MEDICARE FRAUD

WHAT IS MEDICARE?

  • Medicare is a far-reaching federal health insurance program for people who are 65 or older, certain younger people with disabilities, or people with end-stage renal disease, in the United States.1

  • Approximately 59 million Americans are enrolled in Medicare.2

WHAT IS MEDICARE FRAUD?

  • Medicare Fraud typically includes knowingly submitting, or causing to be submitted, false claims or making representations of the fact to obtain a Federal healthcare payment for which no entitlement would otherwise exist.

  • It includes knowingly soliciting, receiving, offering, or paying remuneration (e.g. kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by Federal health care programs; making prohibited referrals for certain designated health services.

  • Some of the examples of Medicare fraud include:

    • knowingly ordering medically unnecessary items or services for patients

    • billing Medicare for patient appointments they fail to keep

    • knowingly billing for services not furnished or supplies not provided

    • knowingly billing for services at a level of complexity higher than services actually provided or documented in the health records

    • or paying for referrals of Federal health care program beneficiaries.

  • During FY 2017, Medicare Fraud Strike Force filed fraud charges against 478 defendants for Medicare Fraud.3

LAW AGAINST MEDICARE FRAUD

The US Department of Health and Human Services (DHHS) and Department of Justice (DOJ) are working to combat the different types of health care fraud through the False Claims Act, Anti-Kickback statue, and the Stark Law.4

  • The False Claims Act of 1863 (FCA) imposes civil liability on any person who submits or causes to be submitted a false or fraudulent claim to the federal government for payment or approval, either knowingly or due to deliberate ignrance.5,6

  • The Anti-Kickback Statue of 1972 prohibits any person from knowingly or willfully offering, paying, soliciting, or receiving remuneration for making a referral to or inducing business from a federally reimbursed healthcare program, including Medicare and Medicaid.5,7

  • Lastly, the Physician Self-Referral Law of 1989 (Stark Law) prohibits physicians from making referrals to certain designated health services paid for by Medicare or Medicaid.5,                                   
                                                                                                               FRAUD ALERT
    Protect Your Patients Against Medicare Fraud During Open Enrollment:

  • The risk for Medicare Fraud increases during the open enrollment period that runs from November 1, 2019 to December 15, 2019 for 2020. Medicare enrollment fraud can occur when a representative or a plan agent purposefully tricks the person into enrolling in their plan without the plan being right for the person.
     

  • Some of the ways of detecting fraud are by watching out for people:

    • who pressure you with time limits to enroll in their plan,

    • who ask for your Medicare number, Social Security Number, and/or bank information just to provide you with information,

    • who threaten you with the loss of your Medicare benefits unless you sign up for their plan,

    • who offer you gifts to enroll in their plan,

    • or who say they represent Medicare.9
       

  • It is important to confirm everything that a plan agent tells your patient before making a final decision about a plan. Ask for everything in writing and call your doctors to make sure that they are in the provider network for the plan they want to join. Never give your Medicare information to anyone but your trusted health providers.9  
     

  • If your patient feels a plan or agent has violated Medicare’s marketing rules, they should save all documented proof, when available, such as an agent’s business card, the plan’s marketing materials, and their phone call records. Report the activity to 1-800-MEDICARE or to the local Senior Medicare Patrol (SMP). Also, if your patient thinks they were enrolled in a plan without their permission, contact 1-800-MEDICARE or the local SMP to report it and request assistance. They can also contact their State Health Insurance Program (SHIP) for help changing their plan. Medicare allows victims of enrollment fraud to makes changes outside of Medicare’s Open Enrollment Period. 9
                                                                          PROTECT YOUR PATIENTS FROM MEDICARE FRAUD!

  • References:

  • Medicare.gov. https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare Published 2019. Accessed October 18, 2019.

  • National Totals. Centers for Medicare & Medicaid Services. https://data.medicaid.gov/Enrollment/National-Totals/e334-kugr Published 2019. Accessed October 18, 2019.

  • Center for Medicare and Medicaid Services. Cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf. Accesses October 18, 2019.

  • DiSantostefano J. Medicare Fraud and Abuse Issues. The Journal for Nurse Practitioners. 2013;9(1):61-63.

  • Krause JH. Kickbacks, self-referrals, and false claims: The hazy boundaries of health-care fraud. Chest. 2013;144(3):1045-1050.

  • Fentin SG. The False Claims Act-Finding Middle Ground between Opportunity and Opportunism: The Original Source Provision of 31 USC 3730 (e)(4). W New Eng L Rev. 1995;17:255.

  • Kalb PE. Health care fraud and abuse. JAMA. 1999;282(12):1163-1168.

  • Sutton PA. The Stark Law in Retrospect. Annals Health L. 2011;20:15.

  • Albama Department of Senior Services. Medicare Minute Script – September 2019 Protecting Yourself from Enrollment Fraud