Presented to The American Academy of Professional Coders
Woodland Hills, California
Christopher Gagnon, Fraud Investigator/ September 19, 2013
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

•
•
•
•
•
SGS Overview
Fraud and Abuse –Definitions and Effects
SGS Investigations
Areas of Concern
What to Do If You Suspect Fraud
• Q & A
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

•
SGS has served as the incumbent Program Safeguard Contractor (PSC) for:
Medicare-Medicaid for California since 2001
• Medicare Part B in California since 2002
• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) for Jurisdiction D encompassing seventeen states, including
California, Nevada, and Hawaii since March 2006
3
• Zone Program Integrity Contractor (ZPIC) Zone 1 operations, integrating
Parts A, B, and DME, Hospice and Home Health claim types for fraud detection and prevention in California, Nevada, American Samoa, Guam,
Hawaii, the Northern Mariana Islands, Palau, Marshall Islands, and the
Federated States of Micronesia since December 2010
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

• When someone intentionally falsifies information or deceives Medicare.
•When health care providers or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren't medically necessary.
4
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

• $60 Billion Estimated Annual Loss
•
•
–
–
–
Increased Costs of Healthcare – Throughout the Industry
Affects Everyone
Taxpayers
Beneficiaries
Providers / Suppliers
– Insurers
• Increased Scrutiny of All Claims
• Greater Burden for Beneficiaries & Providers
• Restrictions of Access to Care for Beneficiaries
• Unfair Competitive Advantage Over Legitimate Providers
• Damaged Reputation for Healthcare Industry
5
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

What We Investigate
• Allegations of Fraud, Waste and Abuse related to Medicare-Enrolled
Providers/Suppliers
Who We Investigate
•
•
•
Hospitals, Home Health Agencies, Hospice Care (Part A)
Physicians, Clinics, Testing Facilities, Labs (Part B)
DME Suppliers (DME)
What We Do Not Investigate
•
•
Billing Errors
Disputes Over Quality Of Service Issues
6
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

•
Where Do our Leads Come From?
External Referrals
• Fraud Prevention System (FPS)
• Medicare Administrative Contractor
• Beneficiaries
• Providers
• Centers for Medicare & Medicaid
Services
• Senior Medicare Patrol
• OIG Hotline Database
• Medi-Cal
• Law Enforcement
• Internally
• Data Team
• Investigators
7
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

•
•
•
•
•
Schemes And Scams
Beneficiary Sharing
• Use of Cappers and other Illegal Marketing
• Soliciting, Offering or Receiving a Kickback, Bribe or Rebate
Provider/Beneficiary Identity Theft
Over Utilized Services
• Providing Unnecessary or Inappropriate Services
• Billing For Services Not Rendered
• Up-coding (Provider claim forms which have been altered to obtain a higher payment amount
DME’s-IDTF’S-Clinics-Physician Assistants
• Hit and Run
Non-existent Provider Office Locations (i.e., False Fronts, Store Fronts)
8
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

•
•
•
•
•
Review of Claims History
•
•
Beneficiary Information
Provider Information
• Payment Information
Review of Multiple Data Bases
Review of Internal Reports/Data Analysis
•
•
•
Patients and Hours per day
Proximity to Office
Peer Comparisons
Review of Internet Sites
• Such as Medical Board
Obtain Provider Enrollment Applications
9
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

• Prepayment Review May be Initiated
•
•
•
Obtain Sample of Claims Universe
Order and Review Medical Records
Post Payment Review by our Medical Review Team
•
•
Perform Beneficiary Validations and/or Interviews
Review Existing Complaints
•
•
•
Perform Provider Interviews
On-sites
Telephone
10
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

– Allegation Not Validated/Closed with No Actions Necessary
– Possible Administrative Actions
• Calculate Overpayment
•
•
•
•
Prepayment Review
Deactivation
Revocation
Payment Suspension
– Referral To Law Enforcement
11
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

12
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

From a Coders Perspective
• Egregious Up-coding
• Suites of Codes
• Unusual Codes for Specialty
• Consistent Use of Qualifying Modifiers
• Pressure from Provider to Change the Codes or Diagnoses
13
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

1-800 Medicare (1-800-633-4227)
The OIG Hotline
• Phone: 800-409-9926
• The Office of Inspector General, HHS website https://forms.oig.hhs.gov/hotlineoperations
• Mail: Office of Inspector General
HOTLINE
P.O. Box 9778
Arlington, Virginia 22219
14
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

15
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

Melisa Mulcahy
Program Director
916-317-2196 melisa.mulcahy@hp.com
Travis Moore
Acting Manager-Task Order 1
(213) 553-5237 travism@hp.com
Beth Romig
Benefit Integrity Manager
(530) 896-7053
Beth.romig@hp.com
Mike Devlin
Manager-Task Order 2
(530) 896-7054
Mike.devlin@hp.com
16
© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

© Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.