LGBT Older Adults and Medicare Fraud:

PowerPoint created by: SAGE (Services & Advocacy for GLBT Elders)

What Can You Do to Help Prevent

Healthcare Fraud?

What is the Senior Medicare Patrol? Help Medicare and Medicaid beneficiaries prevent, detect

and report healthcare fraud

Protect older people and help preserve the integrity of the Medicare and Medicaid programs

Rely on volunteers to help perform SMP work

SMPs

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What is Medicare? Federal health insurance program for people 65 years

and older; also for people with disabilities under 65

Created by Congress in 1965

Administered by the Centers for Medicare & Medicaid Services (CMS)

Medicare covers most medically necessary services a person needs

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Medicare Cost Terms Premium

Deductible

Copay

Coinsurance

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Parts of MedicarePart A: Hospital InsurancePart B: Medical InsurancePart C: Medicare AdvantagePart D: Prescription Drugs

Medicare Supplemental Insurance (Medigap) is insurance sold by private companies that pays some or all of the copayments and coinsurances associated with Original Medicare. People with Medicare Advantage plans cannot have Medigap policies.

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Part A: Hospital Insurance

Inpatient hospital care

Inpatient skilled nursing care

Some home health care services

Hospice care

Part A covers:

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Doctor services

Durable medical equipment (DME)

Some home health care services

X-rays, lab services

Therapy services (physical, occupational, speech)

Outpatient services

Most mental health services

Preventive health care services

Part B: Medical InsurancePart B covers:

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Medicare run by private insurance companies

The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to offer all Medicare benefits through a private plan

Must cover all Part A and Part B services

May offer extra benefits

Usually includes prescription drug coverage (Part D)

Beneficiaries are encouraged to compare plans each year

Visit www.medicare.gov or call 800-MEDICARE for more information

Part C: Medicare AdvantagePart C, known as Medicare Advantage, is a way to get Medicare Parts A, B and D through a private insurance company

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Part D is Medicare drug coverage

Only offered through private plans

The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies to offer Part D plans to people with Medicare

Beneficiaries are encouraged to compare plans each year

Visit www.medicare.gov or call 800-MEDICARE for more information

Part D: Prescription DrugsPart D plans cover prescription drugs purchased at a pharmacy or through mail order

Intentionally billing Medicare for services that were not received, or billing for a service at a higher rate than is actually justified.

What isMedicare Fraud?

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What isMedicare Abuse?Providers supply services or products that are not medically necessary or that do not meet professional standards.

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Fraud & Abuse includes: Billing for services,

supplies or equipment that were not provided

Billing for excessive medical supplies

Obtaining or giving a Medicare number for “free” services

Improper coding to obtain a higher payment

Unneeded or excessive x‐rays and lab tests

Claims for services that are not medically necessary

Using another person’s Medicare number, or letting someone else use your number, to obtain medical care, supplies or equipment

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What About Errors? Healthcare services and billing are complicated,

which can lead to errors

Only a review and investigation of the issue will determine if it is an error, fraud or abuse

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Medicare Fraud, Errors,

and Abuse Affect:

Billions of taxpayer dollars lost to improper claims

Medicare trust fund at risk

Everyone People with Medicare

Copays or coinsurances paid toward unnecessary services or services not received

Higher premiums

Less money for needed benefits

Quality of treatment

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If a Medicare number is stolen, it can’t be cancelled or changed by Medicare

Your file may be flagged “do not pay”

Errors in medical history records can result in benefits being denied later when you need them

Consequences toPeople with MedicareFraudulent use of your Medicare number may affect YOUR Medicare benefits!

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Your Social Security Number and your identity

Your medical identity

Your banking and credit information

Theft of your Medicare number may also lead to theft and misuse of:  

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Consequences toPeople with Medicare

Can be criminal and/or civil

May result in prison sentences, restitution and/or steep fines

Result in mandatory exclusion from the Medicare program for a specific length of time

Consequences forCommitting FraudFraud convictions:

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Stories ofMedicare Fraudand Abuse

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Protect

Three Stepsto Prevent HealthCare Fraud

Detect Report

Treat your Medicare card and number like your credit cards

Watch out for identity theft

Be aware that Medicare doesn’t call or visit to sell you anything

Give out your Medicare number except to your doctor or other Medicare provider

Carry your Medicare card unless you will need it

Do Don’t

Protect

Services you didn’t receive

Double-billing

Services not ordered by your doctor

Review your Medicare Summary Notices (MSNs) and Explanation of Benefits (EOBs) for:

Detect

View most recent MSNs or EOBs

Check Part B deductible status

View eligibility information

Track available preventive services

Access your Medicare information online at MyMedicare.gov or at your Medicare Advantage plan’s website

Detect

Record doctor visits, tests and procedures in this journal, and take it with you to appointments

Ask yourself questions about your healthcare—write the answers and other information in your journal

Compare your MSNs and other statements to your journal to make sure they are correct

Use your Personal Healthcare Journal

Detect

Call the provider

Gather information and documentation

Contact your SMP—this is a free and confidential service!

If you detect Medicare fraud or abuse:

Report

SMP Volunteers

Help other Medicare beneficiaries protect, detect and report?

Give presentations?

Provide one-on-one counseling?

Perform administrative work?

Would you like to:

Join the SMP program as a volunteer!

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Contact your local Senior Medical Patrol

To report suspect fraud/abuse

For training, speakers and/or materials

To volunteer with the SMP program

[your SMP name]

For more information, visit us online at: yourwebsite.com

Or call toll-free [your phone number]

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Questions?For more information, visit:smpresource.orgsageusa.orglgbtagingcenter.org

This project was supported, in part by grant number 90SM0011, from the U.S. Administration

for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees

undertaking projects under government sponsorship are encouraged to express freely their findings and

conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for

Community Living policy.