Transcript Medicare and Durable Medical Equipment: Protect Yourself from Fraud! Updated August 2014 What We Will Cover Today • The SMP Program • Medicare and Durable.

Medicare and Durable Medical
Equipment: Protect Yourself
from Fraud!
Updated August 2014
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What We Will Cover Today
• The SMP Program
• Medicare and Durable Medical
Equipment (DME)
• DME and Fraud
• Protect, Detect, Report!
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How Much is Lost?
How much do you think is lost every year to
health care fraud and abuse?
A) $5-10 million
B) $25-125 million
C) $10-20 billion
D) $75-250 billion
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How Much is Lost?
How much do you think is lost every year to
health care fraud and abuse?
A) $5-10 million
B) $25-125 million
C) $10-20 billion
D) $75-250 billion
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Fraud affects:
• Medicare & Medicaid Beneficiaries
– Loss of benefits
– Higher premiums
– Identity theft
• Taxpayers
– Medicare is paid for by taxes
– Billions of taxpayer dollars wasted
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Why Report Fraud?
• Health care fraud puts you at risk for
identity theft.
• IT’S YOUR MONEY!
• Taxpayer dollars
• Higher premiums
• Saving the Medicare Program
• People who commit fraud are STEALING
from you, not helping you!
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Why Report Fraud?
• Your Medicare account may be flagged:
“Do Not Pay!”
• When things aren’t ordered by your
doctor, they may not fit or work properly.
• When someone gives you something that
you don’t need:
• Your health may get worse
• Your Medicare benefits may be “used up”
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The SMP Program
www.illinoissmp.org
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The SMP Program
• Senior Medicare Patrol
• National Program
– SMP Programs in all 50 states, Washington,
D.C., Puerto Rico, Guam, Virgin Islands
• Goals of program:
– Recruit volunteers to provide outreach
– Educate consumers about health care fraud
and abuse
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SMP Staff and Volunteers…
• Give presentations to groups (like this one!)
• Share information and materials at health
fairs or other events
• Help people with questions about billing
mistakes or fraud issues
• Help report fraud to investigators
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Illinois SMP Program Partners
• Illinois Area Agencies on Aging
• Catholic Charities
• White Crane Wellness Center
• Coalition of Limited English Speaking Elderly
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Medicare & Durable Medical
Equipment (DME)
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What is DME?
• Durable Medical Equipment (DME) is
reusable medical equipment, such as:
– Wheelchairs
– Walkers
– Oxygen Equipment
– Hospital Beds
– Canes
– Crutches
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What is DME?
• Medicare also covers many Prosthetics,
Orthotics, and Supplies, such as:
– Arm, leg, back, and neck braces
– Artificial limbs and eyes
– Diabetic supplies
– Therapeutic shoes or inserts for people
with diabetes who have severe diabetic
foot disesase
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When is DME Covered?
• Durable Medical Equipment is covered by
Medicare when it is medically necessary
- a doctor must prescribe it for you.
• Medicare Part B covers Durable Medical
Equipment when you are going to use it in
your home. If you are in a hospital or
skilled nursing facility, the hospital or
nursing facility should provide you with the
equipment you need while you are there.
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When is DME Covered?
Medicare will only cover DME if it is provided by
a Medicare approved DME supplier. To find a
Medicare approved supplier in your area:
• Call 1-800-MEDICARE (1-800-633-4227)
OR
• Go to Medicare’s website: www.medicare.gov.
Click on “Find Suppliers of Medical Equipment
in Your Area.”
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Power Wheelchairs and Scooters
• Medicare will cover power wheelchairs
and scooters when they are necessary for
your medical condition.
• Medicare will NOT cover a power
wheelchair or scooter if it is only
needed/used outside of the home – these
devices are meant to be used mostly
inside the home.
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How Much Does DME Cost?
• If you have Original Medicare and the
DME supplier “accepts Medicare
assignment,” Medicare will usually pay
80% of the cost of medically necessary
DME. You will usually pay the remaining
20%, after you have paid your Part B
deductible for the year. (Note: If you have
a Medigap or other supplement plan, that
plan may cover this 20%.)
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How Much Does DME Cost?
• If you have Original Medicare and the
DME supplier does NOT “accept
assignment,” there is no limit to what the
supplier can charge you!
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How Much Does DME Cost?
• If you are on a Medicare Advantage plan,
the plan must cover the same items and
services as Original Medicare. However,
the costs will depend on the plan.
• Call your plan to find out if your DME will
be covered and what it will cost.
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Buying vs. Renting DME
• Medicare has rules about when DME will be
rented and when it may be purchased. In
general, certain types of equipment are
usually rented (for example, oxygen
equipment), but other types of equipment
may be bought (canes, walkers, etc.). To find
out if a particular piece of equipment will be
rented or bought, ask the DME supplier or
call 1-800-MEDICARE (1-800-633-4227).
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How Do I Get DME If I Need It?
• If you think you may need medical
equipment, talk to your doctor. S/he will
write a prescription, and if necessary,
complete a “Certificate of Medical
Necessity” – a form that your doctor sends
to Medicare to get approval for certain
kinds of equipment.
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How Do I Get DME If I Need It?
• Before ordering equipment, ask the
supplier if they accept Medicare
“assignment.” If a supplier is enrolled in
Medicare, but does not accept
“assignment,” they can charge you
whatever they want.
• If a supplier is not enrolled in Medicare,
Medicare will not pay for the supplies.
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Durable Medical Equipment
(DME) and Fraud
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DME and Fraud – Medicare Rules
• NO unsolicited telemarketing
– DME suppliers may only contact you if:
• 1) you have given the supplier written permission to
contact you
• 2) the contact is about an item that the company
already provided to you, OR
• 3) the supplier has provided you with at least 1 item
in the last 15 months
– This rule also applies to solicitations
through email, instant messages, in-person
contact, or internet advertising.
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DME and Fraud – Medicare Rules
• DME suppliers must maintain a physical
facility that is open and accessible to the
public.
– In most cases, the supplier must be open to the
public at least 30 hours a week
– The facility must be staffed and accessible
during posted hours of operation
• DME suppliers must have a primary business
telephone number – cell phones may NOT be
used as primary business numbers.
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DME and Fraud – What is Fraud?
• Billing for equipment that you never
received
• Billing for equipment that is different than
what you received
• Billing for more advanced equipment than
what you need
• Giving false or misleading information, such
as offering of “free” equipment when they
are going to bill Medicare
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DME Fraud Schemes:
Scooter Scam
• A DME salesman visits a senior center and
offers everyone at the senior center a “free”
scooter. The salesman asks each person
for his/her Medicare number. The company
then bills Medicare as if they provided each
person with an electric wheelchair. As a
result, when one of these people needs an
electric wheelchair two years later,
Medicare will not pay for it.
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DME Fraud Schemes:
Scooter Scam
• Problems:
– Billing for a more expensive item than what was
provided (wheelchair instead of scooter)
– Equipment given was not medically necessary
– scooters were given to everyone at the senior
center, regardless of medical necessity
– Salesperson offers scooters as “free” and
waives copayments – false and misleading
information
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DME Fraud Schemes:
Diabetic Shoe Scam
• A DME supplier sets up a table in the lobby
of a senior building with a sign that says
“Free shoes for Medicare beneficiaries!”
When senior residents approach the table,
they are given a pair of shoes from a local
convenience store, in exchange for their
Medicare numbers. The supplier then bills
Medicare for “medically necessary” diabetic
shoes for each person.
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DME Fraud Schemes:
Diabetic Shoe Scam
• Problems:
– False/misleading advertising – “free” shoes
– Lack of medical necessity – shoes are being
given to anyone with Medicare coverage,
regardless of whether they have diabetes and
actually need the shoes
– Billing for diabetic shoes while providing
cheaper, non-medical shoes
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DME Fraud Schemes:
Arthritis Kit Scam
• One Saturday morning, Joe receives a visit from a
man who asks if he has arthritis. When Joe
answers, “yes,” the man tells Joe that he is going
to give him a great new product – an “arthritis kit”
– for free! All he needs is Joe’s Medicare number.
Joe gives it to him, and the man gives Joe a
package containing a lamp, a knee brace, and a
box of gloves. Two months later, Joe receives his
Medicare Summary Notice, which shows charges
for thousands of dollars worth of orthotic braces!
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DME Fraud Schemes:
Arthritis Kit Scam
• Problems:
– No such thing as an “arthritis kit” – this is
always a scam!
– Unsolicited door-to-door marketing, asking for
Medicare number
– No prescription or certificate of medical
necessity by a doctor
– Billing for products different than what was
given
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DME Fraud Schemes:
Telemarketing of Diabetic Supplies
• While watching TV one afternoon, Sonia receives
a phone call. When she answers, a robotic voice
asks her to press “1” if she has diabetes. Sonia
presses 1 and speaks to someone who offers to
send her free diabetic supplies. Sonia gives the
caller her Medicare number, but she never
receives any supplies. Now, Sonia is concerned
about identity theft because she realizes that her
Medicare number is the same as her Social
Security number.
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DME Fraud Schemes:
Telemarketing of Diabetic Supplies
• Problems:
– Unsolicited telemarketing, asking for Medicare
number over the phone
– Possible billing for supplies never provided (if
the company is billing for the supplies that have
never been given to Sonia)
– Possible identity theft – the caller could be
using Sonia’s Social Security number to gain
access to other information and accounts.
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Protect!
Detect!
Report!
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PROTECT Yourself
From Fraud!
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PROTECT Yourself From
Fraud!
• If you need durable medical equipment,
prosthetics, orthotics, or supplies, contact
your doctor.
• Do NOT accept services from DME
suppliers who:
– Ask you to use their doctor
– Contact you without your permission
– Tell you that their equipment is “free”
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PROTECT Yourself From
Fraud!
• Do NOT give your Medicare number to
people you do not know!
– On the phone
– At the door
– At a presentation, exercise class, “free”
screening, etc. (“Free” services do not
require a Medicare number!)
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PROTECT Yourself From
Fraud!
• Do NOT accept services from someone
who calls or visits you unexpectedly, even
if they say that your doctor sent them!
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PROTECT Yourself From
Fraud!
• When you order DME, prosthetics,
orthotics, or supplies, ask for a copy of all
documentation for the equipment or
supplies.
• Do NOT sign any forms or paperwork
without reading them first. Never sign
blank forms.
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DETECT Fraud!
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DETECT Fraud!
• Read your Medicare Summary Notice
or Explanation of Benefits from your
insurance company. Watch for:
– Services or supplies that you did not get
– Services or supplies that were not
ordered by your doctor
– Billing for the same thing twice
– Other billing errors
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REPORT Fraud!
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REPORT Fraud!
• If you have questions about services that
you did receive, contact your doctor or the
DME supplier first.
• If this does not work or you suspect fraud
(for example, you see a claim on your
Medicare Summary Notice for a service
that you never received), call the Illinois
SMP program at:
(800)699-9043
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Volunteers are the key to
spreading the SMP message!
We need YOUR help!
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Thank you!
If you have questions, contact:
AgeOptions
(800)699-9043
This presentation was supported in part by a grant (No. 90MP0163 and
90SP0061) from the Administration on Aging (AoA), Administration
for Community Living (ACL), U.S. Department of Health and Human
Services (DHHS). Grantees carrying out projects under government
sponsorship are encouraged to express freely their findings and
conclusions. Therefore, points of view or opinions do not necessarily
represent official AoA, ACL, or DHHS policy.
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