Medicare and Home Health
Services: Protect Yourself from
Fraud!
Updated August 2014
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What We Will Cover Today
• The SMP Program
• Home Health and Medicare
• Home Health 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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Home Health &
Medicare
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Home Health & Medicare
To receive Medicare-covered home
health services, a person must:
1) Be “homebound” AND
2) Need:
• Physical therapy
• Occupational therapy
• Speech therapy OR
• Skilled nursing care
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What Does “Homebound”
Mean?
• “Homebound” means it is very hard to
leave the house.
• The person can still go to religious
services, doctors, and adult day programs
• For example, someone who is
“homebound” would not be able to drive
himself to the grocery store
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What Home Health Services
Does Medicare Cover?
•
•
•
•
•
•
•
•
Physical Therapy
Speech-language Pathology
Occupational Therapy
Skilled Nursing
Medical Social Services
Home Health Aide (ONLY if receiving other services)
Certain medical supplies
Durable medical equipment  covered separately, with
a 20% coinsurance
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Physical Therapy
• Exercises to improve movement and
strength
• Training on how to use special equipment
or do certain activities
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Speech-Language
Pathology
• Therapy for speech, swallowing,
reading, listening, and memory
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Occupational Therapy
• Help learning to perform daily
activities (eating, dressing, etc.)
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Skilled Nursing Care
• Services that a nurse needs to help
with  wound care, changing an IV
or a catheter, etc.
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Medical Social Services
• Services to help with social and
emotional concerns related to your
illness (counseling, finding resources,
etc.)
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Home Health Aide
• IF you are receiving physical therapy,
speech therapy, occupational therapy,
or skilled nursing care, Medicare will
also cover services to help you with
personal care, such as bathing, using the
toilet, or dressing
• Medicare will NOT cover home health aide
services if they are the only services you
receive
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Supplies/Equipment
• Medicare will cover certain medical
supplies as part of your home care, like
bandages that are used for your nursing
care
• Medicare will pay for other durable
medical equipment that you need
separately (oxygen, wheelchairs, etc.) 
20% coinsurance
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What if Medicare Will NOT
Cover Services?
If a home health agency thinks that
Medicare will NOT cover a service they are
going to give you, they MUST ask you to
sign an “Advance Beneficiary Notice”
stating that you will pay for the services if
Medicare doesn’t. If they do not do this, they
cannot charge you!
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How Should I Get Home
Health Care if I Need It?
• Talk to your doctor! Your doctor
should order any care or supplies that
you need.
• A Medicare-certified home health
agency will visit you and do an
assessment. Then, they will write a
“Plan of Care.”
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What is a “Plan of Care?”
• The “Plan of Care” is a document that
states what services the home health
agency will provide to you and why you
need those services
• Your doctor should receive and review a
copy of your Plan of Care, and you should
ask for a copy, too!
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Home Health & Fraud
•
•
•
Charging Medicare for services that you
did not get
Charging for something DIFFERENT than
what you received
Charging for services you don’t need or
that were not approved by your doctor
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Home Health & Fraud
•
•
Charging for more services than you need
Charging for services to people who do
not qualify for Medicare-covered home
health (people who are not homebound
and/or do not need skilled nursing or
therapy)
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Home Health Fraud in Illinois
•
•
Agencies visiting senior buildings and
providing presentations, games, exercise
classes, health screenings, etc. and
asking for Medicare numbers
Billing Medicare as if they provided the
participants with home health services
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Home Health Fraud in Illinois
•
Agencies providing basic or preventative
care services, then bill Medicare as if they
provided home health care
– blood pressure, glucose testing, “If you do not
want to visit your doctor, we can come to
you!”)
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Home Health Fraud in Illinois
•
Agencies sending pre-filled forms to
doctors so that the doctor can ‘sign off’ on
home health services
•
Your doctor should order home health
services, then contact a company – not
the other way around!
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Home Health Fraud in Illinois Example
•
A home health agency in Chicago
provided “free massages” for residents of
a senior building. They billed Medicare for
skilled nursing services.
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Home Health Fraud in Illinois Example
•
A Springfield home health agency
performed door-to-door blood pressure
checks. They told one woman that her
doctor asked them to come. They told
another woman they were helping “to
keep her out of a nursing home.” In each
case, they billed Medicare for home
health services.
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Protect!
Detect!
Report!
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PROTECT Yourself
From Fraud!
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PROTECT Yourself From
Fraud!
• Do NOT give your Medicare number to
people you do not know!
– On the phone
– At the door
– At a presentation, exercise class,
screening, etc  FREE services do
NOT require your Medicare number!
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PROTECT Yourself From
Fraud!
• Do NOT accept services from someone
who calls or visits you unexpectedly, even
if they say that your doctor sent them!
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PROTECT Yourself From
Fraud!
• Do NOT “sign up” for services at a
presentation or event.
If you think you may need home health
services, talk to your doctor FIRST. Let
your doctor help you find a provider.
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PROTECT Yourself From
Fraud!
• If you are being assessed for home health
services, ask for a copy of your Plan of
Care.
• Do NOT sign timesheets or other forms
without reading them.
• Do NOT sign blank forms!
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DETECT Fraud!
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DETECT Fraud!
• Ask for an itemized list of the services that
you have received. Check the list for
errors.
• Read your Medicare Summary Notice
or Explanation of Benefits from your
insurance company. Watch for:
–
–
–
–
Services that you did not get
Services 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 your doctor or the
home health agency first.
• If this doesn’t 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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