The SMP Program: Empowering Seniors to Prevent Healthcare Fraud

1
The SMP Program Empowering Seniors to Prevent
Healthcare Fraud
2
Presented By

• Erin Weir,
• Healthcare Consumer Protection Coordinator
• AgeOptions

3
Agenda

• Overview of the SMP Program
• Healthcare Fraud, Waste, and Abuse
• Reporting Healthcare Fraud
• Benefits of SMP Program
• Tips for Beneficiaries

4
Overview of the SMP Program

• Senior Medicare Patrol (SMP)
• Educates consumers about Medicare and Medicaid
  and how to help identify and reduce fraud, waste
  and abuse.
• Integration Program outreach to specific, hard
  to reach populations

5
History of the SMP Program

• Demonstration Program (1995)
• 5 states CA, TX, NY, IL, FL
• For every 1 spent, 23 returned
• National Program (2006)
• All 50 states Washington, D.C. Puerto Rico
  Guam Virgin Islands

6
SMP Illinois Partners

• Statewide Partners Northeastern IL AAA,
  Northwestern IL AAA, Western IL AAA, Central IL
  AAA, Egyptian AAA, East Central IL AAA, West
  Central IL AAA, AAA for Lincolnland, AAA of
  Southwestern IL, Midland AAA, and Southeastern IL
  AAA
• Local Partners Chicago Department of Senior
  Services, Catholic Charities Lake County, South
  Suburban Senior Services of Catholic Charities,
  Catholic Charities Northwest, and Seniors
  Services Associates
• Special Population Partners Coalition for
  Limited English Speaking Elderly, Illinois
  Centers for Independent Living
• Integration Partners USPIS, MOWAA, Dominicks

7
Fraud In Healthcare Industry

• Home Health Care Providers
• Durable Medical Equipment suppliers
• Pharmacies
• Doctors
• Nursing Homes
• Hospitals

8
Definition Fraud

• Obtaining or attempting to obtain services or
  payments by dishonest means with INTENT,
  KNOWLEDGE, and WILLINGNESS
• when a provider bills an item or service which
  was NOT provided or is different from the service
  provided

9
Real Life Example of Fraud

• VA Services (Motorized Wheelchair Company)
• Billed Medicare for motorized wheelchairs but
  provided scooters
• Billed Medicare for wheelchair accessories that
  were never provided
• 27 months in federal prison and 164,590 in
  restitution

10
Definition Abuse

• Incidents and practices, although not usually
  considered fraudulent, are inconsistent with
  accepted sound medical, business, or fiscal
  practices.
• When a provider bills for medically unnecessary
  items or services
• When the services performed exceed what is needed

11
Real Life Example of Abuse

• Life Care Center of Lawrenceville, Georgia
• Provided residents with poor quality of care,
  which was billed to Medicare and Medicaid
• 2.5 million settlement
• Largest settlement against a single nursing home
  in the country

12
Definition Waste

• Needless consumption or unnecessary usage.
• Mistakes in the processing of claims.
• Billing errors that go uncorrected.

13
Real Life Example of Waste

• One of the Illinois SMP Partners had a client
  whose husband was unnecessarily billed for
  services by a radiology group. As a result of her
  efforts, they were able to return back to
  Medicare 685!

14
Why Report Healthcare Fraud?

• Identity theft
• increased healthcare spending YOUR MONEY!
• Healthcare program integrity ( solvency)

15
Benefits of SMP (National Outcomes)

• Error rate decreased from 14 to 6.3 - 8!
• 45 million people have been reached
• More than 1.1 million beneficiaries have been
  educated
• Have saved tax payers a total of 700,000 in 2007
  and more than 104 million since 1997
• More than 94,000 volunteers have been trained

16
Tips for Beneficiaries

• Never give out personal information to someone
  other than your doctor
• Always read your Medicare Summary Notice (MSN) or
  Explanation of Benefits (EOB)
• Call your insurance provider (number listed on
  MSN) if you see a mistake
• If you suspect fraud, contact AgeOptions

17
Questions/Comments/Experiences

• Erin Weir
• Healthcare Consumer Protection Coordinator
• AgeOptions
• 1048 Lake St., Suite 300
• Oak Park, IL 60301
• Phone [phone]
• TTY [phone]
• Fax [phone]
• Email erin.weir_at_ageoptions.org