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Medicare and Skilled Nursing Facility Care: Protect Yourself from Fraud!

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Title: Slide 1 Author: erinweir Last modified by: jasonechols Created Date: 5/23/2008 2:52:20 PM Document presentation format: On-screen Show (4:3) Company – PowerPoint PPT presentation

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Title: Medicare and Skilled Nursing Facility Care: Protect Yourself from Fraud!


1
Medicare and Skilled Nursing Facility Care
Protect Yourself from Fraud!
Updated August 2014
2
What We Will Cover Today
  • The SMP Program
  • Medicare and Skilled Nursing Facility (SNF) Care
  • Skilled Nursing Facilities and Fraud
  • Protect, Detect, Report!

3
How Much is Lost?
  • 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

4
How Much is Lost?
  • 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

5
Fraud affects
  • Medicare Medicaid Beneficiaries
  • Loss of benefits
  • Higher premiums
  • Identity theft
  • Taxpayers
  • Medicare is paid for by taxes
  • Billions of taxpayer dollars wasted

6
Why Report Fraud?
  • Health care fraud puts you at risk for identity
    theft.
  • ITS 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 arent ordered by your doctor, they
    may not fit or work properly.
  • When someone gives you something that you dont
    need
  • Your health may get worse
  • Your Medicare benefits may be used up

8
  • The SMP Program
  • www.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
  • Medicare Skilled Nursing Facility (SNF) Care

13
What is Skilled Nursing Care?
  • Skilled Nursing Care is health care that
    requires the involvement of skilled nursing or
    rehabilitative staff in order to be given safely
    and effectively
  • (CMS Publication No. 10153)

14
What is Skilled Nursing Care?
  • Skilled nursing staff include
  • registered nurses
  • licensed practical and vocational nurses
  • physical and occupational therapists
  • speech language pathologists
  • audiologists

14
15
What is Skilled Nursing Care?
  • Examples of care that may often be considered
    skilled care
  • Intravenous injections
  • Physical therapy
  • Catheters
  • Wound care
  • Ostomy care

15
16
When does Medicare cover Skilled Nursing Facility
Care?
  • Medicare covers skilled nursing facility care on
    a short-term basis (if you need skilled care) in
    order to
  • Help improve your condition
  • Maintain your current condition and prevent it
    from getting worse

17
When Does Medicare Cover Skilled Nursing Facility
Care?
  • Medicare Part A covers Skilled Nursing Facility
    (SNF) care if you meet the following three
    requirements

18
When Does Medicare Cover Skilled Nursing Facility
Care?
  • 1) Your doctor certifies that you need skilled
    care that can only be provided in a SNF at least
    5 days/week, and you get this care in a
    Medicare-certified SNF

19
When Does Medicare Cover Skilled Nursing Facility
Care?
  • 2) You had a 3 day inpatient hospital stay prior
    to entering the SNF (usually within 30 days).
  • The day that you are admitted to the hospital
    counts
  • The day you are discharged does not count
  • Time spent in observation status does not
    count. (Ask the hospital if you have been
    admitted as an inpatient or if you are under
    observation.)

20
When Does Medicare Cover Skilled Nursing Facility
Care?
  • 3) You have SNF days left in your benefit
    period
  • Medicare covers up to 100 days of SNF care in a
    benefit period. A benefit period begins the 1st
    day you are in the hospital and ends when you
    have received no inpatient care (hospital or SNF)
    for at least 60 days.

21
When Will Medicare NOT Cover Skilled Nursing
Care?
  • If someone only needs custodial care, and does
    not require skilled care, Medicare will not
    pay for a stay in a skilled nursing facility
    (SNF).
  • Custodial care refers to non-medical care that
    provides assistance with activities of daily
    living, such as bathing, dressing, eating, etc.

21
22
How Much Does Medicare Pay?
  • Medicare will pay for the first 20 days of SNF
    care in a benefit period in full (0 copayment).
  • If you spent more than 20 days in a SNF, for days
    21-100, there is a daily copayment. (In 2011,
    this copayment is 141.50/day.) Note some
    Medicare supplement plans may cover this
    copayment.

22
23
What Care Does Medicare Cover?
  • If you qualify for skilled nursing facility
    (SNF) care, Medicare will cover
  • A semi-private room and meals
  • Skilled nursing care
  • Physical therapy, occupational therapy, and/or
    speech-language pathology services

23
24
What Care Does Medicare Cover?
  • If you qualify for skilled nursing facility
    (SNF) care, Medicare will cover
  • Medical social services
  • Medications
  • Medical equipment used while in the facility
  • Some medically necessary ambulance transportation

24
25
What if I have a Medicare Advantage Plan?
  • If you are on a Medicare Advantage plan, the way
    that your plan covers skilled nursing care may be
    slightly different. The plan may
  • Cover more days than Original Medicare or waive
    the 3 day hospital stay requirement
  • Require you to use a Skilled Nursing Facility in
    the plans network
  • Have a different copayment structure than
    Original Medicare

25
26
Your Rights in a Skilled Nursing Facility (SNF) -
Quality of Care
  • If you have a question or complaint about the
    care that you receive in a SNF, you can contact
    the Illinois Long Term Care Ombudsman program. To
    find an Ombudsman in your area, contact the
    Illinois Department on Aging Senior HelpLine at
    (800)252-8966.

27
Your Rights in a Skilled Nursing Facility (SNF) -
Quality of Care
  • The Medicare Quality Improvement Organization
    (QIO) also takes complaints about quality of
    care. To file a quality of care complaint with
    the QIO in Illinois, call IFMC-IL at
    (800)647-8089.

27
28
Your Rights in a Skilled Nursing Facility (SNF) -
Discharge
  • If you have Original Medicare, before you are
    discharged, the SNF must give you a written
    notice stating
  • The date your Medicare coverage will end
  • Why your stay is no longer going to be covered
  • The estimated cost of non-covered care if you
    choose to stay in the SNF
  • Your right to request that the SNF submit a claim
    to Medicare to obtain an official payment
    decision from Medicare (called a demand bill)

28
29
Your Rights in a Skilled Nursing Facility (SNF) -
Discharge
  • If you disagree with the SNFs decision to
    discharge you, you can request an appeal. To
    appeal a discharge, contact the Quality
    Improvement Organization (QIO). In Illinois,
    this organization is IFMC-IL (800)647-8089.
  • The QIO will respond to your appeal within one
    day of receiving it.

29
30
Your Rights in a Skilled Nursing Facility (SNF) -
Discharge
  • If you want to appeal, you must contact the QIO
    no later than your planned discharge date and
    before you leave the hospital.
  • If you do this, you will not have to pay for the
    services you receive during the appeal (except
    for charges like copays and deductibles).

30
31
Your Rights in a Skilled Nursing Facility (SNF) -
Discharge
  • If you do not appeal, but decide to stay in the
    hospital past your planned discharge date, you
    may have to pay for any services you receive
    after that date.
  • If you have private insurance or Medicaid, your
    other insurance may cover your stay even after
    your Medicare coverage stops.

31
32
  • Skilled Nursing Facilities
  • (SNFs) and Fraud

33
SNFs and Fraud What is Fraud?
  • Billing for services that you never received
  • Billing for services that are different than what
    you received
  • Billing for unnecessary services
  • Billing for more or more advanced services than
    you need (upcoding)
  • Kickback arrangements (payments or other
    inducements for patient referrals)

34
SNFs and Fraud Physical Therapy
  • A skilled nursing facility provides physical
    therapy to 10 residents in a group for one hour
    (all at one time). However, when the facility
    bills Medicare, they bill as if they provided
    each of those 10 individuals with 1 hour of
    individual therapy.

35
SNFs and Fraud Physical Therapy
  • Problems
  • Billing for a different type of service than what
    was provided (individual therapy instead of group
    therapy)
  • Billing for more hours of therapy than what was
    actually provided

36
SNFs and Fraud Mental Health
  • A skilled nursing facility provides BINGO games
    for residents on Thursday afternoons. Without
    the residents knowledge, the facility bills
    Medicare for mental health therapy during these
    BINGO sessions.

37
SNFs and Fraud Mental Health
  • Problems
  • Billing for a service that was never provided
    (BINGO does NOT count as mental health therapy!)

38
SNFs and Fraud Kickbacks
  • A skilled nursing facility receives referral
    payments from a local hospice agency in exchange
    for referring many of their residents to receive
    services from that hospice agency.
  • At another skilled nursing facility, a local home
    health agency provides the facility with
    discharge planners in exchange for patient
    referrals.

39
SNF Fraud Schemes Kickbacks
  • Problems
  • The federal Anti-Kickback Statute makes it
    illegal for health care providers to give or
    accept any form of payment in exchange for
    patient referrals. Payment includes money,
    items, or services.

40
SNFs and Fraud Upcoding
  • A skilled nursing facility orders their staff to
    enroll patients into physical therapy when the
    patients do not need (and do not qualify for)
    physical therapy.
  • Another skilled nursing facility falsifies
    documentation to make it look like patients need
    more therapy services than the patients actually
    need.

41
SNFs and Fraud Upcoding
  • Problems
  • The SNF is providing unnecessary/ inappropriate
    services in order to receive higher payments from
    Medicare than they should receive.
  • If someones services are upcoded now, that
    person may not be able to get that care later
    when they need it.

42
Protect! Detect! Report!
43
  • PROTECT Yourself From Fraud!

44
PROTECT Yourself From Fraud!
  • If you need skilled nursing care, contact your
    doctor. Your doctor must certify you to receive
    skilled nursing care.

45
PROTECT Yourself From Fraud!
  • Choose a skilled nursing facility carefully.
  • You can find quality information about skilled
    nursing facilities on www.medicare.gov under
    Nursing Home Compare.
  • Visit the SNF and ask questions using Medicares
    SNF checklist.

45
46
PROTECT Yourself From Fraud!
  • Do NOT sign any forms or paperwork without
    reading them first. Never sign blank forms.

47
PROTECT Yourself From Fraud!
  • Ask questions if you do not understand the care
    you are receiving.
  • Do not accept extra services that you do not
    need - Medicare may be billed fraudulently for
    those unnecessary services.

48
  • DETECT Fraud!

49
DETECT Fraud!
  • Ask the SNF for an itemized statement of all of
    the services you receive while in the SNF.
  • Check that statement for errors, such as services
    you did not receive, or services that are
    different than what you received.

50
DETECT Fraud!
  • Read your Medicare Summary Notice or Explanation
    of Benefits from your insurance company. Watch
    for
  • Services or supplies that you did not get
  • Services or supplies that were not ordered by
    your doctor
  • Billing for the same thing twice
  • Other billing errors

50
51
  • REPORT Fraud!

52
REPORT Fraud!
  • If you have questions about services that you did
    receive, contact the SNF first and ask for an
    explanation.
  • If this does not 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

53
Volunteers are the key to spreading the SMP
message!
We need YOUR help!
54
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.
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