The Missouri SMP. Empowering Seniors to Prevent Healthcare Fraud

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1 The Missouri SMP Empowering Seniors to Prevent Healthcare Fraud

2 SMP s Department of Health and Human Services Administration for Community Living/Administration on Aging

3 Mission of the Missouri SMP Empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect and report healthcare fraud, errors, and abuse through outreach, counselling and education.

4 SMP Specialists Volunteers 2 day training Provide education, advocacy, and counselling to individuals, their families and the general public

5 Services Provided by SMP s - Free of Charge Screening for possible fraud and abuse of the Medicare/Medicaid programs Billing assistance and appeals process Explanation of coverage Policy Comparisons

6 Partnership Missouri Alliance of Area Agencies on Aging Regional Coordinators SMP Specialists

7 Estimate of Loss to Fraud and Abuse Most recent-$60 billion lost annually ($6.8 million/hr)

8 Effects of Fraud to Beneficiaries Diminishes the quality of treatment beneficiaries may receive.

9 Effects of Fraud to Caregivers Decreases funding available for important programs Difficult for honest providers to compete with dishonest providers

10 Effects of Fraud to Taxpayers Raises taxes Raises health insurance premiums Raises health insurance deductibles Raises administrative costs

11 Violators Can Include Organized crime A doctor or provider Durable medical equipment suppliers Medicare beneficiaries Any individual or business Insurance Companies

12 Fraud Fraud occurs when an individual or organization deliberately deceives others in order to gain some sort of unauthorized benefit.

13 Abuse Abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards.

14 Abuse Can Lead to Fraud When a provider continues to abuse regulations after warnings, it can become fraud.

15 Non-Provided Services Most common complaint A physician pled guilty to charges of Medicare fraud related to submitting false claims for house calls. Claims were submitted for persons who had died before the date of claimed services, persons living in other states, persons who were incarcerated, etc.

16 Altered Claim Forms When orders came in to a DME (Durable Medical Equipment) company and the orders were shipped out, the owner would add items to the invoices before billing.

17 Duplicate Billings Simply billing twice for the same service

18 Kickbacks or Bribes For example: Paying a fee to a physician for each patient care plan certified by the physician on behalf of the home health agency.

19 Upcoding This is a statement that the service provided was more complicated than it really was.

20 Unnecessary Services Medicare will only pay if the services are actually needed. For example: Home health services are only needed if the patient is homebound.

21 How Do We Make a Difference? Be a Smart Consumer Avoid offers of free medical tests in exchange for a peek at your Medicare card. Remember that Medicare does not offer free services nor does it employ Medicare Salespeople or doctors who make house-calls. Beware of advertising that promises Medicare will pay for certain care or devices.

22 Smart Consumer Tips Always use your Medicare card whenever you receive care and/or supplies. Do not give out your Social Security or Medicare number over the phone to anyone. Review your Explanation of Benefits or Medicare Summary Notice. Look at the type and the number of services provided. Also, review the dates of services billed. Always count your medication to make sure you received the amount prescribed.

23 Ask Questions If... You do not understand the charges. You did not receive the service billed. You feel that Medicare has paid the provider for more services than you received. You feel that Medicare has paid the provider for services that were not needed.

24 Who Can I Contact? The Missouri SMP , Toll-free