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Medicare Fraud and Abuse

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Medicare Fraud Information Specialist. Medicare Part A Fiscal Intermediary ... Benefits Integrity Units. Respond to beneficiary complaints of fraud ... – PowerPoint PPT presentation

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Title: Medicare Fraud and Abuse


1
Medicare Fraud and Abuse
  • Adele Culpepper
  • Medicare Fraud Information Specialist

2
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
3
Purpose of Presentation
  • To provide information on the Medicare Integrity
    Program
  • what it is,
  • how it works,
  • how it affects you

4
Program Integrity Goals
  • PAY IT RIGHT
  • Pay the right amount
  • To the right provider
  • For the right service
  • For the right beneficiary

5
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

6
Medicare Integrity Program
  • Saved the Medicare Program more than 16 for
    each dollar spent in 2000

7
Medicare AdministrationFiscal Year 2000
  • Payments of 220 billion
  • 40 million persons with Medicare
  • 1 billion claims
  • 1million health care providers

8
Benefits Integrity Units
  • Respond to beneficiary complaints of fraud
  • Develop cases for referral to law enforcement
  • Support law enforcement

9
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

10
Medicare Basics
  • Benefits Under Medicare
  • Part A
  • Part B

11
Administrative Structure
12
Part A Benefits
  • In-patient hospital stays
  • Skilled Nursing Facility
  • Home Health Care
  • Hospice Care

13
Part B Benefits
  • Physician Services
  • Out-patient Hospital Services
  • Ambulatory Surgical Centers
  • Ambulance

14
Non-Covered Part A Services
  • Convenience Items
  • Private Duty Nurses
  • Private Room
  • Custodial Care
  • Housekeeping Services

15
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

16
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.

17
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

18
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

19
OIG Cannot Accept The Case
  • Refund for the overpaid claims
  • OIG may still exclude the provider
  • Review claims before payment
  • Education \ warnings

20
Situations ThatMay Not Be Fraud
  • Beneficiary did not receive the service
  • Billing or processing error
  • Service rendered by physicians employee

21
Situations ThatMay Not Be Fraud
Hospital In-patient Bill
  • High or duplicate charges
  • Billing or charging error

22
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.

23
Examples of Abuse
  • Excessive charges for services or supplies
  • Claims for services notmedically necessary
  • Submitting bills when Medicareis secondary

24
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

25
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

26
Fraud and Abuse Schemes Ambulance
  • Billing for ALS services whenBLS was provided
  • Transports for ambulatory patients
  • Billing for excessive mileage
  • Falsification of documentation

27
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

28
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

29
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

30
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

31
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

32
Fraud and Abuse SchemesHHAs and Hospice
  • Registered nurses provide care to relatives and
    then bill it ashome health care

33
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.

34
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

35
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

36
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

37
Fraud and Abuse Schemes Mental Health
  • PHPs enrolling patients who either cannot benefit
    from the therapy or who receive little more than
    recreational activities

38
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

39
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

40
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

41
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

42
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

43
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

44
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

45
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

46
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.

47
Contacts
  • You can call OIG directly at
  • 1-800-447-8477
  • (HHS-TIPS)
  • Write Benefits Integrity
  • P.O. Box 660156
  • Dallas, TX 75266-0156

48
Thank you for attending Have a great day!
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