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The Administration on Aging (AoA), a division of the U.S. Department of Health and Human Services, has developed a program to help consumers understand more about healthcare fraud.  It involves recruiting retired persons to teach Medicare and Medicaid beneficiaries to recognize and report healthcare fraud. In mid-2002, the Division of Aging and Adult Services (DAAS) received a grant from AoA to recruit volunteers to educate the public about the prevalence of healthcare fraud in Arkansas and what all of us — both beneficiaries and taxpayers — can do to safeguard state and federal dollars for Arkansans who rely on Medicare and/or Medicaid services.

Healthcare Fraud Education

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

Medicare or Medicaid fraud occurs when services provided to beneficiaries are deliberately misrepresented, resulting in unnecessary cost to the program, improper payments to providers, or overpayments.

Medicare/Medicaid fraud generally involves billing for services that were never rendered or billing for a service at a higher rate than is actually justified.

Medicare or Medicaid abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards. Doctors, providers, or suppliers  bill for items or services that should not be paid for by Medicare or Medicaid.

Healthcare fraud is not just a matter of dollars and cents. Equally important is the serious effect on the quality of care received. For example, a doctor prescribes physical therapy for a patient following a stroke, for an hour of physical therapy three times a week.

HOWEVER, the therapist regularly provides only ten minutes of therapy, BUT bills Medicare for the full hour each time.

Not having the full amount of physical therapy could have led to a loss of function for the patient, which may never have been regained. Medicare beneficiaries can now call the ASMP to report such situations and insure receiving the full physical therapy benefit through another company.

Remember: most health care professionals are honest, trustworthy, and responsible. The goal of this initiative is to weed out the few health care providers who operate with the intention of using Medicare and Medicaid as a pipeline to personal profit. The effort to prevent and detect healthcare fraud is a cooperative one that involves:

• The Centers for Medicare and Medicaid Services (CMS), and the Administration on Aging,

• Providers of services,
  

• State and Federal Agencies such as the Department of Health and Human Services Office of the Inspector General (HHS-OIG), the Federal Bureau of Investigation (FBI), the Department of Justice (DOJ), and the Attorney General’s Office,
  

• Medicare and Medicaid Beneficiaries — This means YOU!

Healthcare fraud is not:

An honest mistake by the provider.  Everyone makes mistakes and clerical errors occur all the time. A bill for more time than the patient thinks was spent with the doctor.

Situations where “you just know” something is wrong.  A gut feeling that something is wrong cannot be proven without documentation.

Hospital bills that just seem “too high.”  Providers are contracted at specific amounts for specific services and/or equipment and bill CMS according to those contracted amounts.

Charges on the Medicare statement for doctors such as anesthesiologists, radiologists, etc. that the beneficiary doesn’t remember seeing.  This is not uncommon because these doctors provide specialized services behind the scene or bill separately from the primary care doctor.

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What Does it Cost and Who Pays?

Healthcare fraud affects all Americans. It affects everyone who pays taxes by wasting billions of tax dollars. It affects those who depend on Medicare or Medicaid by diminishing the quality of the treatment they receive.

Loss of money to fraud and abuse means that less money is available for necessary services and programs to assist caregivers. Additionally, poor quality of care can impact a beneficiary's functional level, which may extend his/her need for services.

Higher Medicare costs also result in higher premiums and co-pays.Most Medicare and Medicaid payment errors are simple mistakes by doctors, providers, or suppliers. Most of them provide quality care to their patients and bill the program correctly only for the services they have provided.

However, there are always a few who intentionally cheat these government programs (and in some cases the beneficiaries who are responsible for co-payments) out of millions of dollars annually. The cost is estimated to be over $13 billion annually for Medicare alone. The cost in terms of lost services and poor quality of care is immeasurable.

In order to prevent fraud, first you have to know what it is. Here are some examples:

• Billing for services never performed or medical equipment or supplies not ordered

• Billing for services or equipment that are different from what was provided

• Billing for home medical equipment after it has been returned

• Continuing to provide medical services or supplies when they are no longer necessary

• DOUBLE BILLING — Charging more than once for the same service

• UPCODING — billing for a more expensive or covered item when a less expensive, non-covered item was provided.  Altering claim forms to obtain a higher payment amount.

• UNBUNDLING – billing related services separately to charge a higher amount than if they are combined and billed as one service or group of services.

• Falsely claiming that services are medically necessary when they are not.

• Using another person’s Medicare card to get medical care, supplies, or equipment.

• Soliciting, offering or receiving bribes, rebates or kickbacks.  A kickback is an arrangement between two parties which involves an offer to pay for Medicare business.  Health care providers engaging in kickback activities are subject to criminal prosecution and exclusion from the Medicare and Medicaid programs.

Now that you know what it IS, how can you PREVENT healthcare fraud?

Be suspicious if a provider tells you that:

• The equipment, service or test is free. It won’t cost you anything. MEDICARE DOES NOT PROVIDE ANYTHING FOR FREE! People on Medicare pay with higher premiums.  All of us pay through tax increases.

• Although the equipment, service or test is free, the provider only needs your Medicare number "for our records."

• Medicare wants you to have the item or service.

• The provider knows how to get Medicare to pay for items or services, even if they are not usually covered.

• The more tests they provide, the cheaper they are.

  Be suspicious of providers who:
  
• Claim that they represent Medicare.
  
• Use telemarketing and door-to-door selling as marketing tool.
  
• Advertise "free" consultations to people on Medicare or offer “free” testing or screening in exchange for your Medicare card number, just for their records.
  
• Use pressure or scare tactics to sell you high-priced medical services or diagnostic tests.
  
• Routinely waive co-payments or deductibles on any services, other than those previously mentioned, without either checking your ability to pay or verifying your financial need.Charge co-payments on clinical laboratory tests, and on Medicare covered preventive services such as PAP smears, prostate specific antigen (PSA) tests, or flu and pneumonia shots.

Prevention Do's and Don'ts
Tips to help prevent Medicare fraud

DO Protect your Medicare Health Insurance Claim Number (on your Medicare card). Treat your Medicare card like it is a credit card. Don't ever give it out except to your physician or other Medicare provider. Never give your Medicare/ Medicaid number in exchange for free medical equipment or any other free offer. Unscrupulous providers will use your numbers to get reimbursed for services they never delivered.

DO Remember that nothing is ever “free.”  Don’t accept offers of money or gifts for free medical care.

DO Ask questions!  You have a RIGHT to know everything about your medical care, including the costs billed to Medicare.

DO Educate yourself about Medicare.  Know your rights and know what a provider can and cannot bill to Medicare.

DO Use a calendar to record all of your doctor's appointments and what tests or X-rays are conducted. Then check your Medicare statements carefully to make sure you received each service listed and that all the details are correct.

DO Be cautious of any provider who maintains he has been endorsed by the federal government.

DO be wary of the “We know how to bill Medicare” scam.  Avoid providers who tell you that the item or service is not usually covered, but they know how to bill Medicare.

DO review your Medicare payment notice for errors.  The payment notice shows what services or supplies were billed to Medicare, what Medicare paid, and what you owe.  Make sure Medicare was not billed for health care services or medical supplies and equipment you did not receive. If you spend time in a hospital, make sure the admission date, discharge date, and diagnosis on your bill are correct. Always inventory medical supplies and check against your statement.

DO always count your pills before your leave the drug store to be sure you have received the full amount. If you do not receive your full prescription, report the problem to the pharmacist.

DO Report suspected instances of fraud. Call the Arkansas SMP toll-free Fraud Hotline at 1-866-726-2916 or email John Pollett.

DON’T allow anyone, except appropriate medical professionals, to review your medical records or recommend services.

DON’T contact your physician to request a service that you do not need.  Don’t let anyone persuade you to see a doctor for care or services you don’t need.

DON’T accept medical supplies from a door-to-door salesman. If someone comes to your door claiming to be from Medicare/ Medicaid, remember that Medicare and Medicaid do not send representatives to your home.

DON’T be influenced by media advertising concerning your health.  Television and radio ads are intended to raise money for someone.  They do not have your best interest at heart.

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Volunteering

Due to the unscrupulous practices of some health care providers, Medicare and Medicaid are being drained of valuable resources — resources that you rely on when it comes to your health and the health of your loved ones.

Many people just like you are unaware of the contributions they can make to help curb and even prevent this fleecing of our medical system. By volunteering with Arkansas SMP you can become an integral member of the growing effort to help fight Medicare and Medicaid fraud and abuse, and the wasting of taxpayer dollars.

The Arkansas SMP project is now recruiting and training older volunteers to educate thousands of Arkansans about health care fraud and consumer rights. Volunteers will teach Medicare beneficiaries how to recognize suspected health care fraud, how to protect themselves from it, and how to report it. The Arkansas SMP Project is looking for retired individuals who are interested in spreading the message about health care fraud.

POSITION Volunteers conduct health care fraud presentations for older consumers at senior centers, club meetings, and other settings in the community. Volunteers also assist with identifying facilities and groups for presentations.

Requirements

• Volunteer should be a Medicare beneficiary and/or sixty years old or older.

• Volunteer will attend an initial orientation training and continuing training sessions from experts provided by the project.

• Individuals should be open to sharing information to groups of various sizes.

• A six-month commitment is requested.

  What will YOU get out of it?

• You will be educated regularly on issues pertaining to health care fraud.

• You will have continued support from project staff and other volunteers.

• You will make a difference in your community.

  If you have questions or concerns about health care fraud, are interested in volunteering, or would like to schedule a free speaker, email or call one of the following:

Division of Aging & Adult Services
Contact:
John Pollett
Arkansas SMP Administrator
Phone: 501-682-8504
Kathleen Pursell
Arkansas SMP Coordinator
Phone: 501-682-8497
700 Main Street Suite S530
Little Rock, AR 72203
or the toll-free Fraud Hotline at 1-866-726-2916

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Responsibilities of Caregivers

Health care fraud affects all Americans. Higher Medicare costs means higher premiums and co-pays. It affects those who depend on Medicare/Medicaid by diminishing the quality of the treatment they receive. Money lost to fraud and abuse means less money is available for programs that assist caregivers.

Additionally, poor quality of care can impact a beneficiaries' functioning level, which may extend a beneficiaries' need for services. And it affects everyone who pays taxes by wasting billions of tax dollars.

Tips for fraud prevention for Caregivers:

If you are assisting a person on Medicare/Medicaid with their health care it is important to read all the statements and bills. If you do not recognize a provider's name or service then call the provider and ask them to clarify what services were provided. If you have any further questions about whether the service was provided, please call ASMP.

• If an individual is on traditional Medicare, they should receive monthly statements from Medicare outlining the services that were provided. If you are having difficulty understanding this statement or other bills that have been sent to you, call ASMP and we can assist you in navigating the codes and other information.

• If you are caring for a person who is being denied medically necessary services from an HMO, it could be fraud.

Please call us - we can help resolve this problem and advocate for the services on behalf of the individual.

Review the information provided under PREVENTION.

If you have questions or concerns about health care fraud, are interested in volunteering, or would like to schedule a free speaker call ASMP at 501-682-8504 or toll-free 866-726-2916 or email John Pollett.

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Links

Administration on Aging (AoA) SMPs

American Society on Aging

Area Agencies on Aging (AAA)

Arkansas Attorney General

Arkansas Legal Services "Online Legal Library" website

Arkansas Nursing Home Consumer Guide*

Medicaid

Medicare

Medicare Rights Center

National Consumer Protection Technical Resource Center

Office of the Inspector General, US Department of Health and Human Services

* Arkansas Nursing Home Consumer Guide
To order printed copies of this guide,
please call our toll-free number 866-726-2916
or e-mail Kathleen Pursell.

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ASMP Manual
Chapter 1	Project Overview
Chapter 2	Medicare Versus Medicaid
Chapter 3	Medicare Fraud and Abuse
Chapter 4	Medicaid Fraud and Abuse
Chapter 5	Ambulance
Chapter 6	Durable Medical Equipment Fraud & Abuse
Chapter 7	Home Health Care Fraud & Abuse
Chapter 8	Hospice Fraud & Abuse
Chapter 9	Hospital Fraud & Abuse
Chapter 10	Laboratory Fraud & Abuse
Chapter 11	Mental Health Fraud & Abuse
Chapter 12	Nursing Facility Fraud & Abuse
Chapter 13	Physician Fraud & Abuse
Chapter 14	How to Report Fraud
Appendix 1	Healthcare Glossary
Appendix 2	Acronyms & Abbreviations
Appendix 3	Upcoding Definition
Appendix 4	Expenditures & Cost of Fraud
Appendix 5	Fraud & Abuse Quiz

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