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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.