• SMP: Senior Medicare Patrol – Medicare fraud prevention program

• 1997: Senator Tom Harkin had an idea…

• Today: nationwide program in 50 states, DC, & U.S. territories

• Peer education model: SMPs recruit and train senior volunteers to conduct outreach and education to their peers and caregivers about Medicare fraud prevention

SMP Program: Empowering Seniors to Prevent Health Care Fraud

• Mission: To empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education.

SMP Message

• Prevent fraud by protecting personal information, knowing how to detect fraud, and knowing where and how to report suspected fraud, errors, and abuse

Protect! Detect! Report!

SMP Program: Empowering Seniors to Prevent Healthcare Fraud

• Receive complaints of potential healthcare fraud, errors and abuse and either resolve or refer to OIG for investigation.

• ScamWire Alerts• Emerging scams throughout PA• Distribute to volunteers and partners• Home delivered meals initiative• Legislative outreach• To join listserv: carmody@carie.org

• Outreach and Education• Professional groups• Caregivers• Limited English Proficiency groups

SMP Program: Empowering Seniors to Prevent Healthcare Fraud

SMP Program since 1997:• 60,000 volunteers trained• Over 104,000 complaints handled• 3.5 million people educated• 94,000 group education sessions• 1.2 million 1-on-1 counseling

sessions • Over 1.9 million media airings • Over $106 million in savings

• Prevention hard to quantify• Health Care Fraud and Abuse Control

Program

Take a Guess…

How much do you think is lost to Medicare fraud and

abuse each year?

Why Should We Care About Healthcare Fraud And Abuse?

Each year, Medicare loses over

$60 billion to fraud, abuse, and errors

Why Should We Care About Healthcare Fraud And Abuse?

.

• Increased out of pocket costsBeneficiaries

• Money lost for caregiver support programsCaregivers

• Increased taxes Taxpayers

What Does Healthcare Fraud Look Like?

Traditional Medicare

Fee-for-service Incentive for fraud is

to bill over and above what was actually provided to get higher reimbursement.

Over bill, up-code, send more supplies

Overutilization of system

Managed Care

Capitated payment Incentive for fraud is

to enroll beneficiaries into plans and keep capitated payments in-hand rather than spend on patient care.

Underutilization of system

What Fraud Looks Like: Traditional Medicare

• Billing for a service using a deceased person’s Medicare number.

• Scammers offering free services or products in exchange for a peek at Medicare number.

• Billing for services or supplies never received

• Double-billing: Billing twice for the same service or item

• Up-coding: Billing for services different than what was rendered

• Sending more medical supplies than ordered or needed

What Fraud Looks Like: Managed Care

• Medicare marketing violations by managed care and Part D plans

• Enrollment and disenrollment schemes

• Denial of needed medical care

• A long delay in providing a service; for example, waiting several months for approval for durable medical equipment

• Much harder to identify

Case Examples• Patient complained of sore throat• Doctor confirmed and wrote

prescription• Doctor billed for laryngoscopy! • Patient called office, they fixed the

“error”• R&V Medical Supplies dropping off scooters to seniors in NE Philadelphia

• Claimed they had been selected by City of Philadelphia and local AAA to receive scooter

• Needed to verify Medicare number

• One woman knew better, reported the company, and exposed a fraud ring.

Fraud in the Newso Brotherly Love Ambulance, Inc. –

Owner pleaded guilty for committing $2 million fraud scheme involving submitting false claims and paying kickbacks to patients.

o Home Care Hospice – Owner charged with submitting $14.3 million in false claims for patients who were ineligible for hospice.

o Dr. Joseph Kubacki – Temple University Opthamologist convicted and sentenced to 7 years in prison for falsifying patient charts and submitting $3 million in false claims.

Telephone Scams: Recent Reports from Pennsylvania

• $299 Prescription drug scam• Calling from drug company• Promise something too good to be

true• Ask for bank account #

• Diabetic supply scams• Is someone in the home diabetic?• Promises free supplies delivered

to home• No prescription necessary

• New Medicare card scam• Calling from Medicare or Social Security• Verify basic information• Request Medicare or bank account #• Use fear / make threats

Protect w Detect w Report

Protect! Detect! Report!

Prevent fraud by protecting personal information, knowing

how to detect fraud, and knowing where and how to

report suspected fraud, errors, and abuse

How Can Beneficiaries Protect Themselves?

• Never give any personal information to unsolicited callers or people who show up at their door.

• Remember that Medicare and Social Security will never try to sell a service or product.

• Encourage beneficiaries to work directly with their doctor if they need medical supplies or equipment. Don’t accept equipment from people who call or show up at the door.

• Do not carry Medicare card on SEPTA

• Their Medicare # IS their Social Security #

• Never sign blank insurance forms.

• Be wary of high pressure sales tactics. Don’t enroll unless you’re sure.

How Can Beneficiaries Detect Fraud?

• Keep a healthcare journal/calendar

• Review & reconcile statements• Dates of services• Provider names• Services or supplies received

• If they don’t receive statements, request them.

• Track claims in real time: www.mymedicare.gov

• If Medicare pays for something medically unnecessary now, it may not pay for something medically necessary in the future.

• Be an informed consumer; ask questions.

What to do if Beneficiaries Suspect Fraud or Abuse?

• Report it!

• Call the provider, rule out error.

• Call the Pennsylvania SMP: 1-800-356-3606

• We will work with them to resolve case or refer it to OIG.

• Their call can help warn others via our ScamWire alerts

So, How Do I Help My Clients?

• Understanding how fraud and abuse directly affects the beneficiaries you assist.

• Reinforcing the message of protect, detect, report.

• Be on the lookout for red flags • Stockpiles of supplies• unsolicited visitors/callers

• Encouraging clients to keep healthcare journals.

• Helping to create an account on www.mymedicare.gov

• Helping to review statements and bills to check for accuracy.

• Knowing who to call for help, and calling for help.

• Materials distribution – Scam Wire.

Contact Us1-800-356-3606

• Program Manager Rebecca Nurick – nurick@carie.org

• Regional Volunteer Coordinators Jennifer Carmody – carmody@carie.org

o Southeast PA and Central PA/Capital Region

Vanessa Miller – miller@carie.org o Lehigh Valley and Northeast PA

Alisha Nash - nash@carie.org o Southwest PA and Northwest PA

Thank You

Any Questions?