IMPORTANT New York State OPERATION RESTORE TRUST 2003 Information Provided By Empire Medicare Servic

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IMPORTANT! New York StateOPERATION RESTORE
TRUST 2003Information
Provided By Empire Medicare Services
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Some of What we will cover today...

• Review Basic Medicare - new 2003 information
• Define Medicare Fraud, Waste and Abuse
• Identify Fraud Abuse
• How to report allegations of Fraud Abuse
• How to prevent Fraud Abuse
• Discuss scams and schemes!

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Medicare Part A

• Helps pay for care in hospitals, skilled nursing
  facilities, hospice, and some home health care
• COST - Most people do not have to pay a monthly
  payment (premium) for Part A because they (or a
  spouse) paid Medicare taxes while they were
  working

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Medicare Part B

• Helps cover your doctors services, and
  outpatient hospital care. It also covers some
  other medical services that Part A does not
  cover, such as some of the services of physical
  and occupational therapists, and some home health
  care.

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2003 Part B Premium Deductible

• Monthly Premium - 58.70
• 4.70 increase from 2002
• Annual Deductible - 100
• no increase from 2002

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Part A Cost-sharing 2003

• Inpatient deductible - 840
• Days 1 - 60 (28 increase
  from 2002)
• Coinsurance days - 210 per day
• Days 61-90 (7 increase
  from 2002)
• 60 Lifetime reserve days - 420 per day
  Days 91-150 (14 increase from 2002)
• Skilled Nursing Facility - 105.00 per day
  (3.50 increase
  from 2002)
• Benefit periods - way Medicare measures your use
  of hospital and skilled nursing facility services

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Can Anyone Purchase a Medigap Policy in NYS?

• Any one of the 10 standardized plans (A-J)
• Cannot be denied the purchase of a Medigap for
  any reason regardless of age or health status
• State Health Insurance Programs 1-800-333-4114
• State Insurance Dept 1-800-342-3736
• www.hiicap.state.ny.us

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How to Get Help with Medicare Expenses

• Federal law requires that State Medicaid programs
  pay Medicare costs for certain elderly and
  disabled persons with low incomes and very
  limited assets.

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2003 Medicare Savings Programs

• Qualified Medicare Beneficiary QMB
  
  Single -773
  Couple -1,035
  Premiums, deductible coinsurance
• Specified Low Income Medicare Beneficiary SLMB
  Single - 923 Couple-1,035
  Part B Premium
• Qualified Individual QI-1
  Single - 1,036 Couple -
  1,390
• Part B Premium
• Resources (QMB/SLMB) Single - 4,000 Couple -
  6,000
• Applications for all of these programs may be
  obtained from the Medicaid office at the local
  (county) Dept of Social Services.

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New Program for Military RetireesTRICARE
For Life

• Military retirees who have served at least 20
  years
• Must be registered with Defense Enrollment
  Eligibility Reporting System (DEERS)
• Must be enrolled in Part B Medicare
• 1-877-363-6337

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New this year!

• Step-by-Step Help for Choosing a Health
  Plan
• Medicare Personal Plan Finder
• www. medicare.gov
• Need to answer some questions
• What part of Medicare you have
• Your age
• What your general health is
• Receive Personal Summary Page with general
  information to help you compare

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Health Care Financing Administration (HCFA) is
now

• The Centers for Medicare Medicaid Services
  (CMS)
• Nationally, a new commitment to Customer Service
• 1-800-MEDICAR(E) is available 7 days a week /
  24 hours a day
• www.medicare.gov
• Medicare You 2003 handbook - was sent out the
  last week of October 2002
• Medicare You 2004 handbooks will be sent out
  fall of 2003

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Operation Restore Trust

• Empire Medicare Services is proud to be a part
  of New York States ORT workgroup
• Goal is to fight fraud abuse in Medicare
  Medicaid and maintain the integrity of these two
  programs
• You can help stop Fraud Abuse!
• Read your Medicare Summary Notice carefully -
  report any suspected fraud to Empire Medicare
  Services at 1-800-442-8430
• Mention Operation Restore Trust
• Ask to be transferred to extension 5211-Ginger
  Slionski

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Operation Restore Trust Overview

• Began in 1995 as a 2-year demonstration project
  that developed innovative ways to fight fraud,
  waste, and abuse in the five states with the
  largest Medicare and Medicaid benefit payments -
  New York, California, Illinois, Florida, and
  Texas
• Accounted for 33 of all Medicare beneficiaries
  and 38 of all Medicare payments in the USA

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What is Operation Restore Trust (ORT)?

• Partnership model in fighting fraud and abuse in
  Medicare Medicaid
• Results improve if agencies work together!
• Governor George E. Pataki convened a state work
  group chaired by the State Long Term Care
  Ombudsman Program (LTCOP)

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Lets Review the Basics

• What is Fraud?
• FRAUD IS DEFINED AS OBTAINING OR ATTEMPTING TO
  OBTAIN SERVICES OR PAYMENTS BY DISHONEST MEANS,
  WITH
• INTENT KNOWLEDGE WILLINGNESS

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INTENT...

• A Clinical Psychologist bills for a 50 minute
  session - saw the patient for only 20 minutes
• Mental health providers with patients who are
  non-communicative or cannot benefit from
  psychotherapy

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Knowledge Willingness

• Willingness
• Non-licensed staff have performed therapy
  sessions
• Billing for inpatient psychiatric treatment for
  weight reduction programs

• Knowledge
• Coffee, Cookies, and Conversation, a Community
  Mental Health Center advertised a social
  gathering
• Medicare was billed for psychotherapy services

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Examples of Fraud...

• Billing for services not provided
• Incorrect reporting of diagnoses or procedures to
  get a higher payment (upcoding)
• Billing for covered services when non-covered
  services were provided
• Kickbacks, bribes, rebates
• Routinely waiving deductible or coinsurance

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What is Abuse?

• Incidents and practices which, although not
  usually considered fraudulent, are inconsistent
  with accepted sound medical, business or fiscal
  practices.
• Unnecessary or excessive services
• Increasing charges to Medicare beneficiaries but
  not to other patients
• Improper billing practices
• Billing Medicare instead of primary payer
• Exceeding limiting charge allowance

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Be sure to read your Medicare Summary Notice...

• Your Medicare Number should match the number on
  your Medicare card
• If your Name and Address are incorrect on your
  MSN, contact both the Medicare carrier and Social
  Security
• Dates of Service shows when your doctor provided
  the service(s) listed. You may use these dates to
  compare with your records
• Services Provided is a brief description of the
  service or supply, the number of services and the
  service code

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Your MSN will tell you...

• The amount charged Medicare by the provider
• The amount Medicare approved and paid
• The amount you may be billed
• The providers Name and Address
• Remember - when in doubt let Medicare check it
  out!
• Any questions - call Empire Medicare Services at
  1-800-442-8430

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Medicaid Bureau - Fraud Abuse

• Most Common Rip Offs
• Billing for Phantom Patient Visits
• Billing for Goods/Services Not Provided, or old
  items as new
• Billing for more hours than are in a day
• Billing for medically unnecessary testing
• Paying kickbacks in exchange for referrals
• Inflating the bills for services/provided
• Concealing ownership of related companies
• Falsifying credentials and double billing

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What are the latest scams and schemes . . .
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Illegal Blood Glucose Test Strips

• Allegation of illegal blood Glucose test strips
  being sold in this country - resulting in false
  readings

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Person returning home from hospital receives
visitor

• Individual returning home from the hospital
  receives visitor claiming he was sent by Medicare
  to help organize her hospital papers.
• How did he know she had been in the hospital?
• Person with Medicare was robbed

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Medicare Supplies received - but never ordered

• Medicare beneficiary receives supplies never
  ordered by his physician

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New Medicare Cards Being Issued By SSA

• Beneficiary receives call stating that Social
  Security Administration is issuing new Medicare
  cards because of the tragedy at the World Trade
  Center (computers were lost)
• Beneficiaries were asked their Medicare number

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Thousands of Dollars for Home Visits

• Thousands of dollars in checks made out to
  doctor for home visits - Medicare never billed

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Alert Security Guard Calls Medicare

• Security Guard at assisted living alerts
  Medicare that individuals are trying to gain
  access to Medicare numbers by asking residents to
  fill out surveys - including their Medicare
  numbers

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Free Mud Therapy

• Free mud therapy offered to Medicare
  beneficiaries in Non-English speaking communities
  -
• Medicare billed for physical therapy

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Durable Medical Equipment - FRAUD!

• Pennsylvania DME Company and the Chief Operating
  Officer agreed to pay 265,000 for submitting
  false claims to Medicare
• Billed for body jackets - provided E-Z Vests -
  product does not comply with Medicares criteria
  for reimbursement

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Fraudulent transactions related to Nursing
Facilities...

• Physician billed 350,000 over 2 years for
  comprehensive physical exams without ever seeing
  a single resident
• Physician falsified medical records to indicate
  that nonexistent services were rendered

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Fraud Involving Durable Medical Equipment
Suppliers...

• New York - company owner sentenced to 3 years
  probation ordered to pay 232,402
• Owner submitted false Medicare claims and paid 2
  physicians kickbacks to sign certificates of
  medical necessity for patients they never
  examined

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Nursing Home Scams!

• Company providing mobile x-ray services to
  nursing facilities billed for taking two x-rays -
  only one was taken
• Quality of Care was compromised!
• Investigation revealed company personnel were not
  certified to take x-rays

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Latest Scam - April 2003

• Heres the scam - - -
• Someone representing Medicare calls - states he
  wants to deposit 480 in your bank account for
  emergency medical services.
• The caller states he wants to verify who you are
  by asking for your social security number and
  bank account number. States if the information is
  not supplied, you will lose your Medicare.
• Caller ID indicates the telephone number was from
  Quebec, Canada.

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Protect Yourself Against Health Care Fraud...

• Never give out your Medicare number
• Beware of
• Health care providers/suppliers that use
  telephone calls,door-to-door selling, or pressure
  tactics as a way to sell you goods or services
• Companies that offer free medical equipment or
  offer to waive your co-payment
• Health care providers who say they represent
  Medicare or the Federal government

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Be Suspicious If The Provider Tells You That

• The test is FREE only needs your Medicare number
  for their records
• Medicare wants you to have the item or service
• They know how to get Medicare to pay for it
• The more tests they provide, the cheaper they are
• The equipment or service is FREE, it wont cost
  you anything

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Dont Be A Participant!

• Routine Foot Care
• Usually not covered by Medicare
• Provider submits false diagnosis to get Medicare
  to pay
• Provider submits claims for surgery to get
  Medicare to pay
• Beneficiary usually not asked to pay 20

• Acupuncture
• Not covered by Medicare
• Provider submits claim for physical therapy or
  for injections
• REMEMBER - this is fraud!

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An Unfamiliar Name On Your Medicare Statement May
Also Mean

• Your doctor obtained a sample or specimen and
  sent it to a lab for analysis or - you had x-rays

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Guilty! Yury Bizayko

• Sentenced to 30 months in prison ordered to pay
  1,560,534.80
• Responsible for laundering 1.5 million in
  fraudulently obtained Medicare checks

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Scam Alert!

• Someone claiming to represent Medicare offers you
  free equipment, physical exams, or goods in
  exchange for your Medicare number
• Protect your Medicare card as you would your
  credit card

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Scam Alert!

• If you receive a Medicare statement of services
  by a provider who is not in your area, pay
  particular attention!
• DID YOU HAVE THESE SERVICES?
• The provider may be fraudulently billing Medicare
  and assuming you wont report it because it is
  out of state

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ORT Continues . . .

• 51 Harkin Projects
• 50 States
• Puerto Rico
• Washington, D.C.

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ORT in New York State

• As a result of the efforts of Operation
  Restore Trust, approximately 250,000 individuals
  have received the anti-fraud waste and abuse
  message
• NYS - 73,201,200 dollars identified in
  healthcare fraud Abuse (double billing
  Medicare/Medicaid)
• NYS - 2001 - 12,400,000 dollars identified

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Ten cents out of every dollar spent for Medicare
Medicaid is lost due to Fraud Abuse!

• Training Objectives
• Identify fraud abuse
• Understand how fraud abuse affects you and your
  community
• Share information with others on identifying,
  reporting and preventing health care fraud
  abuse

• Project Goals
• Prevent Medicare Medicaid Fraud Abuse
• Ensure beneficiaries of Quality Care and
  appropriate services

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Not everything is fraud!

• Most doctors are honest and hard working with
  the well being of their patients as their top
  priority
• It only takes a couple of rotten apples to spoil
  the barrel

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Referral Process

• Empire Medicare Services has agreed to be the
  clearinghouse for Medicare Fraud Abuse
  allegations received as a result of the efforts
  of Operation Restore Trust
• To report suspected fraud - call 1-800-442-8430
  and ask for Ginger Slionski at extension 5211

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Tele-Interpreters

• 24 hour telephone language service
• Non-English speaking beneficiary or provider
• Can access over 150 languages
• Conference call with interpreter and
  non-English speaker

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ORT Contacts
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Operation Restore Trust Database

• Created at Empire Medicare Services to track all
  allegations received as a result of our
  participation in ORT
• Query capabilities for -
• Date range
• Medicare Number
• Provider Number
• Money
• Status
• Zip Code
• Our participation in project ORT began in June
  1997
• Allegations received to date is approximately
  800

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Lets take a look to the future...

• 2010 first wave of baby boomers will begin to
  turn 65
• Estimated enrollment in Medicare will be 52
  million
• Estimated Medicare spending - 420 billion

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Questions?

• Thank you for attending
• You made todays session a success