SMP Complex Issues and Referrals Training Manual 5 Page 57 SMP COMPLEX ISSUES AND REFERRALS TRAINING...

SMP Complex Issues and Referrals

Training Manual

CHAPTER 5: Case Studies; Applying What You

Have Learned

Complex Issue Involving Diabetes Supplies Billing ....................... 57

Complex Issue Involving Hospital Billing for MRIs ......................... 58

Complex Issue Involving Hospice Care ......................................... 59

Complex Issue Involving a Power Wheelchair ............................... 60

Complex Issues Involving Medicare Advantage Marketing ........... 62

Scenario #1 .............................................................................. 62

Scenario #2 .............................................................................. 63

Complex Issue Involving Part D Marketing .................................... 64

Complex Issue Involving Prescription Drugs ................................. 66

Complex Issue Involving Both Medicare and Medicaid ................. 67

Complex Issue Involving Compromised Medicare Numbers ......... 68

Complex Issue Involving Quality of Care ....................................... 70

Medicare Coverage Complaint ..................................................... 71

Closing ........................................................................................... 72

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SMP COMPLEX ISSUES AND REFERRALS TRAINING MANUAL

Case Studies

The case studies contained in this chapter will provide you with some concrete examples of how to apply the knowledge you have gained. The following case studies are edited examples of actual SMP cases, though the names in these scenarios are fictional.

You will notice that many examples involve more than one type of insurance or problem – both Medicare Part D and Medicaid, for example –which you will find to be common in your work at the SMP.

Please remember that all complex issues should be entered into the SMP data reporting system according to the training instructions. Though data reporting system instruction is outside the scope of this manual, the absence of data entry instruction is not meant to imply that data entry isn’t necessary. See the SMP Resource Library for the SMP data reporting system manual, which includes detailed instructions on entering a complex issue and making a referral.

Complex Issue Involving Diabetes Supplies Billing

Scenario:

A beneficiary named Tom contacts the SMP because XYZ Pharmacy billed him for the Part B deductible for his diabetes supplies even though his Medicare supplement policy (Medigap Plan F) would pay the deductible if the pharmacy submitted a claim for it. The pharmacy is an enrolled Part B provider but does not always accept assignment on claims. Tom called the pharmacy to explain that his Medicare supplement covers the deductible but the manager insisted that Tom still needed to pay them directly. He paid but went to a different pharmacy for his diabetes supplies the next time. The second pharmacy billed the Medigap insurer and did not charge Tom the deductible. He calls the SMP because he thinks XYZ Pharmacy is engaged in fraud and he wants to report it. This was the second complaint of the same type against that pharmacy received by the SMP in recent months.

Key Concept The flow chart in Appendix A, which illustrates all categories of complaints and

appropriate referrals outlined in this manual, will assist you with these case studies.

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What is the Problem?

There isn’t a problem. Because XYZ Pharmacy did not accept assignment, it can bill Tom for the entire cost of the diabetes supplies at the point of sale, including the Part B deductible and coinsurance charges. As a Part B provider, XYZ pharmacy must submit a claim to Medicare for Medicare’s portion of the bill. With nonassigned claims such as this one, Medicare sends payment to the beneficiary for its share of the Medicare-approved amount. If XYZ pharmacy bills him only for the deductible and charges too much, Medicare rules require it “to refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.”

What is the SMP Response?

The SMP can educate Tom about the important difference between “participating providers” who accept assignment in all cases and those who do not. As explained in the SMP Foundations Training Manual, Chapter 2, the limiting charge that applies to nonassigned claims for physician services does not cover unassigned durable medical equipment, prosthetics, or supplies claims. In this case, the disputed practice was related to diabetes supplies. As mentioned in Chapter 4 of this manual, use the “Find Suppliers of Medical Equipment and Supplies” link at www.medicare.gov and look for suppliers that have a blue “M” logo next to their names. This indicates that they are participating providers who accept assignment in all cases.

Complex Issue Involving Hospital Billing For MRIs

Scenario:

A beneficiary named Gloria who is enrolled in Original Medicare reviews her MSN and calls the SMP to report high charges for a recent hospital stay. Also, there were two charges for MRIs and she only remembers having one MRI. She thinks the hospital might be trying to rip off Medicare. She has not yet talked to the hospital.


• May Not Be a Problem: Complaints of excessive prices are a Medicare benefits issue rather than suspected fraud, errors, or abuse (see the SMP Foundations Training Manual and Chapter 1of this manual).

• May Be a Problem: Billing for two MRIs could be a billing error on the part of the hospital, since it would be unusual for two MRIs to be performed during one hospital stay.

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1. To address Gloria’s concerns that the overall hospital charges were too high, educate her about Medicare’s method of paying inpatient hospital claims. You can send her to either the SHIP program (visit www.shiptacenter.org) or 1-800-Medicare for an explanation of Medicare coverage guidelines.

o For example, Medicare benefits experts can explain that hospital inpatient claims are paid under the Diagnosis Related Group (DRG) system and charges on a hospital claim do not necessarily reflect what Medicare actually allows or pays.

2. To address Gloria’s report that she only received one MRI, yet two MRIs were billed, recommend that she contact the hospital to discuss the potential double billing for her MRI.

o Ask Gloria to follow up with you regarding their response.

o If there was an error, request from her a copy of the original MSN and the corrected MSN for annual outcomes reporting to the OIG.

3. Offer to contact the hospital billing department if Gloria is unable or unwilling to make the contact herself. Take the following steps:

o Contact the hospital on Gloria’s behalf. If they request a release of information before speaking with you about Gloria’s information, follow up with Gloria to have her sign one.

o Clarify whether or not only one MRI was performed. If only MRI was performed, ask them to remove the duplicate MRI charge.

o Follow up with Gloria to explain the results of your work and arrange for her to provide you with a copy of her corrected MSN.

NOTE: As long as the hospital billing department is cooperative, this case remains in the category of suspected error. If the hospital will not address Gloria’s concerns about double billing, escalate this case to suspected fraud or abuse (see Chapter 4).

Complex Issue Involving Hospice Care

Scenario:

A nurse for a skilled nursing facility calls the SMP to report hospice care fraud by her employer. She knows that the facility director altered patient records to falsely indicate they needed a hospice level of care in order to obtain higher reimbursement from Medicare. The nurse does not want her employer to know about her report to the SMP but is willing to be identified to investigators.

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This situation reflects multiple violations of the law, both under the False Claims Act and the Civil Monetary Penalties Law, including: altering patient records to achieve higher payment, incorrect reporting of diagnoses, and submitting claims the provider knows to be fraudulent.


This is a clear-cut case of an immediate referral to the OIG Hotline via ACL. You should not contact the provider due to the egregious nature of the case.

1. Explain your SMP role to the nurse:

o SMPs make referrals of suspected fraud but are unable to provide any information on the status of the case until it has been resolved.

o Referred cases, particularly egregious ones, can take years to resolve.

2. Inform the nurse about the SMP referrals process and that she may be contacted by an investigator as a result of your referral.

o Tell her also that investigators will not inform you – the SMP – about progress on her case, though she may be contacted directly by the investigators. SMPs are only informed by investigators of case status after cases are fully resolved.

o The nurse was willing to be identified to investigators. If she wished to remain anonymous, you would submit an anonymous referral. Anonymous referrals do not carry the same weight with investigators, however, so it is fortunate that she is willing to give her name.

Complex Issue Involving a Power Wheelchair

Scenario:

A beneficiary in Original Medicare named Kim was prescribed a power wheelchair. The durable medical equipment (DME) supplier took measurements and ordered the wheelchair. When it arrived, Kim found that it did not fit her and she was unable to use it. Either the measurements were taken incorrectly or the chair was not ordered according to the measurements. Kim called the DME supplier to complain and request help but was forced to leave repeated messages, which went unreturned. She calls the SMP. Kim does not have a copy of her MSN yet and is not signed up with www.mymedicare.gov, so she is unable to review her claims in real time. Incidentally, the SMP recognizes the name of the DME supplier, since other complaints about this same provider had been made in recent months.

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The supplier neglected to respond to Kim’s complaint directly. Medicare has been billed for her power wheelchair, which does not meet her needs. Not only does unusable equipment waste Medicare dollars, Kim now has a power wheelchair that she cannot use. Because Kim has not used her power wheelchair continuously for five years (see the SMP Foundations Training Manual, Chapter 4), she cannot go to a different supplier for an appropriate power wheelchair without paying out of pocket. In addition:

• The DME supplier is not addressing the problem directly with the beneficiary, which is its obligation.

• DME suppliers must ensure a proper fit the first time.

• The other complaints the SMP has received against this provider raise suspicions.


1. Use your SMP Unique ID with 1-800-Medicare to research whether the supplier has already billed Medicare for the power wheelchair.

2. Contact the DME supplier on Kim’s behalf and ask if it will remedy the situation.

o Though Kim said she had tried and failed to work with the provider, this step gives the provider the benefit of the doubt and allows you to double check the information Kim provided to you.

o If the supplier responds with a willingness to remedy the situation, request a timeline.

3. If the DME supplier is unresponsive, escalate the issue as a case of suspected fraud or abuse and refer it to the OIG Hotline via ACL. In this example, a “pattern of error” is emerging with this particular provider due to the other complaints your SMP has received.

4. Request instruction from CMS about how to remedy Kim’s medical need for a power wheelchair during the investigative process. Your SMP Unique ID with 1-800-Medicare is one CMS resource available to you for this purpose.

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5. Follow up with Kim.

o Explain any guidance you received about how to remedy her need for a power wheelchair.

o If the provider remained unresponsive through this process, suggest she consider filing a complaint with the Better Business Bureau.

o Check in with Kim periodically until her need for a properly fitting wheelchair has been met.

Complex Issues Involving Medicare Advantage Marketing

Scenario #1:

An anonymous senior housing coordinator contacts the SMP to report that residents at a senior apartment complex were visited by Medicare Advantage Plan insurance agents. The senior housing residents had not requested these visits but let the agents into their apartments because the agents said they had been sent by the doctor who sees most of the residents in the housing complex. The agents enrolled the residents in a Medicare Advantage Plan and also attempted to sell life insurance. The agents knew a great deal about the residents, including their Medicare numbers and health conditions. The anonymous complainant knows the name and address of the residents’ doctor and the Medicare Advantage Plan being marketed.


There are multiple violations represented in this scenario:

• It appears that the doctor colluded with the plan to violate CMS marketing guidelines, also violating patient confidentiality.

• Possible kickbacks from the plan to the provider can be suspected.

• The Medicare Advantage Plan agents violated multiple aspects of the CMS marketing guidelines.

• Residents were steered toward and enrolled in a plan that may not meet their needs.

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1. Explain your SMP role to the senior housing coordinator:

o SMPs make the referrals but are unable to provide any information on the status of the case until it has been resolved.


2. Inform the senior housing coordinator of the SMP referrals process. Offer to help inform residents in the building about the SMP program, being respectful of her desire to be discreet about the incidences of fraud and also remain an anonymous complainant.

3. Make a referral to the OIG Hotline via ACL for suspected kickbacks and collusion on the part of the doctor.

4. Make a referral to your CMS RO DOI liaison for the plan marketing violations.

5. Make a referral to the state department of insurance due to the egregious agent behavior.

Scenario #2:

Maria, a resident from the same senior apartment complex involved in Scenario #1, contacts the SMP and reports that she was pressured by her doctor into leaving Original Medicare and enrolling in a particular Medicare Advantage Plan. The SMP recognizes the name of the plan as the same plan involved in Scenario #1. After enrolling, Maria quickly discovered that the plan didn’t meet her needs. She said the doctor had invited the plan representatives into his office, where patients were told they needed to enroll in the Medicare Advantage Plan because it was better. Maria realized, in retrospect, that the situation didn’t “feel right” and decided to call the SMP.


Scenario #2 contains the same problems as those outlined under Scenario #1. In addition, Maria can verify that the plan she was pressured into enrolling in does not meet her needs.

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1. Explain your SMP role to the beneficiary:

o SMPs make the referrals but are unable to provide any information on the status of the case until it has been resolved.


2. Inform the resident about the SMP referrals process and that she may be contacted by an investigator as a result of your referral.

3. Explain that after you refer her case to a CMS representative, CMS will contact her to help her return to Original Medicare.

4. Conduct a referral to the OIG Hotline via ACL for suspected kickbacks and collusion, explaining that the incident happened at the same senior housing residence involving the same doctor as your other case (Scenario #1 above). It is important to point out the links between related cases in your case notes, including the associated case numbers.

5. Make a referral to the CMS RO DOI liaison due to the marketing violations and the senior housing resident’s need for help with the inappropriate disenrollment from Original Medicare.

6. Though the provider’s violation of confidentiality in this case could warrant quality complaints, the egregious nature of this issue dictates that you should leave it in the hands of investigators rather than conducting further referrals to quality improvement organizations or state certification boards – unless you are told otherwise by ACL when you make your referral. You do not want to compromise an investigation.

Complex Issue Involving Part D Marketing

Scenario:

A beneficiary named Carmela was called by an ABC Health Care insurance sales agent who informed her that he was working with low income people to help them get some new benefits they are entitled to, called “Extra Help.” Carmela told the agent she was not interested. However, the next day the agent showed up at her door. He said he was from Medicare, so Carmela let him in. After talking awhile, the agent handed her an ABC Health Care folder. The agent told her that not only would his plan cover her prescriptions, but her doctor was also part of the ABC Health Care provider network. She told him that she still didn't want to change plans because she didn’t want to risk having to change doctors. She was interested in the Extra Help program he described, however.

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A week later, Carmela went to her pharmacy to pick up her prescription drugs and found that she had been switched to a different plan. The prescriptions she was on were not covered under the new plan. She tried to contact the ABC Health Care sales agent who had visited her but the telephone number he provided was out of service. She then contacted the SMP program, having received the SMP brochure at a senior center presentation. She told the SMP that she never agreed to enroll in ABC Health Care. She thought she was only signing up for Extra Help.


• Insurance agents cannot represent themselves as being “from Medicare.”

• Insurance plans cannot make unsolicited telephone calls to beneficiaries with whom they have no prior relationship.

• Insurance plans cannot solicit door to door and cannot visit a beneficiary in the home without an approved scope of sale.

• Extra Help applications are handled through the Social Security Administration, not insurance sales agents (see Chapter 2 of the SMP Foundations Training Manual).

• The insurance agent’s misrepresentations resulted in possible medical identity theft (he obtained her Medicare number) and in her disenrollment from the plan of her choice.

• Carmela’s health and financial well-being were negatively impacted due to the loss of coverage for her prescriptions and subsequent out-of-pocket expenses.





2. Inform Carmela about the SMP referrals process and that she may or may not be contacted by an investigator.

3. Explain that the CMS RO DOI liaison will help her return to the plan of her choice.

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4. Explain to Carmela that she can work with her pharmacist to arrange temporary coverage for prescriptions while her enrollment request is being processed by a CMS representative.

o Educate Carmela about the other appropriate consumer protection and public benefits organizations that can help her, offering assistance in working with them if needed:

§ Inform Carmela that she should contact the Social Security Administration to complete a legitimate Extra Help application or that her state SHIP program can also help (visit www.shiptacenter.org).

§ Inform Carmela of the role of the Better Business Bureau and the procedures for filing a complaint, if she wishes to do so.

5. Refer this case to the CMS RO DOI liaison due to the marketing violations, inappropriate disenrollment from her plan, and enrollment in another plan against her wishes.

6. Make a referral to the state department of insurance due to the egregious agent behavior.

7. Check back with either Carmela or the CMS RO DOI liaison within two weeks to ensure Carmela is re-enrolled in her original Part C and Part D plan.

Complex Issue Involving Prescription Drugs

Scenario:

A beneficiary named Jose calls the SMP to complain that for the third time this year his pharmacy dispensed fewer pills than he was supposed to receive. Each time, he complained to the pharmacy and they corrected the problem. Still, he finds it suspicious that the problem keeps occurring.


It is impossible for the SMP to know whether the pharmacy is knowingly or intentionally shorting their customers on pills. In Jose’s case, if he did not count his pills, find the error, and ask the pharmacy to correct the error, the pharmacy’s practices would have resulted in payment for services that do not meet professional standards. With this happening to Jose three times, there is a pattern and Jose’s efforts to stop the pattern have had no effect.

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2. Tell Jose that you will refer his case to the OIG Hotline, which also works with CMS. Ask him to contact you if the pill-shorting happens again.

3. Make a referral to the OIG Hotline via ACL for suspected prescription drug fraud or abuse.

Complex Issue Involving Both Medicare and Medicaid

Scenario:

David, a Medicare beneficiary dually enrolled in Medicaid, contacts the SMP because he received a notice from a collection agency to pay more than $5,000 to the hospital that treated him for a serious illness two years ago. This was the first time anyone contacted him about a bill. He was surprised to be billed for the charges not covered by Medicare because Medicaid was supposed to cover them. In addition to the notice from the collection agency, the hospital sent him a letter saying they were going to sue him. David was distraught and overwhelmed.


• Because of his dual enrollment in Medicare and Medicaid, David was not responsible for the $5,000 charges. The hospital was in error for trying to obtain payment from him.

• David should not have been sent to collections for a bill that was not his responsibility.

• There seems to have been a breakdown in the payment process between the hospital and the state Medicaid office.


1. Determine whether or not the beneficiary can take action on his or her own behalf. In this example, David is overwhelmed and asked the SMP intervene. He has already made many calls and doesn’t feel like anyone is listening to him.

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2. Gather information. Begin with the Medicaid office to verify that David was covered by Medicaid at the time of service. If so, determine why Medicaid did not pay for the charges Medicare didn’t cover.

o In this example, the Medicaid case worker said the hospital never completed and returned the paperwork required by Medicaid to reimburse the hospital.

o Ask the case worker for information about who at the hospital should be contacted to complete the appropriate steps.

3. Contact the hospital and request that they remedy the situation. Provide them with the information you received from the Medicaid office. Remedies from the hospital should include:

o Submitting a proper claim to Medicaid

o Canceling the involvement of a collection agency

o Sending David a letter removing the threat to sue

4. Follow up with David to inform him of your progress. Ask him to contact you when the problem has been resolved so that you can close the case. Request copies of the revised letters and bills that he receives so that you can document cost avoidance for the OIG Report. Contact him if he does not contact you to ensure that the problem gets resolved.

5. If the hospital neglects to complete the needed paperwork and remedy the situation, make a referral of suspected Medicaid abuse to the OIG Hotline via ACL and the state Medicaid Fraud Control Unit.

Complex Issue Involving Compromised Medicare Numbers

Scenario:

Your SMP receives a complaint from Harriet, who was called by a man from Medicare who asked for her Medicare number in order to issue a new Medicare card. Because the caller threatened her with a loss of Medicare benefits if she didn’t comply. Fearing the loss of her benefits, Harriet gave her Medicare number to the caller. Later, she realized this may have been a mistake and called the SMP.


• Medicare does not issue new Medicare cards (Medicare beneficiaries receive a Medicare card upon enrollment and lost cards can be replaced through the Social Security Administration, not Medicare).

• Most importantly, Medicare will not call beneficiaries to offer a new card.

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NOTE: As you learned in SMP Foundations, Medicare contractors may contact a small percentage of beneficiaries to conduct a Medicare Current Beneficiary Survey. Beneficiaries selected for surveys receive letters in advance, however. Medicare Advantage Plans can also call their existing members to discuss their benefits.

• Harriet was the victim of a common consumer scam targeting Medicare beneficiaries. Because she gave out her Medicare number, it is now compromised and she is at risk for medical identity theft.

• See the SMP Foundations Training Manual, Chapter 4, for more information about this scam.


1. Tell Harriet that her Medicare number has been compromised and that you will report it to the Office of Inspector General (OIG), who will also alert Medicare.

2. Tell Harriet that she should scrutinize her future MSNs or EOBs for services she did not receive and providers she doesn’t know, since she may be a victim of medical identity theft. Tell her to contact the SMP again if she receives more suspicious calls or notices suspicious activity on her MSNs or EOBs.

3. Because Medicare numbers contain Social Security numbers, tell her that she also may become a victim of financial identity theft. Explain how the Federal Trade Commission (FTC) can help.

• The FTC does not resolve individual complaints but filing a complaint with the FTC alerts criminal and civil law enforcement nationwide.

• The FTC has information on its website for identity theft victims: www.ftc.gov/idtheft.

4. Report the scam to your local and state consumer protection authorities, including:

o Local law enforcement

o Your state attorney general’s office

5. Work with the staff at your SMP who conduct public education so that Medicare beneficiaries and caregivers in your state can be warned.

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Complex Issue Involving Quality of Care

Scenario:

A caregiver named Joe calls with concerns about his father, who had received Medicare-covered home health services after a surgery. His father’s doctor will not recertify those services to continue. Joe said that his father is unsafe in his home without the continuation of home health services and disagrees with the doctor’s decision. Joe feels his father still needs skilled nursing and home health aide services in particular, due to his poorly healing wound and his inability to manage it adequately on his own. Joe said his mother had received home health services much longer after a serious surgery and he thinks it is unfair that his father is not receiving an equal quality of care.


• Suspected poor quality of care

• Need for recertification of skilled nursing and home health aide services (see the SMP Foundations Training Manual, Chapter 4)


1. Explain the SMP role and that the problem seems to be poor quality of care, which is handled by Medicare’s Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

2. Tell Joe that you will refer his complaint to the BFCC-QIO on his behalf but that you may not be able to learn the outcome, as BFCC-QIOs are not obligated to follow up with SMPs (see Chapter 4 of this manual for more information about referrals to the BFCC-QIO).

3. Give Joe the BFCC-QIO contact information so that he can follow up with them directly for updates on his case.

4. Suggest other appropriate avenues for this caregiver to pursue in order to remedy the situation:

o Contact the prescribing physician and ask him to reconsider his decision.

o Seek a second opinion from another doctor.

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Medicare Coverage Complaint

Scenario:

A beneficiary named Edward calls the SMP in June, upset because his doctor of 18 years chose to no longer be a covered provider under his particular Medicare Advantage Plan. He has multiple complicated health problems and doesn’t believe another doctor could possibly understand him. He can’t afford to pay out of pocket for his expensive care. He read that the SMP program addresses Medicare fraud. He thinks being forced to find another doctor who participates in his plan is fraud.


• Client dissatisfaction with his Medicare coverage


1. Listen empathetically to his complaint.

o Refer to the SMP Counselor Training Manual for tips on effective counseling skills.

2. Explain that this is a Medicare coverage issue outside the scope of the SMP program rather than suspected fraud. Explain that there are other resources to help him find a covered provider and educate him about when he can change his Medicare coverage and leave his current plan, if desired.

o Suggest that he contact his Medicare Advantage Plan to receive a list of covered physicians.

o Suggest he talk with his doctor about his concerns and to find out what coverage his doctor does accept.

o Provide him with the state SHIP contact information to receive Medicare coverage guidance (see www.shiptacenter.org).

o Remind him of the services of 1-800-Medicare.

3. This complaint does not involve suspected Medicare fraud, errors, or abuse and is not an SMP complex issue. Enter this conversation in the SMP data reporting system as a simple inquiry.

NOTE: For more information about the difference between complex issues and other types of questions received by SMPs, see Appendix A of the SMP Counselor Training Manual.

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Closing

Strategies used by unscrupulous individuals involved in health care fraud are vast and ever-changing. It is impossible to outline every kind of scenario you may encounter in your work at the SMP. Because the methods used to prevent, detect, and report fraud, errors, and abuse evolve over time, this manual will be updated periodically. In addition to the training provided in this manual, the SMP National Resource Center periodically offers additional complex issues and referrals training through webinars, newsletter articles, and online at www.smpresource.org.

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