CMS Initiatives to Combat Medicare
Advantage and Part D Fraud
<Speaker Name>
Tanette Downs
<Date>
Director, Division of Plan Oversight and Accountability
<Subhead to Specific Event>
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Medicare Fraud costs our country $60 Billion a
year
(Attorney General Eric Holder)
If we do not step up our efforts, the Medicare
Trust Funds could become insolvent by 2024
(Medicare Board of Trustees)
And our entire healthcare system would be
compromised…
…for all Americans
But we are fighting back, and it’s working…
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Amazing results from an amazing group of dedicated
people…
Including you and your organization
The fight continues…
We now have new tools to help us work together to
win the war on fraud…
And help ensure healthcare for this generation and
future generations to come.
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“Today, we are releasing a report, which shows that our work
to take on the criminals who steal from Medicare and
Medicaid is paying off:
we are regaining the upper hand in our fight against health
care fraud.
As this report shows, our anti-fraud efforts recovered $4.1
billion last year. That’s up 58 percent from 2009.”
Kathleen Sebelius, Secretary
US Department of Health and Human Services
February 14, 2012
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Our Agenda for Today’s Discussion
1. Building on a Successful Anti-Fraud Effort
2. Introduction to the Center for Program Integrity
(CPI) and its Role in Combating Fraud Waste &
Abuse
3. Outreach & Education Initiatives
4. Prevalent Fraud Schemes
5. Resources & How to Report Fraud
6. Questions & Answers
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Building on a Successful Anti-Fraud Effort
New Initiatives
Detection
• Pre-payment detection
model vs. “pay & chase”
• New technologies, e.g.
predictive modeling and
innovative data sources
• Temporary “stop
payments” for
suspicious claims
• More rigorous provider
enrollment screening
Deterrence
• Expanded overpayment
recovery efforts, e.g.
Recovery Audit
Contractors (RACs)
• Stronger civil and
monetary penalties
• Tougher new sentences
for criminals
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Introduction to the
Center for Program
Integrity (CPI) and its
Role in Combating
Fraud Waste & Abuse
1. Center for Program Integrity
(CPI)
2. Division of Plan Oversight and
Accountability (DPOA)
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Center for Program Integrity (CPI)
In 2010, CMS established
CPI and appointed Dr. Budetti
as Deputy Administrator
• Realigned all CMS fraud,
waste and abuse (FWA)
activities under one Center
• Heightened level of
attention to FWA
• Enhanced data sharing
across programs
• Stronger industry
partnerships for anti-fraud
collaboration
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Division of Plan Oversight and Accountability (DPOA)
Leading the Fight Against Medicare Part C & D Fraud
• DPOA’s Vision: To be the
organization at CMS that
will safeguard the
integrity of the Part C &
Part D programs
• DPOA’s Mission: To
manage all the facets of
program integrity
functions as they relate
to the provision of Part C
& Part D benefits
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Medicare Parts C & D Anti-Fraud Team
Working Together Against Fraud
National Benefit Integrity MEDIC
• Complaints Intake
• Proactive Data Analysis
• Referrals from
Sponsoring
Organizations (SOs)
• Investigations /
Audits
• Collaboration with
Law Enforcement
• Assistance to SOs
CPI
DPOA
Outreach & Education MEDIC
• Outreach Activities
• MEDIC Website
• Education and
Training
• Quarterly Fraud
Workgroups
• Fraud Tools
Part D RAC
Part D Recovery
Audit Contractor
• Audit of (PDE) Claims Paid to Excluded
Providers
• Improper Payment Determinations
• Fraud Referrals to NBI MEDIC
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Medicare Parts C & D Anti-Fraud Team
Working Together Against Fraud
National Benefit Integrity MEDIC
• Complaints Intake
• Proactive Data Analysis
• Referrals from
Sponsoring
Organizations (SOs)
• Investigations /
Audits
• Collaboration with
Law Enforcement
• Assistance to SOs
CPI
DPOA
Part D RAC
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Medicare Parts C & D Anti-Fraud Team
Working Together Against Fraud
CPI
DPOA
Part D RAC
ACLR Strategic
Business Solutions
Part D Recovery
Audit Contractor
• Audit of (PDE) Claims Paid to Excluded
Providers
• Improper Payment Determinations
• Fraud Referrals to NBI MEDIC
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Medicare Parts C & D Anti-Fraud Team
Working Together Against Fraud
CPI
DPOA
Outreach & Education MEDIC
• Outreach Activities
• MEDIC Website
• Education and
Training
• Quarterly Fraud
Workgroups
• Fraud Tools
Part D RAC
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Outreach & Education Initiatives
1. Fraud Work Groups: Working Together to Create Cutting
Edge Tactics
2. O&E MEDIC Website: Keeping Updated on the Latest
Information
3. Fraud Tools: Making it Easier to Detect & Report Fraud
4. Education & Training: Shortening the Learning Curve for
Faster Results
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2012 Fraud Work Groups
VALUE
PROPOSITION:
Coming together to
create cutting edge
tactics for fighting fraud
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http://medic-outreach.rainmakerssolutions.com
Keeping Updated on the Latest Information – Every Day
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O&E MEDIC Website
Resources and Information to Aid Anti-Fraud Efforts
Provides a HIPAA-compliant
secure site for:
Content includes:
•
Fraud news updates
•
CMS
•
Training
•
SOs
•
Fraud tools
•
Law Enforcement
•
•
Other Professionals
Fraud Work Group meeting
registration
•
Consumers
•
e-Resource Library containing
basic references and contact
listings
•
FAQs
VALUE PROPOSITION: Providing you with a
complete online guide for combating fraud
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Fraud Tools
Examples of 2012 Deliverables
VALUE PROPOSITION: Making it easier for you
to detect and report fraud
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Education and Training
Shortening the Learning Curve for Faster Results
VALUE
PROPOSITION:
Helping you get
up to speed
quickly
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Prevalent Fraud Schemes
1. Services Not Rendered/Not
Medically Necessary
2. Top Prescribers/Top Providers
3. Drug Diversion
4. False Front Providers
5. Upcoding
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SERVICES NOT RENDERED or
NOT MEDICALLY NECESSARY
Description: Claims submitted for services that never were
received/ delivered, or were not medically necessary for the patient.
Ways to Identify:
•
Pharmacy audits reveal shortages: invoices for medications
do not support the claims processed by the plan,
falsified invoices for drug manufacturers or distributors
Recently Reported
High Risk Areas:
CA, FL, IL, NC, NJ,
NY, MI, PR, TN, TX
•
Forged physician or patient signatures on documents
•
Physician prescribes outside his/her practice
•
Patient/member complaints of not receiving items received
on EOB or items being delivered that were not requested
•
High claim volume of abused drugs such as controlled
substance medications, pain medications, muscle relaxers, etc.
•
Diagnosis on file does not match the services or items being billed
•
Home Healthcare or other services billed while patient was in the hospital
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TOP PRESCRIBERS/
TOP PROVIDERS
Description: Top prescribers and providers are identified as
prescribing or providing more services or items than others in the
same professional peer group within their respective area or region.
Ways to Identify:
• Proactive data analysis can reveal top
prescribers and providers of highly abused
drugs and/or services in paid claim files
Recently Reported
High Risk Areas:
MI, MO, NC, NY,
OK, PA, TX
• Multiple plans have identified possible
overprescribing physicians
• Prepay review departments reveal no patient
history for services billed
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DRUG DIVERSION
Description: Drug diversion is a criminal act involving
the unlawful distribution of prescription drugs.
Ways to Identify:
•
•
Diversion of drugs for medical purposes to the illegal
market occurs in several ways, including doctor
shopping, drug theft, prescription forgery, and illicit
prescribing by a physician, beneficiaries bribed to
sell their drugs or family members stealing drugs
Recently Reported
High Risk Areas:
AZ, CA, FL, IN, MI,
NJ, NY, OH, PA, WA
Drugs usually abused in this "pill mill" environment
are: Abilify, Zyprexa, Cymbalta, Zetia, Lorazepam,
Hydrocodone, Vicodin, Oxycodone, Oxycontin or
allergy/cough syrups
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FALSE FRONT PROVIDERS
Description: These are fictitious clinics, laboratories or other
fake providers that bill for services or items not delivered. Many
are identified as empty “shell” offices generating false claims.
Ways to Identify:
• New provider with sudden increase in billing
pattern
Recently Reported
High Risk Areas:
South FL, NY
• UPS or FedEx® address
• High number of claims being submitted by a
new provider
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UPCODING
Description: Billing healthcare plans for more costly
services or items versus what was delivered or received by
the patient. This is done by billing a different level code to
obtain a higher reimbursement.
Ways to Identify:
• Data analysis can quantify:
• spikes in specific codes such as durable
medical equipment, prosthetics, and orthotics
( i.e., billing for customized orthotic, but
delivering an off-the-shelf product)
Recently Reported
High Risk Areas:
CA, FL, UT
• spikes in brand name drugs versus generics
• Beneficiary Complaints
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Resources and
How To Report Fraud
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More Resources
• NBI MEDIC
http://www.healthintegrity.org/
• O&E MEDIC Website/Part C & Part D Fraud Work Group
http://medic-outreach.rainmakerssolutions.com/
• Compromised Number Contractor
http://www.tpgsi.com/
• Senior Medicare Patrol (SMP)
http://www.smpresource.org/
• Corrective Action Plans (CAPs)
http://www.cms.gov/MCRAdvPartDEnrolData/CAP/list.asp
• OIG Work Plans
http://oig.hhs.gov/publications/workplan/2011
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How You Can Report Fraud
Contact National Benefit Integrity MEDIC at:
1-877-7SAFERX (1-877-772-3379) or
http://www.healthintegrity.org/html/contracts/medic/case_referral.html
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Questions
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