1

Medicare and Home Health Services: Protect Yourself from

Fraud!

Updated August 2014

2

What We Will Cover Today

• The SMP Program

• Home Health and Medicare

• Home Health and Fraud

• Protect, Detect, Report!

3

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?

4

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?

5

• Medicare & Medicaid Beneficiaries– loss of benefits– higher premiums– identity theft

• Taxpayers– Medicare is paid for by taxes– Billions of taxpayer dollars wasted

Fraud affects:

6

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!

7

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”

8

The SMP Programwww.illinoissmp.org

9

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

10

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

11

Illinois SMP Program Partners

• Illinois Area Agencies on Aging

• Catholic Charities

• White Crane Wellness Center

• Coalition of Limited English Speaking Elderly

12

Home Health & Medicare

13

Home Health & Medicare

To receive Medicare-covered home health services, a person must:

1) Be “homebound” AND

2) Need:• Physical therapy• Occupational therapy• Speech therapy OR• Skilled nursing care

14

What Does “Homebound” Mean?

• “Homebound” means it is very hard to leave the house.

• The person can still go to religious services, doctors, and adult day programs

• For example, someone who is “homebound” would not be able to drive himself to the grocery store

15

What Home Health Services Does Medicare Cover?

• Physical Therapy• Speech-language Pathology• Occupational Therapy• Skilled Nursing• Medical Social Services• Home Health Aide (ONLY if receiving other services)• Certain medical supplies• Durable medical equipment covered separately, with

a 20% coinsurance

16

Physical Therapy

• Exercises to improve movement and strength

• Training on how to use special equipment or do certain activities

17

Speech-Language Pathology

• Therapy for speech, swallowing, reading, listening, and memory

18

Occupational Therapy

• Help learning to perform daily activities (eating, dressing, etc.)

19

Skilled Nursing Care

• Services that a nurse needs to help with wound care, changing an IV or a catheter, etc.

20

Medical Social Services

• Services to help with social and emotional concerns related to your illness (counseling, finding resources, etc.)

21

Home Health Aide• IF you are receiving physical therapy,

speech therapy, occupational therapy, or skilled nursing care, Medicare will also cover services to help you with personal care, such as bathing, using the toilet, or dressing

• Medicare will NOT cover home health aide services if they are the only services you receive

22

Supplies/Equipment•Medicare will cover certain medical

supplies as part of your home care, like bandages that are used for your nursing care

•Medicare will pay for other durable medical equipment that you need separately (oxygen, wheelchairs, etc.) 20% coinsurance

23

What if Medicare Will NOT Cover Services?

If a home health agency thinks that Medicare will NOT cover a service they are going to give you, they MUST ask you to sign an “Advance Beneficiary Notice” stating that you will pay for the services if Medicare doesn’t. If they do not do this, they cannot charge you!

24

How Should I Get Home Health Care if I Need It?

• Talk to your doctor! Your doctor should order any care or supplies that you need.

• A Medicare-certified home health agency will visit you and do an assessment. Then, they will write a “Plan of Care.”

25

What is a “Plan of Care?”

• The “Plan of Care” is a document that states what services the home health agency will provide to you and why you need those services

• Your doctor should receive and review a copy of your Plan of Care, and you should ask for a copy, too!

26

Home Health & Fraud• Charging Medicare for services that you

did not get

• Charging for something DIFFERENT than what you received

• Charging for services you don’t need or that were not approved by your doctor

27

Home Health & Fraud• Charging for more services than you need

• Charging for services to people who do not qualify for Medicare-covered home health (people who are not homebound and/or do not need skilled nursing or therapy)

28

Home Health Fraud in Illinois

• Agencies visiting senior buildings and providing presentations, games, exercise classes, health screenings, etc. and asking for Medicare numbers

• Billing Medicare as if they provided the participants with home health services

29

Home Health Fraud in Illinois

• Agencies providing basic or preventative care services, then bill Medicare as if they provided home health care

– blood pressure, glucose testing, “If you do not want to visit your doctor, we can come to you!”)

30

Home Health Fraud in Illinois

• Agencies sending pre-filled forms to doctors so that the doctor can ‘sign off’ on home health services

• Your doctor should order home health services, then contact a company – not the other way around!

31

Home Health Fraud in Illinois - Example

• A home health agency in Chicago provided “free massages” for residents of a senior building. They billed Medicare for skilled nursing services.

32

Home Health Fraud in Illinois - Example

• A Springfield home health agency performed door-to-door blood pressure checks. They told one woman that her doctor asked them to come. They told another woman they were helping “to keep her out of a nursing home.” In each case, they billed Medicare for home health services.

33

Protect!Detect!Report!

34

PROTECT Yourself From Fraud!

35

PROTECT Yourself From Fraud!

• Do NOT give your Medicare number to people you do not know!– On the phone– At the door– At a presentation, exercise class,

screening, etc FREE services do NOT require your Medicare number!

36

PROTECT Yourself From Fraud!

• Do NOT accept services from someone who calls or visits you unexpectedly, even if they say that your doctor sent them!

37

PROTECT Yourself From Fraud!

• Do NOT “sign up” for services at a presentation or event.

If you think you may need home health services, talk to your doctor FIRST. Let your doctor help you find a provider.

38

PROTECT Yourself From Fraud!

• If you are being assessed for home health services, ask for a copy of your Plan of Care.

• Do NOT sign timesheets or other forms without reading them.

• Do NOT sign blank forms!

39

DETECT Fraud!

40

DETECT Fraud!• Ask for an itemized list of the services that

you have received. Check the list for errors.

• Read your Medicare Summary Notice or Explanation of Benefits from your insurance company. Watch for:– Services that you did not get– Services that were not ordered by your doctor– Billing for the same thing twice– Other billing errors

41

REPORT Fraud!

42

REPORT Fraud!• If you have questions about services that

you did receive, contact your doctor or the home health agency first.

• If this doesn’t 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

43

Volunteers are the key to spreading the SMP message!

We need YOUR help!

44

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.