Health Care Fraud and Abuse Control Program Protects Consumers

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This fact sheet comes from the U.S. Department of Justice.

The Affordable Care Act Has Helped the Government Fight Fraud, Strengthen Health Insurance Programs, Protect Consumers, and Save Taxpayer Dollars

The Obama Administration is committed to reducing fraud, waste, and abuse across the government.  Since 2010, the U.S. Department of Health & Human Services, Office of Inspector General (HHS OIG), the Centers for Medicare & Medicaid Services (CMS), and the U.S. Department of Justice (DOJ) have been using powerful, new anti-fraud tools to protect Medicare and Medicaid by shifting from a “pay and chase” approach toward fraud prevention. Through the groundbreaking Healthcare Fraud Prevention Partnership, stronger relationships have been built between the government and the private sector to help protect all consumers.

These focused efforts are successful.  In Fiscal Year (FY) 2015, the government recovered $2.4 billion as a result of health care fraud judgements, settlements and additional administrative impositions in health care fraud cases and proceedings.  Since its inception in 1997, the Health Care Fraud and Abuse Control (HCFAC) Program has returned more than $29.4 billion to the Medicare Trust Funds.  In this past fiscal year, the HCFAC program has returned $6.10 for each dollar invested.

The Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint initiative between HHS, OIG, and DOJ, has played a critical role in the fight against  health care fraud.

A key component of HEAT is the Medicare Fraud Strike Force – an interagency task force teams comprised of OIG and DOJ analysts, investigators, and prosecutors who target emerging or migrating fraud schemes, including fraud by criminals masquerading as health care providers or suppliers.

Since 2007, the Medicare Fraud Strike Force has charged over 2,536 individuals involved in more than $8 billion in fraud.  Many of these charges have resulted from coordinated, multi-district national takedowns. In June 2015, the Medicare Fraud Strike Force conducted its largest ever nationwide health care fraud takedown, which, for the first time, involved non-Strike Force participants and resulted in charges against a record 243 individuals for approximately $712 million in false Medicare and Medicaid billing.  Since its inception, the Medicare Fraud Strike Force has maintained a conviction rate of approximately 95 percent and an average term of incarceration of more than four years.

Another powerful tool in the effort to combat health care fraud is the federal False Claims Act.  In 2015, DOJ obtained over $1.9 billion in settlements and judgments from civil cases involving fraud and false claims against federal health care programs such as Medicare and Medicaid.  Since January 2009, DOJ has recovered more than $17.1 billion for the federal government in cases involving health care fraud.  In many of these cases, the department was instrumental in recovering additional billions of dollars for state health care programs.

Other steps the administration has taken to fight fraud include:

State-of-the-Art Fraud Detection Technology:  HCFAC funding also supported HHS OIG’s continued enhancement of data analysis capabilities for detecting health care fraud.  HHS OIG continues to use data analysis, predictive analytics, trend evaluation, and modeling approaches to better analyze and target oversight of HHS programs.  Analysis teams use data to examine Medicare claims for known fraud patterns, identify suspected fraud trends, and calculate ratios of allowed services as compared to national averages; new analytic tools and methods are being developed to perform more innovative and complex data analytics.  Combining the expertise of HHS OIG agents, auditors, and evaluators, as well as our HEAT partners, with data analytics and traditional investigative skills has fostered a highly effective model for fighting health care fraud.

Since June 2011, CMS uses the Fraud Prevention System (FPS) on all Medicare fee-for-service claims on a streaming, national basis.  Similar to the fraud detection technology used by credit card companies, FPS applies predictive analytics to claims before making payments in order to identify aberrant and suspicious billing patterns.  CMS uses leads generated by FPS to trigger actions that can be implemented swiftly.  Early results from FPS show significant promise.  Since 2011 the FPS identified savings (certified by HHS OIG) associated with these prevention and detection actions were $820 million.[1]  This resulted in more than a 10-to-1 return on investment for the first three years of implementation.

Enhanced Provider Screening and Enrollment Requirements:  Provider enrollment is the gateway to billing the Medicare program, and CMS implemented new critical safeguards in efforts to better screen providers enrolling in the Medicare program.  The Affordable Care Act required CMS to revalidate all existing 1.6 million Medicare suppliers and providers under new risk-based screening requirements.  As a result of revalidation and other proactive initiatives, CMS deactivated more than 500,000 enrollments meaning,  billing privileges were stopped for these providers but may be restored upon the submission and approval of an updated enrollment application. CMS also revoked more than 34,000 enrollments meaning, these providers were barred from re-entering the Medicare program for one to three years.  These enhanced screening and enrollment requirements have led to more than $2.4 billion in estimated Medicare savings since 2010.

In May 2014, CMS issued a final rule that requires prescribers of Part D drugs to enroll in Medicare and undergo screening.  In December 2014, CMS issued a final rule that provides additional authority to remove bad actors from the Medicare program, including providers affiliated with outstanding Medicare debts and providers that have a pattern or practice of abusive billing.

Health Care Fraud Prevention Partnership (HFPP):  The Obama Administration has joined with private insurers, states, and associations in the HFPP to prevent health care fraud on a national scale.  To detect and prevent payment of fraudulent billings, HFPP participants exchange information and best practices across the public and private sectors.  Since 2013, the HFPP has conducted eight studies that enabled partners, including DOJ, HHS-OIG, FBI, and CMS, states, private plans, and associations to take substantive actions, such as payment system edits, revocations, and payment suspensions to stop fraudulent payments and improve the government’s collective forces against fraud, waste, and abuse.

Senior Medicare Patrols:  The Obama Administration has expanded funding for Senior Medicare Patrols (SMP) – groups of  volunteers who educate and empower their peers to identify, prevent, and report health care fraud.  In 2014, the  SMP projects had a total of 5,249 active volunteers.  These volunteers conducted 202,862 one-on-one counseling sessions and 14,692 group education sessions.  In total, 452,714 beneficiaries attended these group education sessions.  The projects also reported conducting 110,615 media airings (e.g., print, radio, television, or electronic) to provide education about fraud and the services of the project.  Additionally, the projects reported conducting 12,417 community outreach education events.  Local SMP offices provide assistance when issues are identified, ensuring that mistakes are corrected and suspected fraud is referred to the appropriate authorities.  Since the program’s inception 18 years ago, $122 million in total estimated savings to Medicare and Medicaid is attributable to SMP projects.


[1] Note that a portion of the total FPS savings is comprised of payments prevented due to provider revocations. This amount is a subset of the $2.4 billion total prevented payments from revocations reported in section ‘Enhanced Provider Screening and Enrollment Requirements’ of this report.  Therefore, comparison of these two metrics may result in double-counting

Dallas-area doctors charged for roles in $13.4 Million Medicare fraud scheme

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This is being shared from the Healthcare Finance Website

By Beth J. Sanborn, Managing Editor

Two Dallas-area doctors have been charged, according to a superseding indictment that was unsealed Friday, for their alleged participation in a $13.4 million health care fraud scheme that bilked Medicare for millions.

Dr. Kelly Robinett, 66, of Denton County, Texas and Dr. Angel Claudio, 60, of Hood County, Texas were each charged with one count of conspiracy to commit healthcare fraud. They were also charged with multiple counts of health care fraud, announced the U.S. Attorney’s office.

Robinett owns Boomer Housecalls, which is based in Frisco, Texas.  Claudio, a medical doctor, works for Dallas-based Texas Medical Housecalls, the U.S. Attorney’s office said.

Patience Okoroji, 57, of Dallas County, Usani Ewah, 58, of Dallas County, Kingsley Nwanguma, 45, of Dallas County and Joy Ogwuegbu, 39, of Collin County who are charged in the current indictment, were also charged in a previous indictment that did not include the doctors.

Authorities said Okoroji and Ewah co-owned Timely Home Health Services Inc. (Timely), where Okoroji was an administrator and licensed vocational nurse. Ewah was the director of nursing and a registered nurse for Timely, Nwanguma was a licensed vocational nurse for Timely and Ogwuegbu was its former director of nursing.

The allegations accuse Robinett and Claudio of falsely certifying beneficiaries for home health care when the patients weren’t actually under their care and did not qualify for home health services. The defendants allegedly billed Medicare approximately $13,434,550 based on false home health certification signed by doctors, including Robinett and Claudio, as well as  false and fraudulent claims for home health services, said the U.S. Attorney’s office.


Missouri SMP publishes March fraud prevention fact

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The Missouri SMP is publishing monthly Fraud Prevention Facts to remind people of the most recent scams and the ways to protect themselves against them. Here is the March 2016 Fraud fact.

Skilled Nursing Facility Fraud

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Skilled nursing facilities play a crucial role in providing therapy and rehabilitation after you or a loved one has suffered a debilitating illness or stroke. After a qualifying stay in the hospital, Medicare beneficiaries frequently need some time in a rehabilitation center to regain their strength. However, some unscrupulous facilities (even some associated with national chains) have taken to fraudulent billing.

How the Scam Works

  • Fraudulent skilled nursing facilities (SNFs) typically engage in a type of billing fraud called “upcoding.” Upcoding is a misrepresentation of services rendered by using procedure codes not appropriate for the item or service actually furnished. The procedure codes that are used are reimbursed at a higher rate.
  • Another typical scheme used by fraudulent SNFs is where the patient is placed into the highest Resource Utilization Group (RUG) category. This category reimburses the rehab center the most Medicare money. The beneficiary receives excessive therapy time that is billed to the government. This excessive therapy is generally medically unnecessary and could be dangerous to the patient. In addition to physical and occupational therapy, the patient may receive podiatry foot care that may not have been indicated.

How to Fight Back

  • Remember, patients have a right to refuse unwanted and excessive therapy.
  • If you or a loved one is being threatened or coerced by staff to participate in therapy, report this conduct immediately.

From the Office of Inspector General (OIG), U.S. Department of Health & Human Services

Don’t Mess with Martha!

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It’s another hot summer day and Martha is busy with her daily chores when she hears the phone ring.

She answers with a pleasant “Hello.” A man on the other end of the line says, “Is your name Martha?” “Yes, it is,” she said.

The man goes on to explain that he is calling about a new Medicare card that is being mailed out to all beneficiaries and he needs to verify her correct name and address. Martha spells her name out to make sure he gets it down correctly and then verifies that her address is also correct.

The man thanks her and then says; “Tell me the name of your bank.”

Martha is quick to reply, “Sorry I don’t give out my bank information.”

The man replies, “But I need it to verify your information so we will be able to send out your new Medicare card.”

Martha asks, “Are you from the government? “

The man answers, “Yes.” “Well,” Martha says,” I never received any information from the government saying that I would be contacted asking for this information.”

The man answers,” I still need your bank information.” Martha starts to really get suspicious at this point and asks the man if he has a supervisor.  He responds with a yes. She goes on to tell the caller that she has already had experience with people like him and she is not giving him any more information. The man was silent on the other end of the phone, and then he hung up.

Even at 85 years young, you can’t fool Martha!

Martha handled that call perfectly. Here at the Missouri SMP (Senior Medicare Patrol) we educate seniors on how they should protect their personal information from fraudsters trying to steal their identity.” Protect, Detect, and Report” is our motto. That is exactly what Martha did. During that phone conversation with the fraudster she first protected her personal information by not giving out her bank information, then by asking questions of the caller she detected that he was running a scam. Her next call was to report the scam to the Missouri SMP to alert others of the potential scam.

This article is based on an actual call that an older adult received. Name was changed for privacy.

If you have questions or concerns contact the Missouri SMP at 888-515-6565.

Fraud Alert for People with Diabetes

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Criminals who plot to defraud the Government and steal money from the American people have a new target:  people with diabetes.  The Office of Inspector General (OIG) has issued the following fraud alert:

Although the precise method may vary, the scheme generally involves someone pretending to be from the Government, a diabetes association, or even Medicare, calling you.  The caller offers “free” diabetic supplies, such as glucose meters, diabetic test strips, or lancets.  The caller may also offer other supplies such as heating pads, lift seats, foot orthotics, or joint braces, in exchange for the beneficiaries’ Medicare or financial information, or confirmation of this type of personal information.  Additionally, a person may receive items in the mail that were not ordered.

The call is a scam.

If you receive such a call, the following actions are recommended:

Protect Your Medicare and Other Personal Information
Do not provide your Medicare number or other personal information.  Be suspicious of anyone who offers free items or services and then asks for your Medicare or financial information.  These calls are not coming from Medicare, diabetes associations, or other similar organizations.  While the caller says the items are “free,” the items are still billed to Medicare.  Once your Medicare information is in the hands of a dishonest person or supplier, you are susceptible to further scams.  Alert others about this scheme, and remind them not to provide strangers Medicare numbers or other personal information.

Report the Call
Report the call to the Missouri SMP by calling 1-888-515-6565.  The Missouri SMP is funded by the U.S. Department of Health and Human Services’ Administration on Aging to educate beneficiaries and their caregivers about health care fraud and abuse and to help consumers file complaints with the appropriate agencies.   As part of your report, you will need to provide the name of the company that called you, the company’s telephone number and address, and a summary of your conversation with the caller.

Check Your Medicare Summary Notice and Medicare Bills
Check your Medicare Summary Notice and other medical information to see if you were charged for items you did not order or did not receive.  Also, check for items that were billed multiple times, such as glucose meters, diabetes test strips and lancets, and other supplies.  Report any irregular activity to your health care provider and the Missouri SMP at 1-888-515-6565.

Do Not Accept Items That You Did Not Order
You are under no obligation to accept items that you did not order.  Instead, you should refuse the delivery and/or return to the sender.   Keep a record of the sender’s name and the date you returned the item(s) to help identify any future illegal billing.

If you would like to learn more about how you can prevent Medicare and Medicaid fraud and abuse, or how you can help  others, call the Missouri SMP at 1-888-515-6565 for more information.

This website was supported in part by a grant No. 90-SP-0025 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.