Medicare and Skilled Nursing
Facility Care: Protect Yourself
from Fraud!
Updated August 2014
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What We Will Cover Today
• The SMP Program
• Medicare and Skilled Nursing Facility
(SNF) Care
• Skilled Nursing Facilities and Fraud
• Protect, Detect, Report!
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How Much is Lost?
How much do you think is lost every year to
health care fraud and abuse?
A) $5-10 million
B) $25-125 million
C) $10-20 billion
D) $75-250 billion
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How Much is Lost?
How much do you think is lost every year to
health care fraud and abuse?
A) $5-10 million
B) $25-125 million
C) $10-20 billion
D) $75-250 billion
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Fraud affects:
• Medicare & Medicaid Beneficiaries
– Loss of benefits
– Higher premiums
– Identity theft
• Taxpayers
– Medicare is paid for by taxes
– Billions of taxpayer dollars wasted
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Why Report Fraud?
• Health care fraud puts you at risk for
identity theft.
• IT’S YOUR MONEY!
• Taxpayer dollars
• Higher premiums
• Saving the Medicare Program
• People who commit fraud are STEALING
from you, not helping you!
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Why Report Fraud?
• Your Medicare account may be flagged:
“Do Not Pay!”
• When things aren’t ordered by your
doctor, they may not fit or work properly.
• When someone gives you something that
you don’t need:
• Your health may get worse
• Your Medicare benefits may be “used up”
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The SMP Program
www.illinoissmp.org
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The SMP Program
• Senior Medicare Patrol
• National Program
– SMP Programs in all 50 states, Washington,
D.C., Puerto Rico, Guam, Virgin Islands
• Goals of program:
– Recruit volunteers to provide outreach
– Educate consumers about health care fraud
and abuse
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SMP Staff and Volunteers…
• Give presentations to groups (like this one!)
• Share information and materials at health
fairs or other events
• Help people with questions about billing
mistakes or fraud issues
• Help report fraud to investigators
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Illinois SMP Program Partners
• Illinois Area Agencies on Aging
• Catholic Charities
• White Crane Wellness Center
• Coalition of Limited English Speaking Elderly
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Medicare & Skilled Nursing
Facility (SNF) Care
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What is Skilled Nursing Care?
• Skilled Nursing Care is health care
that “requires the involvement of
skilled nursing or rehabilitative staff in
order to be given safely and
effectively”
(CMS Publication No. 10153)
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What is Skilled Nursing Care?
• Skilled nursing staff include:
– registered nurses
– licensed practical and vocational nurses
– physical and occupational therapists
– speech language pathologists
– audiologists
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What is Skilled Nursing Care?
• Examples of care that may often be
considered “skilled” care:
– Intravenous injections
– Physical therapy
– Catheters
– Wound care
– Ostomy care
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When does Medicare cover Skilled
Nursing Facility Care?
• Medicare covers skilled nursing
facility care on a short-term basis (if
you need skilled care) in order to:
–Help improve your condition
–Maintain your current condition and
prevent it from getting worse
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When Does Medicare Cover
Skilled Nursing Facility Care?
Medicare Part A covers Skilled Nursing
Facility (SNF) care if you meet the
following three requirements…
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When Does Medicare Cover
Skilled Nursing Facility Care?
1) Your doctor certifies that you need
skilled care that can only be
provided in a SNF at least 5
days/week, and you get this care in
a Medicare-certified SNF
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When Does Medicare Cover
Skilled Nursing Facility Care?
2) You had a 3 day inpatient hospital
stay prior to entering the SNF (usually
within 30 days).
– The day that you are admitted to the hospital counts
– The day you are discharged does not count
– Time spent in “observation status” does not count.
(Ask the hospital if you have been admitted as an
“inpatient” or if you are under “observation.”)
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When Does Medicare Cover
Skilled Nursing Facility Care?
3) You have SNF days left in your
“benefit period”
Medicare covers up to 100 days of SNF care
in a “benefit period.” A benefit period begins
the 1st day you are in the hospital and ends
when you have received no inpatient care
(hospital or SNF) for at least 60 days.
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When Will Medicare NOT Cover
Skilled Nursing Care?
• If someone only needs “custodial” care,
and does not require “skilled” care,
Medicare will not pay for a stay in a skilled
nursing facility (SNF).
• “Custodial care” refers to non-medical care
that provides assistance with activities of
daily living, such as bathing, dressing,
eating, etc.
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How Much Does Medicare Pay?
• Medicare will pay for the first 20 days of
SNF care in a benefit period in full ($0
copayment).
•If you spent more than 20 days in a SNF,
for days 21-100, there is a daily copayment.
(In 2011, this copayment is $141.50/day.)
Note: some Medicare supplement plans may
cover this copayment.
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What Care Does Medicare Cover?
• If you qualify for skilled nursing facility (SNF)
care, Medicare will cover:
– A semi-private room and meals
– Skilled nursing care
– Physical therapy, occupational therapy,
and/or speech-language pathology
services
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What Care Does Medicare Cover?
• If you qualify for skilled nursing facility (SNF)
care, Medicare will cover:
– Medical social services
– Medications
– Medical equipment used while in the
facility
– Some medically necessary ambulance
transportation
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What if I have a Medicare
Advantage Plan?
If you are on a Medicare Advantage plan, the way
that your plan covers skilled nursing care may be
slightly different. The plan may:
•Cover more days than Original Medicare or waive
the 3 day hospital stay requirement
•Require you to use a Skilled Nursing Facility in the
plan’s network
•Have a different copayment structure than Original
Medicare
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Your Rights in a Skilled Nursing
Facility (SNF) - Quality of Care
If you have a question or complaint about
the care that you receive in a SNF, you
can contact the Illinois Long Term Care
Ombudsman program. To find an
Ombudsman in your area, contact the
Illinois Department on Aging Senior
HelpLine at (800)252-8966.
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Your Rights in a Skilled Nursing
Facility (SNF) - Quality of Care
The Medicare Quality Improvement
Organization (QIO) also takes
complaints about quality of care. To file
a quality of care complaint with the QIO
in Illinois, call IFMC-IL at
(800)647-8089.
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Your Rights in a Skilled Nursing
Facility (SNF) - Discharge
• If you have Original Medicare, before you are
discharged, the SNF must give you a written
notice stating:
– The date your Medicare coverage will end
– Why your stay is no longer going to be covered
– The estimated cost of non-covered care if you
choose to stay in the SNF
– Your right to request that the SNF submit a claim to
Medicare to obtain an official payment decision
from Medicare (called a “demand bill”)
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Your Rights in a Skilled Nursing
Facility (SNF) - Discharge
• If you disagree with the SNF’s decision to
discharge you, you can request an appeal.
To appeal a discharge, contact the Quality
Improvement Organization (QIO). In
Illinois, this organization is IFMC-IL:
(800)647-8089.
• The QIO will respond to your appeal within
one day of receiving it.
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Your Rights in a Skilled Nursing
Facility (SNF) - Discharge
• If you want to appeal, you must contact the
QIO no later than your planned discharge
date and before you leave the hospital.
• If you do this, you will not have to pay for
the services you receive during the appeal
(except for charges like copays and
deductibles).
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Your Rights in a Skilled Nursing
Facility (SNF) - Discharge
• If you do not appeal, but decide to stay in
the hospital past your planned discharge
date, you may have to pay for any services
you receive after that date.
• If you have private insurance or Medicaid,
your other insurance may cover your stay
even after your Medicare coverage stops.
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Skilled Nursing Facilities
(SNF’s) and Fraud
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SNF’s and Fraud – What is Fraud?
• Billing for services that you never received
• Billing for services that are different than
what you received
• Billing for unnecessary services
• Billing for more or more advanced services
than you need (“upcoding”)
• “Kickback” arrangements (payments or
other inducements for patient referrals)
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SNF’s and Fraud: Physical Therapy
A skilled nursing facility provides physical
therapy to 10 residents in a group for one
hour (all at one time). However, when the
facility bills Medicare, they bill as if they
provided each of those 10 individuals with 1
hour of individual therapy.
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SNF’s and Fraud: Physical Therapy
• Problems:
– Billing for a different type of service than
what was provided (individual therapy
instead of group therapy)
– Billing for more hours of therapy than
what was actually provided
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SNF’s and Fraud: Mental Health
A skilled nursing facility provides BINGO
games for residents on Thursday afternoons.
Without the residents’ knowledge, the facility
bills Medicare for mental health therapy
during these BINGO sessions.
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SNF’s and Fraud: Mental Health
• Problems:
– Billing for a service that was never
provided (BINGO does NOT count as
mental health therapy!)
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SNF’s and Fraud: Kickbacks
• A skilled nursing facility receives “referral
payments” from a local hospice agency in
exchange for referring many of their
residents to receive services from that
hospice agency.
• At another skilled nursing facility, a local
home health agency provides the facility
with discharge planners in exchange for
patient referrals.
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SNF Fraud Schemes: Kickbacks
• Problems:
– The federal Anti-Kickback Statute makes
it illegal for health care providers to give
or accept any form of payment in
exchange for patient referrals. “Payment”
includes money, items, or services.
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SNF’s and Fraud: “Upcoding”
• A skilled nursing facility orders their staff to
enroll patients into physical therapy when
the patients do not need (and do not qualify
for) physical therapy.
• Another skilled nursing facility falsifies
documentation to make it look like patients
need more therapy services than the
patients actually need.
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SNF’s and Fraud: “Upcoding”
• Problems:
– The SNF is providing unnecessary/
inappropriate services in order to receive
higher payments from Medicare than they
should receive.
– If someone’s services are “upcoded” now,
that person may not be able to get that
care later when they need it.
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Protect!
Detect!
Report!
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PROTECT Yourself
From Fraud!
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PROTECT Yourself From
Fraud!
• If you need skilled nursing care,
contact your doctor. Your doctor
must certify you to receive skilled
nursing care.
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PROTECT Yourself From
Fraud!
• Choose a skilled nursing facility
carefully.
• You can find quality information about
skilled nursing facilities on
www.medicare.gov under “Nursing
Home Compare.”
• Visit the SNF and ask questions using
Medicare’s SNF checklist.
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PROTECT Yourself From
Fraud!
• Do NOT sign any forms or paperwork
without reading them first. Never sign
blank forms.
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PROTECT Yourself From
Fraud!
• Ask questions if you do not
understand the care you are
receiving.
• Do not accept ‘extra’ services that
you do not need - Medicare may be
billed fraudulently for those
unnecessary services.
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DETECT Fraud!
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DETECT Fraud!
• Ask the SNF for an itemized statement of
all of the services you receive while in the
SNF.
• Check that statement for errors, such as
services you did not receive, or services
that are different than what you received.
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DETECT Fraud!
• Read your Medicare Summary Notice
or Explanation of Benefits from your
insurance company. Watch for:
– Services or supplies that you did not get
– Services or supplies that were not ordered by
your doctor
– Billing for the same thing twice
– Other billing errors
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REPORT Fraud!
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REPORT Fraud!
• If you have questions about services that
you did receive, contact the SNF first and
ask for an explanation.
• If this does not work or you suspect fraud
(for example, you see a claim on your
Medicare Summary Notice for a service
that you never received), call the Illinois
SMP program at:
(800)699-9043
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Volunteers are the key to
spreading the SMP message!
We need YOUR help!
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Thank you!
If you have questions, contact:
AgeOptions
(800)699-9043
This presentation was supported in part by a grant (No. 90MP0163 and
90SP0061) from the Administration on Aging (AoA), Administration
for Community Living (ACL), U.S. Department of Health and Human
Services (DHHS). Grantees carrying out projects under government
sponsorship are encouraged to express freely their findings and
conclusions. Therefore, points of view or opinions do not necessarily
represent official AoA, ACL, or DHHS policy.
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