Arkansas SMP Newsletter!
U of A Cooperative Extension Service Medicare Fraud Podcast
HOW TO READ YOUR MEDICARE SUMMARY NOTICE
SMP (ASMP) Program Overview
on Aging (AoA), a division of the U.S. Department of Health and
Human Services, has developed a program to help consumers understand
more about healthcare fraud. It involves recruiting retired
persons to teach Medicare beneficiaries to recognize and report
In mid-2002, the Division of Aging
and Adult Services (DAAS) received a grant from AoA to recruit
volunteers to educate the public about the prevalence of healthcare
fraud in Arkansas and what all of us — both beneficiaries and
taxpayers — can do to safeguard state and federal dollars for Arkansans
who rely on Medicare services.
Arkansas SMP is one of 54 Administration on
Aging (AOA) projects to educate seniors about fraud in government-run
health programs. The projects have saved taxpayers $100 million during
the last 12 years, according to the Health and Human Services
HHS reviews of the SMP (formerly Senior
Medicare Patrol) Projects, including self-reported information on funds
recovered to Medicare and Medicaid programs, turned up the savings. The
Administration on Aging, an agency within HHS, runs the program, which
relies on volunteers.
"The strongest defense against crime is not
law enforcement, it is informed citizens," said HHS Secretary Kathleen
Sebelius, at an AoA-sponsored conference in Washington on Tuesday during
a keynote address to program volunteer coordinators and trainers.
"[SMP] is empowering seniors at the
grassroots level to prevent healthcare fraud," said Kathy Greenlee,
assistant secretary for aging, at the event.
Volunteers, most of whom are retirees on
Medicare and are well-positioned to assist their peers, staff the 54
nationwide SMP Projects. They teach Medicare and Medicaid recipients how
to protect personal information, identify and report billing errors, and
recognize illegal marketing and unnecessary services. Since its creation
in 1997, SMP has educated 20 million citizens about Medicare fraud. The
$100 million in government savings applies to both Medicare and Medicaid
The government is on track to spend $425
billion on Medicare and $200 billion on Medicaid this year alone. The
Centers for Medicare and Medicaid Services pay 3 million claims to 1.5
million different suppliers and providers daily. The challenge, Sebelius
said, is to ensure that claims payments are processed quickly,
efficiently and legitimately.
“It's definitely a team effort,” she said,
noting that the Justice Department, AoA, CMS and the Office of the
Inspector General are working with HHS to reduce Medicare fraud.
“As any good team, we recognize that everybody has a part to
*Based on an article by Emily Long,
If you have questions or concerns
about healthcare fraud, are interested in volunteering, or would like to
schedule a free speaker, call ASMP at 501-320-6457 or toll-free
1-866-726-2916 or email Kathleen
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What's the Difference
Medicare and Medicaid?
Medicare is the nation’s largest federal health
insurance program, covering nearly 40 million Americans. It is
administered by the Centers for Medicare and Medicaid Services (CMS) and
pays for health care services for:
Medicare hospital insurance (Part A) pays for
limited inpatient care in hospitals, skilled nursing facilities,
psychiatric hospitals, hospice, and home health care services. Medicare
medical insurance (Part B) helps pay for doctor services, outpatient
services, durable medical equipment, and other medical services. These
services are the same nationwide.
Medicaid is a
joint federal and state health care program, authorized by Title XIX of
the Social Security Act, to provide medical care for low-income
individuals with limited resources, regardless of age. Medicaid programs
vary from state to state, but most health care costs are covered if you
qualify for both Medicare and Medicaid.
Fraud occurs when an individual or
organization deliberately deceives others in order to gain some sort of
Medicare or Medicaid fraud occurs when services
provided to beneficiaries are deliberately misrepresented, resulting in
unnecessary cost to the program, improper payments to providers, or
Medicare/Medicaid fraud generally involves
billing for services that were never rendered or billing for a service
at a higher rate than is actually justified.
Medicare or Medicaid abuse occurs when providers
supply services or products that are medically unnecessary or that do
not meet professional standards. Doctors, providers, or suppliers
bill for items or services that should not be paid for by Medicare
Healthcare fraud is not just a
matter of dollars and cents. Equally important is the serious effect on
the quality of care received. For example, a doctor prescribes physical
therapy for a patient following a stroke, for an hour of physical
therapy three times a week.
the therapist regularly provides only ten minutes of therapy, BUT bills
Medicare for the full hour each time.
having the full amount of physical therapy could have led to a loss of
function for the patient, which may never have been regained. Medicare
beneficiaries can now call the ASMP to report such situations and insure
receiving the full physical therapy benefit through another company.
most health care professionals are honest, trustworthy, and responsible.
The goal of this initiative is to weed out the few health care providers
who operate with the intention of using Medicare and Medicaid as a
pipeline to personal profit. The effort to prevent and detect
healthcare fraud is a cooperative one that involves:
Centers for Medicare and Medicaid Services (CMS), and the Administration
State and Federal Agencies such as the Department of Health
and Human Services Office of the Inspector General (HHS-OIG), the Federal
Bureau of Investigation (FBI), the Department of Justice (DOJ), and the
Attorney General’s Office,
Department of Human Services (DHS), Division of Aging and
Adult Services (DAAS), and Area
Agencies on Aging (AAA),
Medicare and Medicaid Beneficiaries — This means
Healthcare Fraud Is Not
Healthcare fraud is
An honest mistake by the
provider. Everyone makes
mistakes and clerical errors occur all the time. A bill
for more time than the patient thinks was spent with the
where “you just know” something is wrong. A gut feeling that something is wrong
cannot be proven without documentation.
bills that just seem “too high.” Providers are contracted
at specific amounts for specific services and/or equipment and bill CMS
according to those contracted amounts.
Charges on the Medicare statement
for doctors such as anesthesiologists, radiologists, etc. that the
beneficiary doesn’t remember seeing. This is not uncommon because
these doctors provide specialized services behind the scene or bill
separately from the primary care doctor.
What Does it Cost and Who
Healthcare fraud affects all
Americans. It affects everyone who pays taxes by wasting billions of tax
dollars. It affects those who depend on Medicare or Medicaid by
diminishing the quality of the treatment they receive.
money to fraud and abuse means that less money is available for
necessary services and programs to assist caregivers. Additionally, poor
quality of care can impact a beneficiary's functional level, which may
extend his/her need for services.
Medicare costs also result in higher premiums and co-pays.Most Medicare
and Medicaid payment errors are simple mistakes by doctors, providers,
or suppliers. Most of them provide quality care to their patients and
bill the program correctly only for the services they have
there are always a few who intentionally cheat these government programs
(and in some cases the beneficiaries who are responsible for
co-payments) out of millions of dollars annually. The cost is estimated
to be over $13 billion annually for Medicare alone. The cost in terms of
lost services and poor quality of care is immeasurable.
In order to prevent fraud, first you have to
know what it is. Here are some
Billing for services
never performed or medical equipment or supplies not ordered
Billing for services
or equipment that are different from what was provided
Billing for home
medical equipment after it has been returned
provide medical services or supplies when they are no longer
DOUBLE BILLING —
Charging more than once for the same
UPCODING — billing for a more expensive or covered item
when a less expensive, non-covered item was provided. Altering
claim forms to obtain a higher payment
UNBUNDLING – billing related services separately to charge
a higher amount than if they are combined and billed as one service or
group of services.
Falsely claiming that
services are medically necessary when they are
Using another person’s Medicare card to get
medical care, supplies, or equipment.
offering or receiving bribes, rebates or kickbacks. A kickback is
an arrangement between two parties which involves an offer to pay
for Medicare business. Health care providers engaging in
kickback activities are subject to criminal prosecution and exclusion
from the Medicare and Medicaid programs.
you know what it IS, how can you PREVENT healthcare
Be suspicious if a provider tells you
The equipment, service or test is free. It
won’t cost you anything. MEDICARE DOES NOT PROVIDE
ANYTHING FOR FREE! People on Medicare pay
with higher premiums. All of us pay through tax
Although the equipment, service or test is
free, the provider only needs your Medicare number "for our
Medicare wants you to have the item or
The provider knows how to get Medicare to
pay for items or services, even if they are not usually
The more tests they provide, the
cheaper they are.
Be suspicious of providers who:
- Claim that they represent
- Use telemarketing and door-to-door selling as
- Advertise "free" consultations to people on
Medicare or offer “free” testing or screening in exchange for
your Medicare card number, just for their records.
- Use pressure or scare tactics to sell you
high-priced medical services or diagnostic tests.
- Routinely waive co-payments or deductibles on any
services, other than those previously mentioned, without either
checking your ability to pay or verifying your financial
need.Charge co-payments on clinical laboratory
tests, and on Medicare covered preventive services such as PAP smears,
prostate specific antigen (PSA) tests, or flu and pneumonia
Tips to help prevent Medicare
your Medicare Health Insurance Claim Number (on your Medicare card). Treat your Medicare
card like it is a credit card. Don't ever give it out except to your
physician or other Medicare provider. Never give your Medicare/
Medicaid number in exchange for free medical equipment or any other
free offer. Unscrupulous providers will use your numbers to get
reimbursed for services they never
DO Remember that nothing is
Don’t accept offers of money or gifts for free medical
DO Ask questions!
You have a RIGHT to know everything about your medical care, including
the costs billed to Medicare.
yourself about Medicare. Know your rights and know what a
provider can and cannot bill to
a calendar to record all of your doctor's appointments and what tests
or X-rays are conducted. Then check your Medicare statements carefully
to make sure you received each service listed and that all the details
cautious of any provider who maintains he has been endorsed by the
DO be wary of the “We know how to bill
Medicare” scam. Avoid providers who tell you that the item or
service is not usually covered, but they know how to bill
DO review your Medicare payment notice for
errors. The payment notice shows what services or supplies were
billed to Medicare, what Medicare paid, and what you owe. Make
sure Medicare was not billed for health care services or medical
supplies and equipment you did not receive. If you spend time in a
hospital, make sure the admission date, discharge date, and diagnosis
on your bill are correct. Always inventory medical supplies and
check against your statement.
DO always count your pills before your leave the
drug store to be sure you have received the full amount. If you do not
receive your full prescription, report the problem to the
DO Report suspected instances of fraud. Call the Arkansas SMP toll-free Fraud Hotline at 1-866-726-2916 or email Kathleen Pursell
DON’T allow anyone, except appropriate medical
professionals, to review your medical records or recommend
DON’T contact your physician to request a service
that you do not need. Don’t let anyone persuade
you to see a doctor for care or services you don’t
medical supplies from a door-to-door salesman. If someone comes to your door claiming to be
from Medicare/ Medicaid, remember that Medicare and Medicaid do not
send representatives to your
DON’T be influenced by media advertising concerning
your health. Television and radio ads are intended to raise
money for someone. They do not have
your best interest at heart.
to the unscrupulous practices of some health care providers, Medicare
and Medicaid are being drained of valuable resources — resources that
you rely on when it comes to your health and the health of your loved
Many people just like you are unaware of the
contributions they can make to help curb and even prevent this
fleecing of our medical system.
By volunteering with Arkansas SMP you can become an integral member of
the growing effort to help fight Medicare and Medicaid fraud and
abuse, and the wasting of taxpayer dollars.
The Arkansas SMP project is now recruiting
and training older volunteers to educate thousands of Arkansans about
health care fraud and consumer rights. Volunteers will teach Medicare
beneficiaries how to recognize suspected health care fraud, how to
protect themselves from it, and how to report it. The Arkansas SMP
Project is looking for retired individuals who are interested in
spreading the message about health care fraud.
POSITION Volunteers conduct health care fraud presentations for
older consumers at senior centers, club meetings, and other settings
in the community. Volunteers also assist with identifying facilities
and groups for presentations.
Volunteer should be a Medicare beneficiary
and/or sixty years old or older.
Volunteer will attend an initial orientation
training and continuing training sessions from experts provided by the
Individuals should be open to sharing
information to groups of various sizes.
A six-month commitment is
What will YOU get out of
You will be educated regularly on issues
pertaining to health care fraud.
You will have continued support from project
staff and other volunteers.
You will make a difference in your
If you have questions or concerns about
health care fraud, are interested in volunteering, or would like to
schedule a free speaker, email or call one of the
Division of Aging & Adult
Arkansas SMP Coordinator
700 Main Street Suite S530
Little Rock, AR
or the toll-free Fraud Hotline at
Health care fraud
affects all Americans. Higher Medicare costs means higher premiums and
co-pays. It affects those who depend on Medicare/Medicaid by diminishing
the quality of the treatment they receive. Money lost to fraud and abuse
means less money is available for programs that assist
quality of care can impact a beneficiaries' functioning level, which may
extend a beneficiaries' need for services. And it affects everyone who
pays taxes by wasting billions of tax dollars.
Tips for fraud
prevention for Caregivers:
If you are
assisting a person on Medicare/Medicaid with their health care it is
important to read all the statements and bills. If you do not
recognize a provider's name or service then call the provider and ask
them to clarify what services were provided. If you have any further
questions about whether the service was provided, please call
If an individual
is on traditional Medicare, they should receive monthly statements
from Medicare outlining the services that were provided. If you are
having difficulty understanding this statement or other bills that
have been sent to you, call ASMP and we can assist you in navigating
the codes and other information.
you are caring for a person who is being denied medically necessary
services from an HMO, it could be fraud.
Please call us -
we can help resolve this problem and advocate for the services on
behalf of the individual.
information provided under PREVENTION.
If you have
questions or concerns about health care fraud, are interested in
volunteering, or would like to schedule a free speaker call ASMP at
501-320-6457 or toll-free 866-726-2916 or email Kathleen Pursell.
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HOW TO READ YOUR MEDICARE SUMMARY NOTICE
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This page was updated on February 10, 2014