9/26/2012. Medical Identity Theft. Definition. Types of Medical Identity Theft

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1 Medical Identity Theft Health Care Compliance Association Clinical Practice Compliance Conference October 16, 2012 Julie K. Taitsman, M.D., J.D. Chief Medical Officer Christi Grimm, MPA Special Assistant to the Principal Deputy Inspector General Definition Medical Identity Theft is the appropriation of a patient s or provider s unique medical identifying information with the intent to misuse this information to bill for or obtain medical goods or services from public or private payers. 2 Types of Medical Identity Theft Provider identity stolen to: Authorize or order items or services Bill insurers for items and services 3 Beneficiary identity stolen to: Bill insurers for items and services never rendered Bill insurers for items and services rendered to someone other than the beneficiary 1

2 How Big Is the Problem? 3,600 cases reported to the FTC in 2009 CMS identified 5,000 compromised Medicare provider numbers (Parts A/B/D) 280,000 compromised beneficiary numbers Many cases go undetected and unreported 4 Whom Does Medical Identity Theft Hurt? Health insurers Cost for fraudulent claims Resources to develop safeguards Taxpayers Increased Medicare & Medicaid expenses Cost to implement protective/preventive laws & systems Law enforcement Beneficiaries Financial liability Service limits Corrupted medical records Compromised care Providers Professional reputation Financial liability Incorrect overpayment assessments Incorrect income tax assessments 5 Case Study # 1 Fraudulent Prescriptions 6 2

3 Case Study # 1 Lessons &Tips Keep track of prescription pads Educate your patients Be on the Lookout! Open lines of communication with pharmacies 7 Case Study # 2 Patient Recruiting Schemes 8 Case Study # 2 Lessons & Tips Never authorize unnecessary items or services Perform all necessary exams and testing before authorization Set internal policies to avoid taking shortcuts Choose business partners carefully 9 3

4 Directly Billing for Services Using Stolen Physician Identity 10 Case Study # 3 Complicit Physician Allows Misuse of Physician Identity 11 Case Study # 3 Lessons &Tips Maintain accurate medical record documentation Ensure your records support medical necessity Only bill and chart for the services provided If someone else provided a service, don t bill as if you provided it yourself Only certify accurate and truthful claims 12 4

5 Case Study # 4 Recruited Medical Directors 13 Case Study # 4 Lessons &Tips If it sounds too good to be true, it probably is Choose business partners carefully Determine how much time the position will require Monitor the use of identifiers 14 Consequences to Victimized Physician Overpayment demand letters Tax liabilities Credit issues Exoneration difficulties Damaged reputation 15 5

6 What Can You Do to Protect Yourself? Actively manage enrollment information with payers Monitor billing and compliance processes Control prescribing authorities and medical identifiers Choose staff and business partners carefully 16 Consequences to Victimized Beneficiary Financial liability Denial of services Difficulty accessing needed care Corrupted medical records and compromised care 17 What Can You Do to Protect Your Patients? Hire and supervise staff carefully Store medical records and other documents with patient information securely Use computers and mobile digital devices responsibly Educate your patients to protect themselves 18 6

7 Resource for Patient Education Guard your card What Can You Advise Your Patients to Do to Protect Themselves? Only give information to providers you trust Don t reveal personal information to strangers Hang up or walk away Review all medical bills, summary notices, and explanation of benefit statements Don t share your card Some Risks Are Beyond Your Control Public access to physician identifiers Large number of providers with legitimate access to identifiers Use of Social Security numbers as beneficiaries Medicare numbers 21 7

8 If You Identify Fraud, What Next? Report medical identity theft to: Local law enforcement State Medicaid Agencies (SMA) Federal Trade Commission (FTC) HHS-OIG CMS regional offices CMS CPI identity remediation process for providers 22 Where Should Beneficiaries Report Identity Theft? State Medicaid Agency (SMA) Website: Prevention/FraudAbuseforConsumers/Downloads/smafraudcontacts.pdf Federal Trade Commission (FTC) Phone: (1-877-ID-THEFT) TTY #: Website: 23 HHS-OIG Hotline Phone: (1-800-HHS-TIPS) TTY #: Fax #: Website: CMS CPI Identity Remediation Process for Providers Proactively identify and help victims by: Responding to the needs of legitimate providers Helping to absolve related debts, overpayments, and/or tax obligations Websites: Prevention/MedicaidIntegrityProgram/downloads/cpiinitiatives.pdf Certification/MedicareProviderSupEnroll/downloads/ProviderVictimPOCs.pdf 24 8

9 HHS-OIG Compliance Guidance 25 Questions? Christi Grimm Phone: (202) Julie Taitsman Phone: (202) OIG Website: