Tricenturion

Fraud and Abuse

FRAUD ALERT

Medicare beneficiaries need to be aware of a fraudulent scheme that has been perpetrated recently. An individual has called beneficiaries indicating that there are $3,000 worth of Medicare benefits for the beneficiary and the caller has the beneficiary's savings account number to deposit the money into. The caller requests that the beneficiary tells him what the account number is to verify the correct account number.

Medicare does not conduct business in this fashion and if you are called about the same or similar scheme please fill out the Referral to Benefit Integrity Form.

Individuals, under the guise of performing HIPAA compliance audits, have approached a medical group requesting access to the provider's computers and database. The individuals refused to produce identification or documentation confirming their identity. Access was denied by the provider's billing manager.

There are currently no on-site HIPAA audits being conducted. Providers should never allow ANY individuals access to their computers, medical records, billing information, etc., who fail to produce identification and proper documentation from the auditing entity. As outlined in the Program Integrity Manual and the Social Security Act suppliers do have to grant access to authorities who are conducting reviews and properly identify themselves.

If ANY recent or future attempts are made by individuals to gain access to your facilities and/or information, please contact TriCenturion at (803) 264-7700 immediately.

A major task of TriCenturion is to support efforts to eliminate Medicare fraud and abuse.

To report fraud and abuse, go to the Referral to Benefit Integrity Form.

Fraud is defined as knowingly and willfully executing, or attempting to execute a scheme to defraud any health care benefit program or to obtain, by means of false pretenses or promises, any of the money or property owned by, or under the custody or control of any health care benefit program.

Examples of Fraud

Billing for services not rendered.
Soliciting, offering, or receiving a kickback, bribe, or rebate.
Using an incorrect or inappropriate provider number in order to be paid (e.g. using a deceased provider’s number).
Signing blank records or certification forms that are used by another entity to obtain Medicare payment.
Selling or sharing patient’s Medicare numbers so false claims can be filed.
Offering incentives to Medicare patients that are not offered to non-Medicare patients (e.g. routinely waiving or discounting the Medicare deductible and/or coinsurance amounts).
Falsifying information on applications, medical records, billing statements, and/or cost reports or on any statement filed with the government.
Misrepresenting as medically necessary, non-covered services by using inappropriate procedure or diagnosis codes.

Abuse may, directly or indirectly, result in unnecessary costs to the Medicare program, improper payment, or payment for services which fail to meet professionally recognized standards of care, or that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented the facts to obtain payment.

Although many types of inappropriate practices may be considered abusive, they may evolve into fraud.

Examples of Abuse

Using procedure or revenue codes that describe more extensive services than those actually performed.
Collecting more than the 20% coinsurance or the deductible on claims filed to Medicare. Providers may, of course, bill patients for services not covered (e.g. service exclusions).
Routinely submitting duplicate claims.
Billing for services grossly in excess of those needed by patients.
Incorrectly apportioning costs on cost reports for Part A providers.
Charging more than the actual purchase price of a service, item, or drug.

Protecting Yourself

Fraudulent suppliers need your Medicare number before they can submit a false claim. Here are a few schemes they might use to try to trick you out of your number.

A person calls you claiming to be from “Medicare” and asks you to provide personal information like your Medicare or Social Security number.
A person offers you free milk or groceries in exchange for your Medicare or Social Security number.
A person asks you to provide your Medicare or Social Security number in exchange for money.
A person offers you a free health screening but wants you to provide your Medicare or Social Security number.
A person offers you money in exchange for visiting a doctor’s office.
A person offers you money in exchange for letting them see or use your Medicare card.

All of these techniques are used to get information that will be used to bill Medicare. Never release your Medicare or Social Security number in exchange for money or gifts. Report anyone you suspect of committing Medicare fraud.

Stopping Fraud

To report an incident of suspected fraud or abuse, call the number listed on the top of your Medicare Summary Notice (MSN). You may also call the National Medicare Hotline at 1-800-MEDICARE. TDD: 1-800-842-9519.

Here are a few examples of when you should report suspected fraud.

Report a company that provides you with items that you do not need.
Report a company that does not pick up an item after you have asked them to or after you have told them you no longer need it.
Report a company that continues billing Medicare after they have picked up a piece of equipment.
Report a company that bills Medicare a large sum of money for an item that you think is worth far less.