if the services are actually needed. For example: Home health services are only needed if the patient is homebound.

Unbundling

Billing for a service in parts than as a whole, such as billing for a wheelchair as though you are ordering parts rather than for the wheelchair.

How Do We Make a Difference?

Be a Smart Consumer

Avoid offers of “free medical tests in exchange for a peek at your Medicare card”.

Remember that Medicare does not offer “free services” nor does it employ “Medicare Salespeople” or “doctors who make house-calls”.

Beware of advertising that promises Medicare will pay for certain care or devices.

Smart Consumer Tips

Always use your Medicare card whenever you receive care and/or supplies.

Do not give out your Social Security or Medicare number

over the phone to anyone.

Review your Explanation of Benefits or Medicare Summary Notice. Look at the type and the number of services provided. Also, review the dates of services billed.

Always count your medication to make sure you received the amount prescribed.

Ask Questions If...

You do not understand the charges.

You did not receive the service billed.

You feel that Medicare has paid the provider for more services than you received.

You feel that Medicare has paid the provider for services that were not needed.

Who Can I Contact?

The Missouri SMP

660-747-5447

1-888-515-6565, Toll-free

This document was supported, in part, by grant number 90-MP-0060 from the Administration on Aging, Department of Health & Human Services. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings & conclusions. Points of view or opinions do not therefore necessarily represent official Administration on Aging policy.