CHOICES SMP Program (formerly Medi$ave):
Don’t Be A Victim of Health Care Fraud or Scams!
Protect, Detect & Report
What is SMP?
What Does the SMP Program in Connecticut Do?
Why should I care?
What is Health Care Fraud?
What can I do?
Please follow this link for the Latest Information on Scams and Reported Fraud.
Please follow this link for SMP Tip Sheets
Want to learn about TRIADS and how they help? TRIADS also offer the "Yellow Dot" program. Please follow this link to learn more.
What is SMP?
The federal Administration on Aging funds projects (Senior Medicare Patrols) throughout the country to ensure that seniors are empowered to address issues of health care fraud, errors, abuse and other related health care scams. In Connecticut, that project – SMP, formerly Medi$ave, - is one of the CHOICES programs operated by the Aging Services Division of the CT Department of Social Services and the regional Agencies on Aging. CHOICES provides enhanced training on the issues of fraud and abuse to its network of CHOICES health insurance volunteer and staff counselors. Staff and volunteers can then provide education, assistance and advocacy to residents in order to identify, report and prevent Medicare and Medicaid fraud, waste and abuse and other health care related concerns such as identity theft and internet drug scams.
What Does the SMP Program in Connecticut Do?
Through the recruitment and training of staff and volunteers the Medi$ave Project provides the following services:
One-on-one counseling and assistance to seniors. Have questions about possible Medicare or Medicaid fraud or need help in understanding your health care documents accurately? Counselors are available to help seniors review their cases and understand billing and other paperwork. In suspicious cases, SMP can help you to report fraud to the proper authorities.
Presentations to groups of seniors, caregivers and other concerned citizens. Presentations cover the types of fraud and abuse that occur and the steps that seniors can take to protect themselves.
Why should I care?
Health care fraud is not just about the government. People can get sick, lose benefits, lose money, and get stuck with bad equipment or other things they don’t need. Money lost by older Americans to Internet fraud increased 375% from 2002 to 2003 alone. Fraud investigations by the Postal Inspection Services in fiscal year 2003 resulted in nearly $1.5 billion in court-ordered and voluntary restitution payments. And further, identity theft has cost businesses and financial institutions nearly $48 billion, in addition to the reported $5 billion in out-of pocket expenses incurred by consumer fraud victims. Not surprisingly, therefore, 37% of older Americans ranked fear of fraud ahead of concern for health crises and terrorism according to a study conducted by Harris Interactive.
The Medicare and Medicaid programs provide security for all of us. We want to ensure these programs will have money to operate and to provide good, quality health care for you and future generations. Although the vast majority of health care providers are honest, the activities of the remaining few result in wasted funds and a loss of quality of care for yourself and others.
Health Care Fraud Costs! In the United States, we lose as much as $80 - $100 billion each year to health care fraud and errors. Medicare lost more than $16 billion dollars to fraud, abuse and errors in 2004. Consumers lose as much as $10 billion dollars a year. Remember, people who steal from Medicare and Medicaid are stealing from YOU. Let's work together to stop thieves!
What is Health Care Fraud?
Fraud occurs when an individual or organization deliberately deceives others in order to gain some sort of unauthorized benefit. Medicare or Medicaid fraud occurs when services provided to beneficiaries are deliberately misrepresented, resulting in unnecessary cost to the program, improper payments to providers, or overpayments. Medicare/Medicaid fraud generally involves billing for services that were never rendered or billing for a service at a higher rate than is actually justified.
Medicare or Medicaid abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards. Doctors, providers, or suppliers bill for items or services that should not be paid for by Medicare or Medicaid.
Healthcare fraud is not just a matter of dollars and cents. Equally important is the serious effect on the quality of care received. For example, a doctor prescribes physical therapy for a patient following a stroke, for an hour of physical therapy three times a week. HOWEVER, the therapist regularly provides only ten minutes of therapy, BUT bills Medicare for the full hour each time. Not having the full amount of physical therapy could have led to a loss of function for the patient, which may never have been regained. Medicare beneficiaries can now call Medi$ave to report such situations and insure receiving the full physical therapy benefit through another company.
Examples of health care fraud include:
· 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
· Continuing to provide medical services or supplies when they are no longer necessary
· DOUBLE BILLING — Charging more than once for the same service
· 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 amount.
· 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 not.
· Using another person’s Medicare card to get medical care, supplies, or equipment
· Soliciting, 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
Healthcare fraud is not:
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 doctor.
Situations where “you just know” something is wrong. A gut feeling that something is wrong cannot be proven without documentation.
Hospital 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 can I do?
Protect, Detect, and Report: The effort to prevent and detect healthcare fraud is a cooperative one that involves an interdisciplinary team of federal, state and local resources – including CT Triad programs, the CT Consumer Hotline for Elders, AARP’s Benefit Check-Up initiative, and elder abuse prevention organizations – as well as Medicare and Medicaid beneficiaries – That Means YOU!
yourself from becoming a victim of health care fraud or scams:
· Never give any personal information, such as your Medicare or Medicaid, Social Security, bank account or credit card numbers over the telephone or to people you do not know who come to the door!
· Protect 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 delivered.
· Hang up the phone – or shut the door – if someone tries to pressure you into providing personal information or buying medical equipment. (Medicare does not sell anything!)
· Remember that nothing is ever “free.” Don’t accept offers of money or gifts for free medical care.
· Get medical help only from your personal doctor, hospital, or clinic – trusted sources. They are the only ones who should make referrals for equipment, services, or medicine. Check with you health care provider before buying any Internet drug products or services.
· Ask questions! You have a RIGHT to know everything about your medical care, including the costs billed to Medicare.
· Educate yourself about Medicare. Know your rights and know what a provider can and cannot bill to Medicare.
· Bring your mail in every day – thieves can get personal information from your bills and letters. Also, rip up or shred and documents that have personal information on them before throwing them away – crooks can rummage through your trash to steal your identifying information.
· 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.
possible instances of fraud:
· Always keep a record of your health care appointments and the services. You can do that by using 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 are correct.
· Always review your explanation of Medicare/Medicaid benefits (EOMB) or Medicare summary notices (MSN) to ensure they properly reflect services that you received. The payment notice shows what services or supplies were billed to Medicare, what Medicare paid, and what you owe. Look for any charges that seem wrong to you – charges for something you didn’t get, billing for the same thing twice, or services not ordered by your doctor. 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.
· 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 pharmacist.
· Be suspicious if a provider tells you that:
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 increases.
Although the equipment, service or test is free, the provider only needs your Medicare number "for our records."
Medicare wants you to have the item or service.
The provider knows how to get Medicare to pay for items or services, even if they are not usually covered.
The more tests they provide, the cheaper they are.
- Be suspicious of providers who:
Claim that they represent Medicare or Be cautious of any provider who maintains he has been endorsed by the federal government.
Use telemarketing and door-to-door selling as marketing tool.
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 shots.
suspected instances of fraud or scams to your Agency on Aging:
CHOICES SMP -- 1-800-994-9422
· NOTE: If you feel threatened by someone who is trying to steal your money or personal information – immediately call your local police or 911.
· Remember: Most health care professionals are honest, trustworthy, and responsible. The goal of this initiative is to weed out the few health care and other providers who operate with the intention of using Medicare and Medicaid or your personal savings as a pipeline to their own personal profit.
Many people just like you are unaware of the contributions they can make to help prevent seniors from becoming victims. By volunteering with CHOICES, you can become an integral member of the growing effort to educate senior consumers about Medicare, health care fraud and consumer rights, as well has empower them to recognize suspected fraud, protect themselves from it, and report it.
What will you get out of it? You will be educated regularly on issues pertaining to Medicare and health care fraud and scams. You will have continued support from CHOICES staff and other volunteers. YOU WILL MAKE A DIFFERENCE IN YOUR COMMUNITY!
If you have questions or concerns about health care fraud, are interested in volunteering, or would like to schedule a free speaker, call your regional Agency on Aging at 1-800-994-9422
1. U.S. Department of Health & Human Services
a. Administration on Aging – Senior Medicare Patrols - http://www.aoa.gov/smp
b. Centers for Medicare and Medicaid Services -
Medicare - http://www.medicare.gov/
Medicaid - http://www.cms.hhs.gov/medicaid/
c. Office of the Inspector General, - http://oig.hhs.gov/fraud/fraudalerts.html
d. "Stop Medicare Fraud" website:
2. National Consumer Protection Technical Resource Center: http://www.smpresource.org/
Our Partners in CT:
1. CT Area Agencies on Aging: http://www.ctagenciesonaging.org/
2. Legal Assistance for Elders in CT / Consumer Law Project for Elders (CLPE) -http://www.ctelderlaw.org/
3. Center for Medicare Advocacy - http://medicareadvocacy.org/
State of Connecticut Attorney General’s Office http://www.ct.gov/ag/site/default.asp
Identity Theft Alerts and other Health Care Fraud information
FTC - Identity Theft Site http://www.consumer.gov/idtheft/
Contains Q&A and resources for victims.
National Internet Fraud Watch Information Center
Contains section on fighting fraud against older consumers, as well as telemarketing fraud, and information on how to get your name off mailing lists.
State of Connecticut Department of Consumer Protection
Do Not Call Registry, more.
Consumer Law Project for Elders http://www.ctelderlaw.org/Consumer/CLPE%20brochure%2007%20final.pdf