[ Music ] >> Welcome to our first live broadcast Healthcare Fraud: What You Need to Know I’m Sheila Davis, a public affairs specialist for the Department of Health and Human Services, Office of Inspector General And I’m moderating today’s discussion Joining me are two healthcare fraud experts OIG’s assistant, Inspector General for investigations Shimon Richmond and Dr. Michael Cohen, an operations officer with the Office of Investigations Together they have 25 years of fraud-fighting experience If you have questions during our discussion, please send them via Facebook And if you’re watching us on Twitter, tweet using the hashtag ask an investigator So, let’s get started Healthcare fraud waste taxpayer dollars and can significantly harm people and patients, including those who have Medicare or Medicaid Shimon, can you start by explaining what healthcare fraud is and maybe share a few of the most common schemes? >> My pleasure, Sheila Healthcare fraud is a crime of theft and a crime of deception And because of that deception, oftentimes the fraud looks like just the provision of regular healthcare services On its surface, it may not be apparent to the naked eye that something is actually wrong As we dig into our healthcare fraud investigations, we find a variety of common schemes The first is billing for services not rendered That’s very simply billing for things that never occurred or maybe billing for a wheelchair or a back brace or something that the patient never received We also see frequently inflating of services So, you may have a patient that went to a doctor and they had, for example, their blood drawn, had some lab tests But in addition to the tests that they actually did undergo, the lab or the provider bills for additional tests that didn’t actually occur just in order to inflate the reimbursement from Medicare or Medicaid and increase their profits >> And, Mike, what have you seen? >> In addition to that you may see some misrepresentation of services So, maybe a non-covered service that’s actually billed as covered service So, for example, someone may be getting massages and they’ll bill it as like physical therapy or something like that In the world of pharmaceuticals, we may see drugs that are expensive specialty drugs that are billed and not dispensed Or medically unnecessary services DME supplies like back braces and knee braces and neck braces that type of thing Diabetes testing strips that aren’t requested or needed Or most recently genetic testing which we can talk about as well >> Okay So, how does healthcare fraud impact a person? Walk me through what someone might experience from unnecessary medical tests or being charged for services that they didn’t need >> Well, you can imagine medical tests on their face are not pleasant to go through anyway, much less going through unnecessary blood draws or procedures such as biopsies or something that weren’t even necessary, to begin with Also, you may get — we see people getting imaging studies which involves radiation We even had an oncologist a few years ago that was falsely diagnosing people with cancer and was giving them radiation therapy as well as chemotherapy So, that was a really egregious example >> And this is done so that the providers can bill more despite the best needs of the patient? >> It was all just to make money, it was just greed >> Okay Shimon >> You know, in addition to the potential physical harm or issues that patients can endure, they also face some financial risk, as well as risk to their benefits In the financial arena, they may incur, you know, expensive copays and other costs that aren’t medically necessary and that otherwise wouldn’t incur if the provider was acting in their best interest as opposed to looking to increase their bottom line Additionally, there are many benefits that have limits And so if those benefits are exhausted in Medicare’s view because they’ve been billed, for example, say for a power wheelchair that they actually didn’t receive or didn’t need and then, you know, some time elapses and that patient develops a legitimate medical need for that power wheelchair, in Medicare’s view, that client may be denied because Medicare believes they’ve already been provided one and so they’re no longer eligible to receive, you know, that item or that service And so it can cause real problems for patient’s benefits should they legitimately need them at a later point in time >> So, it can cause physical harm and financial harm >> Absolutely >> Okay So, now we’ve heard about some common schemes, can you give the viewers some tips on how

they can protect themselves? >> Certainly Some of the quick and easy things that all patients can do, first and foremost, look at that letter that comes in the mail that explanation of benefits that comes in the mail for Medicare That lists on there what items and services Medicare is paying on behalf of the patient For example, check if the date of service on that explanation of benefits lines up with the date that you last went to the provider See if you recognize the provider name on there that is billing services to Medicare And if that is, in fact, one of your doctors And maybe scan through quickly This all takes a matter of seconds Look through the services being billed and if those line up with the services that you received when you went to your doctor >> And if somebody on Medicare is reviewing that statement and they see something that isn’t correct, should they call their doctor first, when do they reach out to the OIG if they may suspect fraud? >> Those EOB statements can be very complicated to weed through so sometimes is best just pick up the phone and call your provider And sometimes they can clear it up right over the phone Beyond that, if you still have some questions or the answers weren’t what you thought they would be, you can reach out if you have an issue with your benefits to 1-800-MEDICARE or the SHIP program, the State Health Insurance Program, who can discuss the benefits and what you’ve received If you’re thinking more along the lines of fraud, you can start out with senior Medicare patrol who can go over your statement and the provision of care and if they think that there’s something that doesn’t look right, they can assist you in reporting it to our hotline 1-800-TIPS — HHS-TIPS and report it as fraud >> And that’s really important that it’s very easy and accessible for folks to report their concerns or suspected fraud to us either through the hotline, that 1-800-HHS-TIPS or through our website at oig.hhs.gov >> Okay Great So, we’ve talked about now reviewing the explanation of benefits and Medicare summary notice, what else are some of the things that might be common in scams? You talked about what people should do to protect themselves if say they are approached by somebody at a health fair or they get a knock on the door or the phone rings >> Well, that’s a great point, Sheila, because we do commonly see patients fall prey to scammers and healthcare fraudsters In parking lots of shopping centers and other stores, being approached and solicited for a product or for a service And walking by a kiosk in the mall or through an unsolicited phone call marketing to them, you know, some product or some service like a cancer screening test that is of no cost to you and Medicare will pay, you know, 100%, you know, of the cost And the most important piece of advice that we can give patients is know who you’re dealing with When I want care, I identify the doctor that I know and I have trust and confidence and I seek out that care Don’t accept care or services or products from someone that you don’t know and certainly don’t hand over your Medicare or your other benefit information to someone that you don’t know and that you don’t trust >> Mike, anything else to add? >> Sometimes patients have told us that when they receive these solicitations, your doctor told me to call you type of thing So, if you don’t think that that’s the case, call your doctor first before you engage with them We’ve even seen people coming door to door knocking So, you have to be very careful just because they’re in scrubs it doesn’t always mean that they’re medical professionals >> And it’s important to remember that Medicare doesn’t call patients and ask for their information or solicit services to them So if someone calls a patient and is marketing themselves as calling from Medicare — >> That’s a red flag >> That’s a red flag Be very wary >> Right Because Medicare has their information There’s no need for Medicare to call >> And a lot of times they will use sound-alike names You can form a corporation that’s called Medic Care and when you answer the phone they say, “I’m from Medic Care.” It sounds like they’re from the government agency rather than the creation of their own company >> So, the same principle would apply that they should still follow up with They can contact Medicare, a beneficiary can contact Medicare or contact their doctor to confirm anything before giving any information Okay Alright So, let’s go to the next question Tell us what you all are doing on the ground to combat healthcare fraud >> Well, our viewers should know that the OIG is an organization over 1600 strong of professional federal law enforcement agents, attorneys, analysts, data scientists, auditors,

program evaluators that are leveraging a multi-discipline approach to detect, prevent, and deter, root out fraud wastes and abuse throughout the programs And in doing so we leverage partnerships at the federal, state and local level with our other law enforcement agencies and health organizations and state agencies in order to harness the power of kind of our collective tools and abilities in order to protect the patients and the taxpayer >> So, actually, Mike, can you tell us a little bit about the exclusions program? Maybe just explain what an exclusion is and how that can help to protect people and patients >> We consider participation in the Medicare program a privilege So, for individuals that have committed to healthcare fraud, we eliminate them from being able to bill our federal healthcare programs in the future And they are put on an exclusion list so that they can no longer do that It could be for a short period of time or it could be a life-time exclusion depending on what they did wrong And then they can no longer harm our beneficiaries in the future >> Thank you, guys So, now we’re going to give the audience a chance to ask questions If you have a question, please type it in the Facebook live feed Or you can follow — you can tweet us by using hashtag ask an investigator We do have some questions to get us started So, the first question, what if someone calls you saying they’re from Medicare and request your personal information over the phone? What should people do? >> Well, again, you know, we go back to the point we made earlier Medicare doesn’t call you So, certainly don’t give out your Medicare information over the phone Frankly, I’d say hang up But if, in fact, they’re marketing some service or some product that a patient has an interest in and they think that they may need that to improve their care, well, that’s okay Take that information and go back and consult your primary care physician, your doctor that you know and that you trust And they can advise you on how to proceed if, in fact, it’s something that will benefit in your care >> So, they can take that information but they should not give any of their personal information, name or anything else >> Patients should protect their Medicare information, their ID in the same way they would protect their bank account information or their driver’s license or other sensitive documents And don’t put that in the hands of anyone that they don’t know >> Okay Next question So, somebody says, “I’m getting frequent calls from Medicare services — and for free Medicare services.” Excuse me “And I’m told that they have a physician standing by to talk to me about the product or service Should I do so if I’m interested?” >> A lot of that goes back to the same answer that Shimon gave before First of all, nothing’s free Somebody is paying for that And a lot of times the fraudulent companies will waive the copays for a lot of these items as well which is illegal So, there is a cost to the beneficiary for some of these services So, you have to be careful with that So, when they tell you that it’s at no cost to you, there’s always a cost involved and you should never engage with them directly on the phone or door to door solicitation >> Okay So, actually, that leads into the next question If I see signs in clinics that offer free services for people on Medicare, is that legitimate? >> You know, again, any time, you know, there’s that old saying, you know, nothing in life is free And so, you know, our recommendation is that folks should always be wary and be very careful when things are marketed to them as absolutely free And if they have questions about their benefits and if it’s legitimately covered by Medicare or is indeed free meaning, there’s no out of pocket costs to the patient then they should call Medicare or they could talk with a patient advocate and they can, you know, clarify any benefits and coverage determinations So, know whether this is legitimate or whether there is something fishy going on >> So, they should use their judgment and the information that you’ve provided, reach out to a trusted provider first Okay So, we do have a question from Facebook and the question is how are you helping physicians to detect fraud? >> So, it’s a great question The OIG doesn’t just engage in enforcements and audits and litigation to deal with fraud but as an organization, we engage in events like this as well as many others to outreach and education to the industry Our agents frequently and representatives of OIG will speak at conferences and trade groups and others in order to again educate providers on what fraud is and what it isn’t,

what is accidental and the difference between intentional fraud in order to help them avoid the mistakes or the temptations to engage in these illicit schemes >> Also the Office of Counsel will give industry guidance So, if they have a question as to whether a business arrangement or something may or may not be acceptable or legal or violate the law, they can inquire and they can get industry guidance review of it >> So, that’s OIG’s team of attorneys that can advise on a legal side to make sure providers are in compliance with the rules >> And that’s done on a case by case basis >> And there’s an incredible amount of information available on our website at oig.hhs.gov both for educating providers, patients, and the industry at large >> Thank you So, we have another question Please differentiate between a billing error and outright fraud I don’t think you want to have beneficiaries accusing their providers of fraud >> That would be correct and that goes back to what Shimon said earlier the difference between accidental billing and actual fraud There’s no such thing as accidental fraud Fraud is a crime There has to be an intent You know the bill is wrong and then you submit it anyway with the intent of getting paid for it So, that’s the criminal aspect of it If you want to question your provider about a billing statement, don’t be accusatory because, like I said before, these bills can be very difficult to figure out what is actually contained in them Just ask them to go over it with you And then if you still have questions, there’s SEP and SHIP and your health plan and others that can help you with that >> And it’s important to remember that the vast majority of providers are out there doing the right thing And operating in good faith to try to take care of patients’ healthcare needs Unfortunately, it’s our job to deal with the smaller portion of that population that are knowingly engaging in criminal acts and taking advantage of patients and stealing from the taxpayer But the other thing that we do at OIG is that we work closely with the Department of Health and Human Services and specifically the Center for Medicare and Medicaid Services to identify ways to strengthen the programs and to differentiate on the front end between errors and potential vulnerabilities through billing mistakes versus outright fraud and those schemes that look to take advantage of the system >> Okay Here’s another question If someone has my Medicare ID number, what harm am I exposed to? For example, if a home caregiver may have — hold on one second Excuse me For example, can I give my home caregiver my ID number? >> So, again, our recommendation is know who you’re giving your information to and know who you’re receiving care from Unfortunately, many times we will see providers that will trick a patient into through some of these marketing ploys or other tactics into turning over their Medicare information and oftentimes they may act or call on the phone acting as if they’re Medicare, they’re calling from Medicare Remember that once you turn over that information, it is no longer in your control And so, unfortunately, we frequently see where a fraudulent provider will bill not just for maybe a service, you know, they convince you, Sheila, to, “Give me your Medicare information and we’ll get you — we’ll send you a cheek swab then you can get a free cancer screening test to identify your risk of getting cancer later in life And Medicare will pay for it It’s not going to cost you a penny.” And they may turn around and do that And you may not be aware that that’s actually a fraudulent bill because Medicare doesn’t cover curiosity screening tests for cancer But they may also then turn around and take your information and pass that on or either use it themselves to bill for other services that you had no idea that they were going to bill for And you didn’t receive or they may even take that and sell that to someone else that is going to use your information again to continue to bill Medicare or Medicaid or even private insurance for other if you have it — for other services or items that you have no idea is occurring >> We see a lot of these lists wind up on the dark web and then, not only do you have to worry about medical identity theft but there could be other kinds of thefts as well where they could take your identity, open accounts in your name, and that type of thing >> And so for vulnerable populations, people who are, you know, at home and require care, is it ever appropriate for that caretaker to ask for the person’s Medicare? >> It would be unusual, not necessarily inappropriate But usually, before the individual comes out to provide that care, that exchange of information

has already occurred between your doctor’s office and the home health agency Like Shimon said, if you know who the provider is, they’re already providing you care, that’s probably pretty safe as opposed to someone that just knocks on the door or gives you a phone call >> But the important thing is patients should remember that they’re in the driver seat, they’re the gatekeeper It’s their information, and they have the right to ask questions and to gain additional information in order to feel comfortable with turning over their Medicare information and they shouldn’t allow any provider, and they should be very — ask a lot of questions if, in fact, they feel like a provider or someone pretending to be a provider is bullying them into turning that information over The patient is in the driver seat You’re in control >> Okay Can you provide new methods to identify fraud, waste or abuse? So, maybe new investigative techniques or tactics that you all are doing I know we’re really moving on the forefront of data analytics >> So, for a variety of reasons we don’t discuss some of the cutting edge investigative technology or investigative techniques, law enforcement techniques that we use in further investigations But certainly, we can say that at OIG we are harnessing the power of modern technology and advanced data analytics in order to identify potential fraud, to detect it early on, and then to as close to real-time as possible address that fraudulent activity Both to hold accountable bad actors as well as to prevent maybe an emerging broad scheme from spreading into a broader national problem >> Okay And actually, Mike, can you just give the viewers some perspective in terms of how data has helped us work faster and smarter? Do you have any examples off the tip of your tongue of, you know, years ago it used to take X amount of time to get this data, and now we’re able to see things more in real-time? >> Most of our investigations are originated early on, they spawned off the other investigations These days we’re doing more proactive approach and looking at the data and we’re able to move very quickly when we see an anomaly in the data So, our whole mindset and the way we approach things has drastically changed just in the past couple of years We were talking about genetic testing a little bit ago, we did a massive effort to move forward with that with our data analytics and jumped on that massive fraud right away >> Okay Here we have another question How do you foresee the proposed rule changes of the Stark Law anti-kickbacks will help reduce fraud, waste, and abuse? >> Well, it’s important to understand that at the end of the day when we are conducting healthcare fraud investigations, we are looking for a lie, a theft And so addressing that underlying theft, that lie, that deception of the patient or the American taxpayer doesn’t change the foundation of our law enforcement efforts What we will continue to do is engage in education, both to industry and to the patients in terms of, you know, how these changes to the law affect them Our office of counsel puts out some excellent industry guidance that can help providers understand what the differences mean or what the changes mean And at the end of the day if a provider is doing the right thing and are putting patients above profits and upholding their Hippocratic Oath then they have nothing to be concerned of However, those doctors out there that would take advantage of the patients and would steal from the taxpayer and from the American public, they should know that we will be coming for them and we will hold them accountable >> Okay Another question How many people call the Medicare tip line annually? Are there any new — oh, there we go That’s the end of that question >> For the past couple of years, it’s been in the tens of thousands I think it’s a lot We get a lot of calls to our hotline every year >> It’s both through our websites, portal as well as through the hotline at 1-800-HSS-TIPS number Thousands and thousands of calls every year And it’s important that the viewers know that we do assess those They don’t just go into oblivion but we have a team of folks that work very diligently on going through that information and making sure that it gets in the hands of the right people to address it whether that’s within our agency, at other agencies, whether it’s

a matter for an agent to go investigate in the field or for our office of counsel to look at in a different arena >> And actually to follow-up with that because we get this question a lot Mike, can you just address the issue when people say, “I called in I reported a tip and I haven’t heard anything.” >> Yeah, that’s a common question that people have When someone calls in and we start an investigation, we can’t go publicizing that we’re doing an investigation So, we have to look at the data of what’s occurring and we may be doing some sort of investigation We may already have that individual under investigation But we don’t loop back with individuals and tell them about open and active investigations We just can’t >> So, most of the time they should not expect — >> No, we have to worry about operational security during an investigation and of the rights and privacy of a provider as well So, we don’t give feedback on the stages of the investigation At some point, if the investigation comes to a conclusion, it’s publically announced and they’ll be able to find out if there was something that came out of that >> Okay Are there any other new schemes out there besides genetic testing and the brace scheme? Anything else that you all are seeing, that you are able to share? >> There’s always new iterations of the old scheme sort of things whether they’ll be pharmaceuticals or the brace scams There are always new Medicare rules coming out that people try to find holes in and try to generate new ways around something that we’re doing So, it’s not always that there’s a new scam going on, it’s just the re-swizzling of the old one Recently there was an ear acupuncture device that was being sold And what they were billing for was an implantable nerve stimulator So, again, that goes back to what we said at your original question It’s a provision of a non-covered service that was billed as a covered service So, that was an example of something that came up just recently >> And one of the most pervasive trends in healthcare fraud right now is the use of telemarketing to solicit patients for products or for services that they may or may not need, under the guise of telemedicine And so it’s important for patients to be aware of the difference between true telemedicine where perhaps they’ve sought out care from a provider and they’ve had interaction with the provider and consulted with that provider about their healthcare needs and services and received services from that doctor Versus someone calling them out of the blue and marketing to them for a product or for a healthcare service that — >> Not in the best interest >> They may or may not even need or they weren’t looking for >> And some of the telemarketing companies we’re finding recently are not even in this country They’re calling from overseas >> Interesting Alright How often should people and vendors be checked against the exclusions list? >> So, this is really important and not all the viewers may understand but the exclusions list is essentially like Mike talked about before when we find a bad actor and they are held accountable whether it’s through a criminal conviction or otherwise, we will take — essentially we’ll boot them out of the program through an exclusion So that they can no longer bill Medicare or Medicaid or other federal healthcare programs at all And so providers and healthcare companies out there have an obligation to check against the exclusions list that is publically available to ensure that they’re not inadvertently employing someone or they’re not facilitating indirectly, billing to Medicare or Medicaid by someone who’s been barred from the program >> Is it every time they bring on a new employee or we update our exclusions list each month? Is it every time a new employee comes on board they should check it? >> It should be checked every time you bring a new employee on board Because if you billed on behalf of that employee for a couple of years and then you find out they were excluded, all that money has to be paid back Those are not legitimate claims that were submitted >> Alright So, I think this will be our last question here So, how can a provider know what the current schemes are being played out or what current schemes are being played out in their area? >> Well, one of the easiest ways that a provider can, you know, be aware of what’s going on in their area is to follow our website There’s information — or I’m sure any of our social media feeds But on the website, there’s frequently information, our press releases, and others both for federal

law enforcement action against healthcare providers in different areas as well as state action, say by the Medicaid fraud control units >> And Senior Medicare Patrol on the local area will have whatever the local flavor is for the frauds in their particular area so they may want to reach out to them as well >> Alright Well, great tips Thank you both for those answers and sharing that valuable information with our viewers So, that’s a wrap for us We know that there are a few questions that we didn’t get to so we’ll follow up in the comment section after we wrap Thank you for watching And together we can fight healthcare fraud and help to protect people and patients Thanks again to Shimon and Mike for joining us And if you suspect healthcare fraud, waste or abuse, please report it to our fraud hotline And for more information, visit our website at oig.hhs.gov Thank you [ Music ]