Medicare Fraud and Abuse

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Medicare Fraud and Abuse

• Adele Culpepper
• Medicare Fraud Information Specialist

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TrailBlazer Jurisdiction Map
Medicare Part A Fiscal Intermediary
Medicare Part A Regional ESRD Fiscal Intermediary
Medicare Part B Carrier
Medicare Part A Rural Health Clinic Fiscal
Intermediary
PART A FI--TX,CO,NM PART A REG ESRD
FI--TX,CO NM,AR,LA,OK PART A RURAL HEALTH CLINIC
FI-- TX,NM,CO,AR,LA,OK,ND,MT,ND,SD, UT,WY PART B
CARRIER-TX,DE,MD,VA,DC ALSO THE CARRIER/FI FOR
INDIAN HEALTH SERVICE NATIONALLY
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Purpose of Presentation

• To provide information on the Medicare Integrity
  Program
• what it is,
• how it works,
• how it affects you

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Program Integrity Goals

• PAY IT RIGHT
• Pay the right amount
• To the right provider
• For the right service
• For the right beneficiary

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Program Integrity Goals

• EMPHASIS ON PREVENTION
• Make accurate payments when claims are first
  submitted
• Work with our partners - providers,
  beneficiaries, contractors, other Federal State
  agencies
• Protect strengthen the MedicareTrust Fund

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Medicare Integrity Program

• Saved the Medicare Program more than 16 for
  each dollar spent in 2000

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Medicare AdministrationFiscal Year 2000

• Payments of 220 billion
• 40 million persons with Medicare
• 1 billion claims
• 1million health care providers

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Benefits Integrity Units

• Respond to beneficiary complaints of fraud
• Develop cases for referral to law enforcement
• Support law enforcement

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Medicare Basics

• Medicare is a federal healthinsurance program
• Medicare is the nations largest health payer
• Coverage for Medicare began onJuly 1, 1966
• Medicare is Title 18 of the SocialSecurity Act

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Medicare Basics

• Benefits Under Medicare
• Part A
• Part B

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Administrative Structure
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Part A Benefits

• In-patient hospital stays
• Skilled Nursing Facility
• Home Health Care
• Hospice Care

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Part B Benefits

• Physician Services
• Out-patient Hospital Services
• Ambulatory Surgical Centers
• Ambulance

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Non-Covered Part A Services

• Convenience Items
• Private Duty Nurses
• Private Room
• Custodial Care
• Housekeeping Services

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Non-Covered Part B Services

• First Three Pints of Blood
• Routine Physical Exams
• Cosmetic Surgery
• Non-Ambulance Transportation
• Hearing Aids and Testing
• Prescription Drugs and Biologicals

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What Is Fraud?

• Fraud is the intentional deception or
  misrepresentation which an individual knows to be
  false or does not believe to be true and makes
  knowing the deception could result in some
  unauthorized benefit to himself \ herself or some
  other person.

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Examples of Fraud

• Billing for services or suppliesnot provided
• Altering claim forms
• Kickbacks, bribes, rebates
• Using another persons Medicare card
• Suppliers completing a CMNfor the physician

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Possible Outcomes of Fraud

• Referral to the OIG
• Administrative sanctions
• Civil money penalties
• settlement agreement
• pay 3X the amount of damages
• Exclusion from the Medicare program

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OIG Cannot Accept The Case

• Refund for the overpaid claims
• OIG may still exclude the provider
• Review claims before payment
• Education \ warnings

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Situations ThatMay Not Be Fraud

• Beneficiary did not receive the service
• Billing or processing error
• Service rendered by physicians employee

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Situations ThatMay Not Be Fraud
Hospital In-patient Bill

• High or duplicate charges
• Billing or charging error

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What Is Abuse?

• Abuse is the incident or practice of providers
  that are inconsistent with accepted sound
  medical, business or fiscal practices. These
  practices may directly or indirectly result in
  unnecessary costs to the Medicare program.

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Examples of Abuse

• Excessive charges for services or supplies
• Claims for services notmedically necessary
• Submitting bills when Medicareis secondary

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Possible Outcomes Of Abuse

• Recoup amount overpaid
• require refunds
• payment withheld from future claims
• suspend payments \ Medicare holds checks
• Education and \ or warnings
• Referral to the Medical Review Unit
• Prepayment review of certain practices
• Postpay audit or review of claims

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Referral To OIG

• Possible sanctions or exclusion from the Medicare
  program
• Possible Civil Money Penalties
• Criminal Penalties
• incarceration, fines/ restitution,
• asset seizure, loss of license

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Fraud and Abuse Schemes Ambulance

• Billing for ALS services whenBLS was provided
• Transports for ambulatory patients
• Billing for excessive mileage
• Falsification of documentation

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Fraud And Abuse Schemes Clinical Laboratory

• Tests not ordered by the physician
• Unbundled a panel of laboratorytests to
  receive higher reimbursement
• Rolling Labs offering freediagnostic tests

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Fraud and Abuse Schemes DME

• Adult diapers billed as Urinary Collection
  Devices
• Nebulizer drugs supplied in inappropriate
  quantities or notprovided at all
• Supplies ordered that are notmedically necessary

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Fraud and Abuse Schemes DME

• Oxygen concentrators provided that were not
  medically necessary
• DME companies provided hospitals with discharge
  planners
• Suppliers in arrangementwith an IDTF falsifies
  tests to certify apatients need for a supply

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Fraud and Abuse SchemesHHAs and Hospice

• Services for patients who arenot homebound
• Billing for more visits than provided
• Housekeeping or custodial services billed as a
  skilled nursing service
• Unfair marketing practices

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Fraud and Abuse SchemesHHAs and Hospice

• Kickbacks, bribes, rebates
• Patients who do not meet eligibility requirements
  for hospice
• Billing both Medicare and Medicaid to receive
  duplicate payments
• Home Health Aides providedto patients in
  assisted livingfacilities

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Fraud and Abuse SchemesHHAs and Hospice

• Registered nurses provide care to relatives and
  then bill it ashome health care

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Fraud and Abuse SchemesHHAs and Hospice

• Some home health agencies have ties with DME
  companies. Because of these financial
  relationships, the HHA personnel have ordered
  large numbers of supplies that the patient does
  not need.

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Fraud and Abuse SchemesHospital

• Billing multiple view x-rays when only one view
  was taken
• Misrepresentation of discharge date in order to
  obtain in-patient and out-patient reimbursement
• Misrepresentation of the patients diagnosis to
  change theDRG category

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Fraud and Abuse SchemesHospital

• Patients held in observation status for three to
  four days rather than being admitted as a
  hospital in-patient
• Ineligible items such as trips, club membership,
  dinner and drinks have been billed to Medicare
  via thecost report

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Fraud and Abuse Schemes Mental Health

• Routine upcoding of psychotherapy sessions by a
  mental health provider
• A psychiatrist conducts group but bills for
  individual therapy
• A CP bills for a 50-minutesessions, but only
  sawpatients for 20-30 minutes

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Fraud and Abuse Schemes Mental Health

• PHPs enrolling patients who either cannot benefit
  from the therapy or who receive little more than
  recreational activities

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Fraud and Abuse Schemes Mental Health

• Non-licensed staff performing therapy sessions
  billed as though provided under direct
  supervision of a licensed practitioner
• Social activities billed aspsychotherapy services

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Fraud And Abuse SchemesNursing Facility

• Providing medically unnecessary physical,
  occupational, and speech therapy
• Therapies supplied to large groups of patients,
  but billed as if provided individually

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Fraud And Abuse SchemesNursing Facility

• Billing for medical supplies not provided
• Supplies ordered in quantities greater than
  needed
• Gang Visits - practitioners visit all or most
  of the patients in a facility without rendering
  any service

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Fraud And Abuse Schemes Physician \ Practitioner

• Routine foot care billed with a diagnosis
  warranting professional services
• Comprehensive eye exam billed when a lower level
  exam was performed
• A chiropractor bills forthree services each
  weekwhen he only sees hispatients twice a week

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Fraud And Abuse Schemes Physician \ Practitioner

• An ophthalmologist falsified documentation for a
  test used to establish the need for cataract
  surgery
• A physician bills a non-coveredservice
  (acupuncture) asa covered service

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Kickback Schemes

• Providing hospital or nursing homes with
  discharge planners
• Paying a fee to physician for each patient care
  plan certified by the physician on behalf of the
  HHA
• Providing free patient services for each
  resident referred to a HHA

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Kickback Schemes

• Paying a fee to an employee of a personal care
  home for each resident referred to a HHA
• Offering free services to beneficiaries if they
  agree to switch HHAs
• Paying beneficiaries each time they
  receivetreatment at a clinic

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Conclusion

• Most providers, suppliers and physicians are
  honest, careful and conscientious
• Mistakes can and do happen
• Medicare does not routinely refer providers to
  law enforcement unless there is strong evidence
  of fraud

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Conclusion

• Remember that when someone commits fraud or
  abuse, they are taking money from the Medicare
  trust fund.
• We all share the responsibility of protecting
  Medicare.

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Contacts

• You can call OIG directly at
• 1-800-447-8477
• (HHS-TIPS)
• Write Benefits Integrity
• P.O. Box 660156
• Dallas, TX 75266-0156

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Thank you for attending Have a great day!