Reporting Medicare Fraud

What is Fraud and Abuse?

While most health care providers, beneficiaries and employees are honest, a small minority commit health care fraud and abuse that can cost the Medicare program a lot of money every year and harm beneficiaries. Fraud is an intentional representation that a person knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person. The most frequent kind of fraud arises from a false statement or misrepresentation that can affect a person???s eligibility, enrollment or payment under the Medicare program. The violator may be any person in a position to file a claim for Medicare benefits, sell a plan, or write or fill a prescription.

Fraud schemes range from those committed by individuals acting alone to more complex activities committed by institutions or groups of individuals. It can be telemarketing and other promotional techniques that misrepresent the health plan and its benefits or it can be offering kickbacks to providers or other individuals to steer a beneficiary???s enrollment into a specific plan.

Although Medicare beneficiaries tend to be the victims of fraud, sometimes they can be perpetrators of fraudulent, wasteful behavior. Windsor takes fraud and abuse of all kinds seriously and has processes in place to detect and report cases of suspected unethical activities.

Examples of beneficiary fraud, waste or abuse:

Misrepresentation of status: A Medicare beneficiary misrepresents personal information, such as identity, eligibility, or medical condition in order to illegally receive the drug benefit. Enrollees who are no longer covered under a drug benefit plan may still attempt to use their identity card to obtain prescriptions.

Identity theft: Perpetrator uses another person???s Medicare card to obtain prescriptions.

True out of Pocket (TrOOP) manipulation: A beneficiary manipulates TrOOP to push through the coverage gap, so the beneficiary can reach catastrophic coverage before they are eligible.

Prescription forging or altering: Where prescriptions are altered, by someone other than the prescriber or pharmacist with prescriber approval, to increase quantity or number of refills, especially narcotics.

Prescription diversion and inappropriate use: Beneficiaries obtain prescription drugs from a provider, possibly for a condition from which they do not suffer, and gives or sells this medication to someone else. Also can include the inappropriate consumption or distribution of a beneficiary???s medications by a caregiver or anyone else.

Resale of drugs on black market: Beneficiary falsely reports loss or theft of drugs or feigns illness to obtain drugs for resale on the black market.

Prescription stockpiling: Beneficiary attempts to ?game? their drug coverage by obtaining and storing large quantities of drugs to avoid out-of-pocket costs, to protect against periods of non-coverage (i.e., by purchasing a large amount of prescription drugs and then disenrolling), or for purposes of resale on the black market.

Doctor shopping: Beneficiary or other individual consults a number of doctors for the purpose of inappropriately obtaining multiple prescriptions for narcotic painkillers or other drugs. Doctor shopping might be indicative of an underlying scheme, such as stockpiling or resale on the black market.

Improper Coordination of Benefits: Improper coordination of benefits where beneficiary fails to disclose multiple coverage policies, or leverages various coverage policies to ?game? the system.

BACK TO TOP

Health Plan Marketing Schemes and Sales Tactics

A beneficiary may be victimized by a marketing scheme where a health plan, or its agents, violates the Medicare Marketing Guidelines, or other Federal or State Laws, Rules, and Regulations to improperly enroll the beneficiary in a Part D Plan. Some examples of marketing or sales fraud and abuse are:

Misrepresentation: The plan must provide beneficiaries with complete and accurate information. This includes information on the use of network vs. non network providers, benefit limits and co-pays and other plan requirements that can effect payment of a claim or access to services.

Discrimination: A plan must enroll all eligible Medicare beneficiaries who want to enroll, regardless of their age, health status or the amount or cost of the health services needed unless the beneficiary has End Stage Renal Disease (ESRD) and is receiving dialysis. Beneficiaries with ESRD however, should keep their original Medicare coverage until off of dialysis or after a kidney transplant.

Gifts for enrolling: It is illegal for a health plan to offer free gifts or incentives to get anyone to enroll in their plans. Gifts can be distributed at marketing events as long as the value of the gift is under $15.00 and as long as everyone at the event is eligible for the gift regardless of whether they enroll in the plan. There should never be an obligation attached to a marketing promotion.

Door Knocking and Unsolicited Sales Visits: Sales representatives are not allowed to go to people???s homes unless they have been given permission by the beneficiary in advance. This restriction applies to any personal residence, including a room in a nursing home, rest home or assisted living arrangement.

Telemarketing: Sales agents must comply with the National-Do-Not-Call Registry and honor ?do not call again? requests. They also cannot ask for payment over the telephone or web. The plan must send a bill.

Non-Compliance with Anti-Kickback Laws: The purchase or sale of goods and services must not lead to employees, providers or agents receiving kickbacks. Kickbacks or rebates may take many forms and are not limited to direct cash payments or credits. If an employee, agent or a provider stands to gain personally through a transaction, it is prohibited.

BACK TO TOP

Provider Fraud

Beneficiaries should be suspicious if their doctor tells them any of the following things:
  • Your test is free; he only needs your Medicare number for his records.
  • Medicare wants you to have the test or service.
  • They ?know how to get Medicare to pay for it.?
  • The more tests they provide the cheaper they are.

Be suspicious of providers that:

  • Make billing errors such as charging co-payments on clinical laboratory tests, and on preventive services such as PAP smears, prostate specific antigen (PSA) tests, or flu and pneumonia shots.
  • Advertise “free” consultations to people with Medicare.
  • Claim they represent Medicare.
  • Use pressure or scare tactics to sell high priced medical services or diagnostic tests.
  • Bill Medicare for services you did not receive.

BACK TO TOP

How to Prevent Fraud

  • Whenever you receive a payment notice from your health plan or Medicare, review it for errors. The payment notice shows what was billed for, what the plan paid and what you owe.
  • Don’t ever give out your Medicare Health Insurance Claim Number (on your Medicare card) except to your provider.
  • Don’t allow anyone, except appropriate medical professionals, to review your medical records or recommend services.
  • Do be careful in accepting health services that are represented as being free.
  • Do be cautious when you are offered free testing or screening in exchange for your Medicare card number.
  • Do be cautious of any provider who maintains they have been endorsed by the Federal government or by Medicare.

BACK TO TOP

How to Report Your Concerns

Windsor Health Plan, Inc. wants to hear from you if you have any concerns.

WHP has a ?fraud hotline? through which employees, health care providers, and enrollees can report potential violations. This ?hotline? ensures that these reports cannot be diverted by supervisors or other personnel. This is a confidential phone number and you may stay anonymous if you prefer. The ?hotline? number is made available to all employees, enrollees, providers and independent contractors. Simply call 1-615-782-7899; toll free, 1-866-379-2438; or, TTY: 1-800-848-0298.

You can also write Windsor Health Plan, Inc. to report suspected fraud. Please send your concerns to:

Windsor Health Plan, Inc.
7100 Commerce Way Suite 285
Brentwood, TN 37027
Attention: Compliance Department

You can also contact the following government offices:

Centers for Medicare & Medicaid Services (CMS)

7500 Security Blvd.
Baltimore, MD 21244-1850
1-800-633-4227, TTY 1-877-486-2048 or
1-877-7SAFERX (1-877-772-3379)
24 hours a day; seven days a week

Medicare

Suspicions of fraud or abuse may also be reported to Medicare???s Customer Service Center at:

1-800-MEDICARE (1-800-633-4227) TTY Toll-Free: 866-226-1819 www.medicare.gov

Social Security Administration – Office of Public Inquires

Windsor Park Blvd.
6401 Security Blvd.
Baltimore, MD 21235
1-800-325-0778 / TTY 1-800-325-0778
7 a.m. ??? 7 p.m.
“http://www.ssa.gov”: www.ssa.gov

SHIP – Seniors Health Insurance Information Program

Tennessee:
Commission on Aging and Disability
Toll Free (877) 801-0044 / TDD: (615) 532-3893 / state.tn.us/comaging

Arkansas:
Seniors Health Insurance Information Program (SHIIP)
Arkansas Insurance Department: (800) 224-6330
Access Arkansas

Alabama:
SHIP Office: (800) 243-5463 “www.ageline.net”: http://www.ageline.net

Mississippi:
MS Insurance Counseling and Assistance Program (MICAP)
(800) 948-3090 / (601) 359-4929
www.mdhs.state.ms.us

BACK TO TOP

Healthcare Providers Who Have been Excluded from the Medicare Program

The HHS Office of Inspector General is responsible for excluding individuals who have participated or engaged in certain impermissible, inappropriate, or illegal conduct. The OIG???s List of Excluded Individuals and Entities (LEIE) provides information on all healthcare providers and facilities currently excluded from participation in the Medicare and other Federal health care programs. The exclusion list, along with other information pertaining to OIG exclusions, may be accessed at http://oig.hhs.gov/fraud/exclusions.html via the Internet.

Contacting the HHS OIG Hotline

By Phone: 1-800-HHS-TIPS (1-800-447-8477)
By Fax: 1-800-223-8164
By E-Mail: HHSTips@oig.hhs.gov
By TTY: 1-800-377-4950

By Mail:
Office of Inspector General
Department of Health and Human Services
Attn: HOTLINE
330 Independence Ave., SW
Washington, DC 20201

The General Services Administration (GSA)Website

The GSA is responsible for maintaining an index of individuals and entities that have been excluded throughout the U.S. Government from receiving Federal contracts or certain subcontracts and from certain types of Federal financial and non-financial assistance and benefits. The GSA maintains the Excluded Parties List System (EPLS), which may be accessed at http://epls.arnet.gov via the Internet.

BACK TO TOP