CMS

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CMS

• CENTERS FOR MEDICARE AND MEDICAID SERVICES
• (HEALTH CARE FINANCING ADMINISTRATION)
• RENAMED IN 2004)

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• CENTERS FOR MEDICARE AND MEDICAID SERVICES IS
  WITHIN THE U.S. DEPARTMENT OF HEALTH AND HUMAN
  SERVICES.

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• OPERATES MEDICARE AND MEDICADE PROGRAMS
• OPERATES CHILDRENS HEALTH INSURANCE PROGRAM

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• REGULATES ALL LABORATORY TESTING (EXCEPT
  RESEARCH) PERFORMED ON HUMANS IN THE UNITED
  STATES.

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• IN CONJUNCTION WITH DEPARTMENTS OF LABOR AND
  TREASURY, HELP SMALL COMPANIES GET AND KEEP
  HEALTH INSURANCE.

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• MAGNITUDE OF THE PROGRAM

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• CMS SPENDS OVER 360 BILLION A YEAR BUYING HEALTH
  CARE SERVICES FOR THE BENFICIARIES OF MEDICARE,
  MEDICAID AND THE CHILDRENS HEALTH INSURANCE
  PROGRAM.

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• ASSURES THAT THE MEDICAID, MEDICARE AND
  CHILDRENS HEALTH INSURANCE PROGRAMS ARE PROPERLY
  RUN BY ITS CONTRACTORS AND STATE AGENCIES.

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• ESTABLISHES POLICIES FOR PAYING HEALTH CARE
  PROVIDERS.

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• CONDUCTS RESEARCH ON THE EFFECTIVENESS OF VARIOUS
  METHODS OF HEALTH CARE MANAGEMENT, TREATMENT, AND
  FINANCING AND

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• ASSESSES THE QUALITY OF HEALTH CARE FACILITIES
  AND SERVICES AND TAKING ENFORCEMENT ACTIONS AS
  APPROPRIATE.

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• AREAS OF SPECIAL INTEREST

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• FIGHTING FRAUD AND ABUSE

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• CMS HAS A COMPREHENSIVE PROGRAM TO COMBAT FRAUD
  AND ABUSE.
• TAKES STRONG ENFORCEMENT ACTION AGAINST THOSE WHO
  COMMIT FRAUD AND ABUSE

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• PROTECTS TAXPAYERS DOLLARS
• GUARANTEES SECURITY OF MEDICARE, MEDICAID, AND
  CHILD HEALTH PROGRAMS

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• QUALITY ASSESSMENT AND PERFORMANCE REVIEW

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• DEVELOPING AND ENFORCING STANDARDS THROUGH
  SURVEILLANCE
• MEASURING AND IMPROVING OUTCOMES OF CARE

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• EDUCATING HEALTH CARE PROVIDERS ABOUT QUALITY
  IMPROVEMENT OPPORTUNITIES
• EDUCATING BENEFICIARIES TO MAKE GOOD HEALTH CARE
  CHOICES

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• MEDICARE AND MEDICAID BASICS

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• WHAT IS MEDICARE?

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• MEDICARE IS A HEALTH INSURANCE PROGRAM FOR

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• PEOPLE 65 YEARS OF AGE OR OLDER
• SOME PEOPLE WITH DISABILITIES, UNDER 65 YEARS OF
  AGE.
• PEOPLE WITH END-STAGE RENAL DISEASE (PERMANENT
  KIDNEY FAILURE REQUIRING DIALYSIS OR A TRANSPLANT

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• MEDICARE HAS FOUR PARTS
• PART A (HOSPITAL INSURANCE) PEOPLE DO NOT HAVE
  TO PAY FOR PART A
• HELPS PAY FOR HOSPITALS, SKILLED NURSING
  FACILITIES, HOSPICE, AND SOME HOME HEALTH CARE

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• NO PREMIUM CHARGE IF MEDICARE TAXES WERE PAID
  WHILE WORKING

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• PART B (MEDICAL INSURANCE) MOST PEOPLE PAY
  MONTHLY FOR PART B
• HELPS PAY FOR DOCTORS, OUTPATIENT HOSPITAL CARE,
  AND SOME OTHER MEDICAL SERVICES NOT COVERED IN
  PART A.

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• BASIC COST TO THE ENROLLEE IS 93.50 A MONTH

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• PART C MEDICARE ADVANTAGE. PEOPLE WITH
  MEDICARE A B CAN RECEIVE CARE THROUGH AN HMO.

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• PART D PRESCRIPTION DRUG COVERAGE

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• MEDICAID

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• MEDICAID IS A HEALTH INSURANCE PROGRAM FOR
  CERTAIN LOW-INCOME PEOPLE. IT IS FUNDED AND
  ADMINISTERED THROUGH A STATE-FEDERAL PARTNERSHIP.
  

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• STATES HAVE A WIDE DEGREE OF FLEXIBILITY TO
  DESIGN THEIR PROGRAMS

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• MAY ESTABLISH ELIGIBILITY STANDARDS
• DETERMINE WHAT BENEFITS AND SERVICES TO COVER
• SET PAYMENT RATES

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• WHO QUALIFIES?
• ON ANY GIVEN DAY ABOUT 33 MILLION PEOPLE ARE
  ELIGIBLE FOR MEDICAID.

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• LOW-INCOME FAMILIES WITH CHILDREN
• BLIND OR DISABLED PEOPLE
• LOW INCOME PREGNANT WOMEN AND CHILDREN
• PEOPLE WITH VERY HIGH MEDICAL BILLS.

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• HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
  ACT OF 1996

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• HIPAA Administrative Simplification
• The Administrative Simplification provisions of
  the Health Insurance Portability and
  Accountability Act of 1996 (HIPAA, Title II)
  require the Department of Health and Human
  Services to establish national standards for
  electronic health care transactions and national
  identifiers for providers, health plans, and
  employers.

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• It also addresses the security and privacy of
  health data. Adopting these standards will
  improve the efficiency and effectiveness of the
  nation's health care system by encouraging the
  widespread use of electronic data interchange in
  health care.

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• FRAUD AND ABUSE

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• IT IS ESTIMATED THAT FRAUD AND ABUSE COST
  MEDICARE AND MEDICAID ABOUT 33 BILLION EACH YEAR.

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• IN 1995, THE CLINTON ADMINISTRATION LAUNCHED
  OPERATION RESTORE TRUST
• 23 IN OVERPAYMENTS FOR EVER 1 SPENT LOOKING AT
  HOME HEATH CARE, SKILLED NURSING FACILITIES, AND
  SUPPLIERS OF DURABLE MEDICAL EQUIPMENT.

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• AT A COST OF 100,000,000 NEW TOOLS WERE CREATED
  TO COMBAT FRAUD ABUSE
• NEARLY 1,000,000,000 WAS RETURNED TO THE
  MEDICARE TRUST FUN FROM FINES, JUDGEMENTS, AND
  SETTLEMENTS.

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• 2,700 FRAUDULENT HOME CARE PROVIDERS AND ENTITIES
  WHO WERE THEN EXCLUDED FROM DOING BUSINESS WITH
  MEDICARE

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• CONVICTIONS UP 20
• NEW CIVIL HEALTH FRAUD CASES UP 61

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• TESTIMONY FROM CONVICTED FELONS
• ACQUIRED 7 MILLION DOLLARS BY CHARGING 5 T0 7
  FOR GAUZE SURGICAL DRESSINGS THAT COST A PENNY
  EACH.

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• ANOTHER SHAKEDOWN PRACTICE CONSISTED OF
  SUBMITTING BILLS FOR THE TREATMENT OF DEAD
  PATIENTS.
• SCAM ARTISTS USE THEIR COMPUTERS TO FIND HOLES IN
  THE MEDICARE AND MEDICAID PAYOUT SYSTEM TO COMMIT
  MASSIVE FRAUD.

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• IN A RECENT FLORIDA CASE, A BUSINESS CONSISTING
  OF TWO RENTED MAILBOXES AND A BEEPER PHONE WAS
  PAID 2.1 MILLION BY MEDICARE IN FIVE MONTHS
  BEFORE THE OWNER VANISHED.

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• BEN CARROLL OF KISSIMEE, FLA., COLLECTED 51
  MILLION BY CHARGING MEDICARE 8.45 PER
  FEMALE-URINARY-COLLECTION DEVICE COMMONLY KNOWN
  AS AN ADULT DIAPER AND SOLD FOR 35 CENTS EACH.

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• COLUMBIA SETTLEMENT

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• COLUMBIA/HCA WILL SETTLE WITH THE JUSTICE
  DEPARTMENT FOR CIVIL CLAIMS FILED AGAINST THE
  COMPANY.
• INVOLVED CODING ISSUES, OUTPATIENT LAB BILLING,
  AND HOME HEALTH CARE.

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• AGREEMENT INCLUDES TERMS OF A CORPORATE INTEGRITY
  AGREEMENT WITH HEALTH AND HUMAN SERVICES
  DEPARTMENT.
• IN ADDITION TO THE 745 MILLION DOLLAR
  SETTLEMENT, COLUMBIA WILL PAY 6.5 ON THAT AMOUNT
  ACCRUING IMMEDIATELY.

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• THERE ARE ALSO CRIMINAL CHARGES INVOLVED

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• DETECTION TIPS

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• YOU SHOULD BE SUSPICIOUS IF THE PROVIDER TELLS
  YOU THAT
• THE TEST IS FREE HE ONLY NEEDS YOUR MEDICARE
  NUMBER FOR HIS RECORDS.

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• MEDICARE WANTS YOU TO HAVE THE ITEM OR SERVICE.
• THEY KNOW HOW TO GET MEDICARE TO PAY FOR IT.

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• THE MORE TESTS THEY PROVIDE THE CHEAPER THEY ARE.
• THE EQUIPMENT OR SERVICE IS FREE IT WONT COST
  YOU ANYTHING.

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• BE SUSPICIOUS OF PROVIDERS THAT
• ROUTINELY WAIVE COPAYMENTS WITHOUT CHECKING ON
  YOUR ABILITY TO PAY.

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• ADVERTISE FREE CONSULTATIONS TO MEDICARE
  BENEFICIARIES.
• CLAIM THEY REPRESENT MEDICARE.

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• USE PRESSURE OR SCARE TACTICS TO SELL YOU HIGH
  PRICED MEDICAL SERVICES OR DIAGNOSTIC TESTS.

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• BILL MEDICARE FOR SERVICES YOU DO NOT RECALL
  RECEIVING.
• USE TELEMARKETING AND DOOR-TO-DOOR SELLING AS
  MARKETING TOOLS.

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• End of lecture for September 12th, 2007
• 7th period.
• Questions?