Fraud

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Fraud

Protect, detect, and report health care fraud, errors, and abuse.

Anybody can be a health care fraud criminal - doctors, health care providers, medical equipment suppliers, telemarketers or your neighbor. Each year more than $60 billion is spent on Medicare fraud committed against seniors.

• Protect yourself from Medicare errors, fraud, and abuse.

• Detect potential errors, fraud, and abuse.

• Report errors, fraud, and abuse.

Protect

Protecting your personal information is the best line of defense in the fight against health care fraud

and abuse. Here are some ways to take an active role in protecting your health care benefits:

• Treat your Medicare, Medicaid, and Social Security numbers like a credit card number. Never give these numbers out to a stranger.

• Don’t carry your Medicare or Medicaid card unless you will need it.

• Record all doctor visits, tests, and procedures and keep it in a safe place.

• Save all Medicare Summary Notices and Part D Explanation of Benefits. Shred the documents when they are no longer useful.

Detect

Take these steps to detect potential errors, fraud and abuse:

• Always review your Medicare Summary Notice (MSN) and Part D Explanation of Benefits (EOB) for mistakes.

• Compare your MSN and EOB to your records to make sure they are correct.

Look for three things on your billing statement:

1. Charges for something you did not get;

2. Billing for the same thing twice;

3. Services that were not ordered by your doctor.

Report

If you suspect errors, fraud, or abuse, repoit rt immediately! You will protect other people from

becoming victims and help to save your Medicare benefits. Call your local Sofficeram if you suspect errors, fraud, or abuse.

Have this information before you report fraud:

• The provider's name and any identifying number you may have

• The service or item you're questioning

• The date the service or item was supposedly given or delivered

• The payment amount approved and paid by Medicare

• The date on your MSN

• Your name and Medicare number

• The reason you think Medicare shouldn't have paid

• Any other information you have showing why Medicare shouldn't have paid for a service or item

Tips for Avoiding Health Care or Health Insurance Fraud

» Never sign blank insurance claim forms.

» Never give blanket authorization to a medical provider to bill for services rendered.

» Ask your medical providers what they will charge and what you will be expected to pay out of pocket.

» Carefully review your insurer’s explanation of the benefits statement. Call your insurer and provider if you have questions.

» Do not do business with door-to-door or telephone salespeople who tell you that services of medical equipment are free.

» Give your insurance/Medicarecard identification only to those who have provided you with medical services.

» Keep accurate records of all health care appointments.

» Know if your physician ordered equipment for you.

Scams

Medicare

Scams for Obtaining Medicare Numbers

Scammers target Medicare beneficiaries to obtain their Medicare, Social Security, and bank account numbers, which they can use for a variety of fraudulent purposes.

Sometimes the Medicare number is simply stolen by an employee at a nursing home, long-term care facility, hospital, clinic, etc. and then sold to organized crime units or gang leaders, who use the information to bill Medicare. In other cases, perpetrators provide an offer for “free services” but require the person’s Medicare number to provide those services. In some instances, scam artists target financially needy individuals and offer to pay them for their Medicare number or pay them to receive services they don’t need.
The Milk/Grocery Scheme

In this scheme, the promoter of the scam may be offering free milk, groceries, or some other product or service. Regardless of the specific product being offered, any scheme following this general process is referred to as a milk/grocery scheme.
• Promoter visits adult living facilities, senior communities, or government program offices and identifies specific individuals.
• Promoter approaches consumers and tells them that Medicare, Medicaid, or a private insurance company wants to take care of them or is conducting a provider survey.
• Promoter gives consumers milk and/or food, cleans their homes, or delivers various equipment and tells consumers that everything is free and provided by the government or a health insurance company.
• Promoter asks consumers to complete and sign a form proving they were visited. The form asks for Medicare and/or Medicaid numbers.
• Promoter leaves name and number and guarantees to return to bring more free items.
• Promoter also solicits names of other potential targets.
Free Medical Evaluations/Testing

The free medical evaluations/testing scheme is similar to the previous scheme, except that in this case, free medical tests or evaluations are offered.

• Companies use phone solicitation, ads in newspapers, and coupons mailed or delivered to consumer's home to advertise free testing or services.
• Mobile testing centers frequent shopping malls, retirement communities, fraternal organizations, civic groups, and conventions.
• Consumer is asked to complete a form to receive free tests. The form asks for Medicare, Medicaid, Social Security, or insurance numbers.
Telemarketing/Boiler Room Scams

In telemarketer/boiler room scams, the telephone is used to obtain Medicare numbers.
Telemarketing company identifies specific targets through mailing lists and contacts consumers. Caller uses a high-pressure sales pitch to obtain Medicare, Medicaid, Social Security numbers or private insurance information. Sales pitch deliberately confuses people into believing the caller represents the government or private insurers.
$299, $389, or $399 Scams

In these types of scams, Medicare numbers are not the only goal. The scammers also obtain the beneficiary’s bank account information and use it to take as much money as possible directly from the beneficiary.

• Telemarketers/individuals identify themselves as a prescription drug plan.
• Caller offers a prescription drug plan that will provide a year’s supply of prescription drugs for one payment of $299, $389, or $399.
• The beneficiary is told payment can only be made by automatic withdrawal. The beneficiary is asked for his/her Medicare and/or Medicaid and bank account numbers so the plan can start the first of the month.
• The money is withdrawn with no prescription drugs delivered or the bank account is cleaned out.

Prescription Drug Fraud - Pill Shorting

In these types of scams, the Medicare is billed for medications not dispensed.

• A fraudulent pharmacy routinely dispenses prescriptions a few pill short. Medicare is billed for the full amount
• A fraudulent pharmacy fills a partial month's drug supply and ask the beneficiary to come back later for the remainder. The pharmacist then bills Medicare twice for the full amount
Home Healthcare Fraud

Under this scheme a fraudulent physician declares a beneficiary "homebound" but no actual home health therapy is provided.

The beneficiary is asked to sign forms that verify a nurse of therapist showed up at her home and provided services. To justify charging for a nurse, the fraudulent physician certifies that the patient is an insulin-dependent diabetic, cannot self-inject, and is homebound.
Nursing Facility Fraud

• Facility engages in fraud known as "upcoding." Upcoding misrepresents services using inappropriate procedure codes to be reimbursed at a higher rate. Patients might be placed into the highest Resource Utilization Group category. This category reimburses the most Medicare money.
• Unnecessary and excessive therapy time is billed to Medicare.
Durable Medical Equipment Fraud

Fraudulent company uses an unsuspecting physician's stolen identity to medically certify that a beneficiary needs supplies. They then bill Medicare for "custom" diabetic shoes, oxygen, nebulizers, therapeutic mattresses, and nutritional supplements.
"Lifetime" Certification Fraud

A supply company contacts a Medicare beneficiary and offers a new glucose test monitor. The company then obtains a "lifetime" certification from the beneficiary's physician. Test strips and other supplies are automatically shipped and the beneficiary is charged a co-pay each time. The volume of supplies exceeds what the beneficiary can possibly use. The "lifetime" certification makes it extremely difficult to switch to another supplier.