FraudAlert! Helping keep the promise. March 2015 Volume 18, No. 8 Coalition of Wisconsin Aging Groups Elder Law Center From the Project Director. . . . . . . Kevin Brown Check out our website at www.wisconsinsmp.org Let’s Get Acquainted By Judy Steinke, Wisconsin SMP Volunteer Coordinator Wisconsin SMP (Senior Medicare Patrol) is delighted to introduce Janis Schnabl of Wausaukee as this month’s featured volunteer. Janis heard about the work of Wisconsin SMP in 2012. She is very annoyed by the thought of elderly people being taken advantage of, so she attended the SMP Volunteer Foundations training held in Marinette. After graduating from Bay View High School in Milwaukee, Janis was employed in the clerk’s office of the Village of West Milwaukee. She later became a State of Wisconsin Certified Building Inspector and retired after serving in that position for 22 years. Retirement brought Janis to Marinette County where, in addition to sharing SMP information with seniors, she is a musician who plays the flute on most Sundays and holidays at St. Joseph and Edwards Church in Walsh. Janis’ family includes a son, daughter-in-law, and three “fantastic” grandchildren with whom she enjoys spending time. When asked why she volunteers for Wisconsin SMP, Janis said, “Life is good! But beware, be smart, and ask questions.” She has learned that sometimes seniors are confused by Medicare and are hesitant to ask for help. Wisconsin SMP In this issue: Let’s Get Acquainted with Janis Schnabl, SMP Volunteer Spending Money to Combat Healthcare Fraud is an Excellent Investment KEPRO: A New Medicare QIO for WI Study: Over Two Million Americans Victimized by Medical ID Theft in 2014 Medicare Toughens Nursing Home Standards Credit Agencies to Wait Before Adding Medical Debt to Ratings DATCP Consumer Alert DHHS News Release Identity Theft Tops FTC’s 2014 Consumer Complaints List Upcoming Wisconsin SMP Activities Published and distributed by the Coalition of Wisconsin Aging Groups Elder Law Center. This project was supported, in part by grant #90MP0187, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy. EDITOR AND PROJECT DIRECTOR Kevin Brown This publication may be reproduced ONLY in its entirety. Permission to excerpt portions must be obtained prior to use. © 2015 CWAG. All rights reserved. Thank you, Janis, for sharing your wisdom with seniors in your community. FRAUD ALERT! ● Coalition of Wisconsin Aging Groups Elder Law1 Center 2850 Dairy Drive Madison, WI 53718-6742 608-224-0606 www.cwag.org kbrown@cwag.org Spending Money to Combat Healthcare Fraud is an Excellent Investment By Kevin Brown, Wisconsin SMP Project Director On March 19, U.S. Attorney General Eric Holder and Health and Human Services (HHS) Secretary Sylvia Burwell released a new report showing that for every dollar spent on healthcare-related fraud and abuse investigations in the last three years, the government recovered $7.70. This is the thirdhighest return on investment in the history of the Health Care Fraud and Abuse (HCFAC) Program, a joint Justice Department and HHS effort initiated in 1997 to coordinate federal, state, and local law enforcement activities to fight healthcare fraud and abuse. The two Obama Administration officials announced that the government had recovered $3.3 billion in taxpayer dollars in Fiscal Year 2014 from individuals and companies that attempted to defraud federal health programs. Attorney General Holder said, “The extraordinary return on investment we’ve obtained speaks to the skill, the tenacity, and the inspiring success of the hardworking men and women fighting on behalf of the American people. And with these outstanding results, we are sending the unmistakable message that we will not waver in our mission to pursue fraud, to protect vulnerable communities, and to preserve the public trust.” More than two pages of the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2014 are devoted to the activities and accomplishments of the Senior Medicare Patrol (SMP) program. The report notes that the 54 SMP projects across the nation referred 698 complex issues to healthcare fraud investigators for further action in 2013. A total of over $121 million in savings have been attributed to the SMP program as a result of beneficiary complaints since its inception in 1997. The primary mission of the SMP program, though, is to prevent healthcare fraud through education and education, and it is very difficult to measure prevention efforts. As the HCFAC report states, “As the SMP program is focused on education and prevention, the true value of the program comes from beneficiaries avoiding fraud in the first place.” In 2013, the Administration for Community Living awarded a three-year grant to identify a way to measure the overall impact of the SMP program. Wisconsin SMP is very proud to be part of the dedicated team of professionals and volunteers who are working tirelessly across the country to prevent, detect, and investigate healthcare fraud and save valuable taxpayer dollars. Please join our team by contacting Wisconsin SMP Volunteer Coordinator Judy Steinke at (800) 488-2596, Ext. 342 or jsteinke@cwag.org. It could be the best investment you ever make. KEPRO: A New Medicare QIO for Wisconsin In August 2014, the Centers for Medicare and Medicaid Services (CMS) began restructuring the Medicare Quality Improvement Organization (QIO) program to improve patient care and health outcomes and save taxpayer dollars. Previously, CMS would contract with one QIO to perform both case review and quality improvement support for a state. Under the new system, these two functions must be performed by different contractors. KEPRO, a diversified healthcare information company based in Ohio, is the new Beneficiary and Family Centered Care QIO (BFCC-QIO) for Wisconsin. MetaStar, which has served as Wisconsin’s QIO for 40 years, is now the Quality Innovation Network QIO (QIN-QIO) for our state. 2 According to information on the CMS website, “A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare. QIOs work under the direction of the Centers for Medicare & Medicaid Services to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.” The three essential functions of the QIO program are to: Improve the standard of care for Medicare beneficiaries; Preserve the Medicare Trust Fund by ensuring medical services and goods are necessary, reasonable, and provided in an appropriate setting; and Protect Medicare beneficiaries by addressing unique beneficiary complaints, provider-based notice appeals, and violations of the Emergency Medical Treatment and Labor Act (EMTALA), as well as other responsibilities found in QIO-related law. KEPRO is available to assist Medicare beneficiaries in Wisconsin with the following issues: Filing a quality of care complaint. KEPRO will review the medical records of Medicare beneficiaries to determine if suitable care was delivered. Filing an appeal concerning a discharge. KEPRO will assist Medicare beneficiaries with filing an appeal regarding a discharge from a hospital, skilled nursing facility, hospice, or home health agency. Medicare beneficiaries are not financially liable during the discharge appeal process. Advocating for immediate concerns. KEPRO can contact providers on behalf of Medicare beneficiaries and advocate for them. Beneficiaries may reach KEPRO by calling 855-408-8557, the company’s toll-free phone number. KEPRO Outreach Specialists are also available to give educational presentations to providers and Medicare beneficiaries to make them aware of Medicare rights. They do not charge a fee for this service. To request a KEPRO speaker, call 216-447-9604, ext. 7202. You can also schedule a presentation online at www.keproqio.com. Sources: CMS website and KEPRO materials Study: Over Two Million Americans Victimized by Medical ID Theft in 2014 On February 23, the Medical Identity Fraud Alliance released the 2014 Fifth Annual Study on Medical Identity Theft. The report found that more than 2 million Americans were impacted by medical identity theft in 2014, an increase of nearly 500,000 over the previous year. The study was conducted by the Ponemon Institute and released with support from Kaiser Permanente, ID Experts, Experian Data Breach Resolution, and Identity Finder, LLC. “Over the past five years, we’ve seen medical identity theft steadily rising with no signs of slowing,” said Dr. Larry Ponemon, chairman and founder of the Ponemon Institute. The main findings of the study were: Medical identity theft is costly to consumers 3 Sixty-five percent of medical identity theft victims paid at least $13,000 to resolve the crime. In 2014, U.S. consumers paid over $20 billion in out-of-pocket costs because of medical identity theft. The number of medical identity theft victims who paid out-of-pockets costs increased sharply from 36% in 2013 to 65% in 2014. Medical identity theft is a complicated crime Victims of medical identity theft learn about the crime, on average, more than three months after it has occurred, and 30% of the victims do not know when their personal medical information was stolen. Fifty-four percent of the victims surveyed found an error in their Explanation of Benefits (EOB), but only about half of them knew where to report the error. Resolution of medical identity theft is time consuming and may never occur Many victims find it very difficult to resolve incidents involving medical identity theft. Only 10% of survey respondents felt completely satisfied with the conclusion of the incident. Medical identity theft can cause embarrassment; negatively impact consumer confidence Almost half of the respondents (45%) indicated that medical identity theft had impacted their reputation. Many victims were embarrassed because their sensitive personal health information had been disclosed. Over 20% of respondents believed that medical identity theft had caused them to miss out on career opportunities or lose their jobs. Consumers expect healthcare providers to be proactive in preventing and detecting medical identity theft The vast majority (79%) of respondents expected their providers to guarantee the privacy of their health records, and 48% reported that they would contemplate changing providers if their medical records were stolen or lost. Finally, 40% reported that they would expect a prompt notification to come from their provider if their information was compromised. For a copy of the 2014 Fifth Annual Study on Medical Identity Theft, go to http://medidfraud.org/2014-fifth-annual-study-on-medical-identity-theft. Source: PR Newswire (February 23, 2015) Medicare Toughens Nursing Home Standards The star ratings for almost a third of the nursing homes in the U.S. were lowered in February when federal officials altered quality standards. The changes came about after critics claimed the old rating system was inaccurate and exaggerated the quality of facilities. Officials hope the changes will spur improvements in nursing homes and allow consumers to more easily judge the level of care each facility provides. “You do need to raise the bar,” said Dr. Patrick Conway, chief medical officer at the Centers for Medicare and Medicaid Services. When it is relatively easy to achieve a high rating, he said, “that’s not going to incentivize the same level of improvement.” The changes that were implemented mostly affected one of the three major criteria that are used to rate facilities on the Nursing Home Compare website: quality measures. Officials basically adjusted the curve for the quality-measures scores on the website, which rates over 15,000 nursing homes on a oneto-five star scale. Nursing Home Compare is the premier website for evaluating nursing homes, despite the fact that it relies on self-reported, unverified data. The website receives 1.4 million visits a year, according to federal officials. 4 Some nursing home representatives feel that the changes will only frustrate consumers. “Any time that nearly a third of an entire sector is impacted by a change of this magnitude, there will be confusion,” said Mark Parkinson, chief executive of the American Health Care Association, a trade group representing for-profit nursing homes. “We’re not helping patients and their families get the information they can trust when the star rankings don’t match the quality care being delivered.” In August 2014, The New York Times reported that the Nursing Home Compare’s star rating system relied so heavily on unverified information that even homes with a history of quality problems were earning top scores. Two of the three major criteria that are used to rate nursing home operations – staffing levels and quality measures statistics – were self-reported and not verified by the government. In October, the federal government announced that nursing homes would be required to start reporting staffing levels quarterly, using an electronic system that could verify the information with payroll data. The government also announced that it would begin implementing a nationwide program to audit the quality statistics reported by facilities. Prior to the changes implemented in February, approximately 80 percent of the nursing homes in the U.S. received a rating of four or five stars on their quality measures score. Now, less than half do. The percentage of nursing homes with a one-star rating increased from 8.5% to 13%, after the changes took effect. Overall, the changes adversely affected the quality-measure rating for 63 percent of nursing homes and the staffing score for 13 percent of the homes. “We expect improvement over time,” said Thomas Hamilton, director of Survey and Certification for CMS. “Just like the Model A in its day was – I’m told – an excellent care, it wouldn’t measure up to today’s standards.” Source: New York Times (February 20, 2015) Credit Agencies to Wait Before Adding Medical Debt to Ratings The three major credit agencies – Equifax, Experian, and TransUnion – have agreed to implement a 180-day waiting period before medical debt is added to a consumer’s credit rating. The agencies also agreed to remove medical debt from credit ratings promptly after insurers pay medical bills. The policy changes are part of a settlement between the New York Attorney General’s office and the three credit agencies, which will affect consumers across the country. The new policies should help prevent a consumer’s credit rating from plummeting because of incorrect medical billing or stalled payments due to a disagreement between an insurance company and provider. The new six-month waiting period will give consumers time to resolve such disputes. A bad credit rating can negatively impact an individual’s ability to obtain a loan and the interest rate of the loan. “This is going to help millions of people access more affordable loans,” says Mark Rukavina, a principal at Community Health Advisors. “People will no longer be penalized for having a medical bill slip past them and get on their credit report even though the bill gets paid.” 5 According to the Consumer Financial Protection Bureau, medical debt currently accounts for over half of the collection items on credit reports. Approximately half of the consumers who face collection for only medical debt have clean credit reports with no signs of past debt collection problems. Source: NPR (March 13, 2015) Reprinted with permission of the Wisconsin Department of Agriculture, Trade and Consumer Protection March 17, 2015 DATCP Consumer Alert: Pot of Gold Filled with Empty Promises MADISON – The mythical story of the “pot of gold” says to search for the treasure at the end of a rainbow, but scammers will have you believe that the pot of gold is coming directly to you. Among their favorite tricks are foreign lottery scams. The Wisconsin Department of Agriculture, Trade and Consumer Protection (DATCP) warns that foreign lottery promotions are phony – and illegal. “Americans lose more than $120 million a year to foreign lottery schemes,” said Sandy Chalmers, DATCP Assistant Deputy Secretary. “If you purchase a foreign lottery ticket through a solicitation, your name will be placed on a ‘sucker list’ used by crooks, and you can expect more offers for phony lotteries or investments.” DATCP occasionally hears from consumers who are tied up in a cycle of payments to scammers after falling for a fake foreign lottery pitch. Initially they received a phone call or mailing from a scammer telling them that they can win a major prize by purchasing a lottery ticket using the sender’s “secret system.” The payment cycle kicks in as victims are repeatedly asked for money for additional tickets or to secure a non-existent prize. Over time, victims begin to fear stopping these payments at the risk of losing out both on the expected prize and on the money that they have already invested in the scheme. DATCP offers the following tips for avoiding these and other prize scams: It is illegal to enter foreign lotteries and there are no secret systems for winning them. Ignore all mail and phone solicitations that promise big prizes in foreign lotteries or contests. If you receive what looks like lottery or sweepstakes material from a foreign country, destroy it or report it to the Bureau of Consumer Protection. You should never have to pay to win a prize or to “improve” your chances of winning (unless you are entering a local raffle). Never wire money, turn over the card numbers on a prepaid debit card or provide personal or banking information in response to an unsolicited offer. Some scams may require you to call a “900” number to claim your prize. Calling this number will cost you a per-minute fee. Legitimate contest offers will include rules, information on how to enter and the odds of winning. For additional information, visit the Consumer Protection Bureau at http://datcp.wisconsin.gov, send an e-mail to datcphotline@wisconsin.gov or call the Consumer Information Hotline. 6 Reprinted with permission of the U.S. Department of Health and Human Services March 19, 2015 Departments of Justice and Health and Human Services Announce Over $27.8 Billion in Returns from Joint Efforts to Combat Health Care Fraud Administration recovers $7.70 for every dollar spent to fight health care-related fraud and abuse; third-highest on record More than $27.8 billion has been returned to the Medicare Trust Fund over the life of the Health Care Fraud and Abuse Control (HCFAC) Program, Attorney General Eric Holder and HHS Secretary Sylvia M. Burwell announced today. The government’s health care fraud prevention and enforcement efforts recovered $3.3 billion in taxpayer dollars in Fiscal Year (FY) 2014 from individuals and companies that attempted to defraud federal health programs, including programs serving seniors, persons with disabilities or those with low incomes. For every dollar spent on health care-related fraud and abuse investigations in the last three years, the administration recovered $7.70. This is about $2 higher than the average return on investment in the HCFAC program since it was created in 1997. It is also the third-highest return on investment in the life of the program. “Eliminating fraud, waste and abuse is a top priority for the Department of Health and Human Services,” Secretary Burwell said. “These impressive recoveries for the American taxpayer demonstrate our continued commitment to this goal and highlight our efforts to prosecute the most egregious instances of health care fraud and prevent future fraud and abuse. New enrollment screening techniques and computer analytics are preventing fraud before money ever goes out the door. And together with the continued support of Congress and our partners at the Department of Justice, we’ve cracked down on tens of thousands of health care providers suspected of Medicare fraud – all of which are helping to extend the life of the Medicare Trust Fund.” “As the innovative and collaborative work of the Health Care Fraud and Abuse Control Program proceeds, more taxpayer money is being recovered, more criminals are facing justice, and more fraud is being punished, prevented, and deterred,” said Attorney General Holder. “The extraordinary return on investment we've obtained speaks to the skill, the tenacity, and the inspiring success of the hardworking men and women fighting on behalf of the American people. And with these outstanding results, we are sending the unmistakable message that we will not waver in our mission to pursue fraud, to protect vulnerable communities, and to preserve the public trust.” The recoveries announced today reflect a two-pronged strategy to combat fraud and abuse. Under new authorities granted by the Affordable Care Act, the administration continues to implement programs that move away from “pay and chase” efforts targeting fraudsters to preventing health care fraud and abuse in the first place. In addition, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), run jointly by the HHS Office of the Inspector General and DOJ, is changing how the federal government fights certain types of health care fraud. These cases are being investigated through realtime data analysis in lieu of a prolonged subpoena and account analyses, resulting in significantly shorter periods of time between fraud identification, arrest, and prosecution. Increased funding from the administration and Congress has allowed HHS and DOJ to build on early successes of the Medicare Strike Force by expanding into nine geographic territories – Miami; Los Angeles; Detroit; Houston; Brooklyn, New York; Southern Louisiana; Tampa, Florida; Chicago; and Dallas. Since its inception, Strike Force prosecutors have filed more than 963 cases, charging more 7 than 2,097 defendants who collectively billed the Medicare program more than $6.5 billion; 1,443 defendants pleaded guilty and 191 others were convicted in jury trials; and 1,197 defendants were sentenced to imprisonment for an average term of approximately 47 months. Through the Strike Force and other efforts, in FY 2014 alone, DOJ opened 924 new criminal health care fraud investigations. Federal prosecutors filed criminal charges in 496 cases involving 805 defendants. A total of 734 defendants were convicted of health care fraud-related crimes during the year. Another powerful tool in the effort to combat health care fraud is the federal False Claims Act. In 2014, the Civil Division of the Justice Department and the United States Attorneys’ Offices obtained $2.3 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, the Justice Department has recovered more than $15.2 billion in cases involving health care fraud. These amounts reflect federal losses only. In many of these cases, the department was instrumental in recovering additional billions of dollars for state health care programs. In FY 2014, DOJ continued its enforcement of the civil False Claims Act and the Federal Food, Drug and Cosmetic Act, and opened 782 new civil health care fraud investigations. The Centers for Medicare & Medicaid Services (CMS) is also adopting a number of preventive measures to combat fraud and abuse. Provider enrollment is the gateway to billing the Medicare program, and CMS has put critical safeguards in place to make sure that only legitimate providers are enrolling in the program. The Affordable Care Act required a CMS revalidation of all existing 1.5 million Medicare suppliers and providers under new screening requirements. CMS will have requested all revalidations by March 2015. As a result of this and other proactive initiatives, CMS has deactivated 470,000 enrollments and revoked nearly 28,000 enrollments to prevent certain providers from re-enrolling and billing the Medicare program. Both of these actions immediately stop billing. A provider with deactivated billing privileges can reactivate at any time, and a revoked provider is barred from re-entry into Medicare for a period ranging from 1 to 3 years. CMS has also issued a regulation requiring prescribers of Part D drugs to enroll in Medicare and undergo screening. CMS also continued the fiscal 2014 temporary moratoria on the enrollment of new home health or ambulance service providers in six fraud hot spots: Miami, Chicago, Dallas, Houston, Detroit and Philadelphia (which includes some counties in New Jersey). This extension will allow CMS to continue its actions to suspend payments or remove providers from the program before allowing new providers into potentially over-supplied markets. Similar to the technology used by credit card companies, CMS is using its Fraud Prevention System to apply advanced analytics to all Medicare fee-for-service claims on a streaming, national basis. The Fraud Prevention System identifies aberrant and suspicious billing patterns which in turn trigger actions that can be implemented swiftly to prevent payment of fraudulent claims. In the second year, the system saved $210.7 million, almost double the amount identified during the first year of the program. The HCFAC annual report is available at www.oig.hhs.gov/publications/hcfac.asp. For more information on the fraud prevention accomplishments under the Affordable Care Act visit: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/201503-19.htm. 8 Identity Theft Tops FTC’s 2014 Consumer Complaints List According to the 2014 Consumer Sentinel Network Data Book, which was released by the Federal Trade Commission (FTC) on February 27, identity theft topped the FTC’s national ranking of consumer complaints for the 15th consecutive year. The agency also recorded a large increase in the number of complaints about “imposter” scams, which moved into third place on the list of consumer complaints, entering the top three complaint categories for the first time. In imposter scams, con artists impersonate government officials, such as IRS officials, or other people to deceive consumers. Debt collection held steady as the second-most-reported complaint. “While identity theft remains a huge issue, consumers should also keep a close eye out for imposter scams,” said Jessica Rich, director of the FTC’s Bureau of Consumer Protection. “Whether it’s pretending to be the IRS during tax season, or making false promises of a lottery win, scammers are increasingly sophisticated in their efforts to deceive consumers, but the FTC will continue working to shut these scammers down.” Source: Federal Trade Commission News Release (February 27, 2015) Upcoming Wisconsin SMP Activities Date Activity County March 31 April 1 April 2 April 7 April 7 April 8 April 8 April 8 April 8 April 8 April 8 April 12 April 13 April 18 April 20 April 21 April 22 April 27 April 28 April 28 April 29 SMP Presentation-Kenosha Senior Center Dining Site SMP Presentation-Boys & Girls Club Sr. Dining Site-Kenosha SMP Presentation-Three Lakes Senior Dining Site SMP Presentation-Edgewater Apts.-Berlin SMP Presentation-St. Nazianz Nutrition Site SMP Presentation-Lakeside Apts.-Menasha SMP Presentation-Valders Nutrition Site SMP Presentation-Chippewa Falls Senior Center SMP Presentation-Mt. Pleasant Manor-Racine SMP Presentation-Silvercrest Apts.-Silver Lake SMP Booth-Colonial Club Health Fair-Sun Prairie SMP Booth-50+ Challenge (Cedar Mall)-Rice Lake SMP Presentation-Beaver Dam Senior Center SMP Booth-Ready, Set, Retirement Event-Madison SMP Presentation-Manitou Manor Nutrition Site SMP Presentation-Pioneer Place-Poynette SMP Booth-Healthy Living Seminar-Sheboygan SMP Presentation-Faith in Action-Friendship SMP Volunteer Foundations Training-Campbellsport SMP Presentation-Highlands at Riverwalk Apts.-Mequon SMP Presentation-College Court Apts.-Milwaukee Kenosha Kenosha Oneida Green Lake Manitowoc Winnebago Manitowoc Chippewa Racine Kenosha Dane Barron Dodge Dane Manitowoc Columbia Sheboygan Adams Fond du Lac Ozaukee Milwaukee We are always looking for opportunities to support our colleagues in the aging network. Please contact Wisconsin SMP and let us know about upcoming events in your area. 9 Wisconsin SMP Coalition of WI Aging Groups 2850 Dairy Drive Ste. 100 Madison WI 53718 ATTENTION: All of You with Email… In an effort to save paper, postage and be “volunteer friendly,” we will email issues of the Fraud Alert! to those who have email. Please contact Kevin Brown at kbrown@cwag.org and give him your email address to add to our list. Thank you! For more information, contact: Kevin Brown, SMP Project Director Coalition of Wisconsin Aging Groups Elder Law Center 2850 Dairy Drive – Suite 100 Madison, WI 53718-6742 Phone: 800/488-2596 608/224-0606 Email: kbrown@cwag.org You can also access our publication by visiting our web site www.wisconsinsmp.org Or you can visit the Coalition of Wisconsin Aging Groups web site www.cwag.org Click on Publications then click on Wisconsin Senior Medicare Patrol (SMP) and scroll down and click on the edition you wish to view.
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