Wisconsin SMP In this issue:
Let’s Get Acquainted with Terri Klubertanz, SMP Volunteer CMS Launches New Video on Medicare
Enrollment Fraud OCI News Release
DATCP: Beware of IRS and Computer Tech Support Scams
Medicare Scammers Target Low-Income Beneficiaries in Chicago OIG: Nursing Homes Bill Medicare for
More Therapy Than Patients Need DOJ News Release
FTC News Release
Upcoming Wisconsin SMP Activities I
From the Project Director. . . Kevin Brown
Check out our website at www.wisconsinsmp.org
Let’s Get Acquainted
By Judy Steinke, Wisconsin SMP Volunteer Coordinator
Wisconsin SMP (Senior Medicare Patrol) is pleased to introduce Terri Klubertanz of Merrimac as this month’s featured volunteer.
Terri, who has a BA degree in Management and
Communication from Concordia University, recently retired after a 33-year career working with the Social Security
disability program as a disability examiner, unit supervisor, and quality assurance manager.
Wisconsin SMP recruits volunteers in several different ways, but Terri’s recruitment story is unique. Kevin Brown, Wisconsin SMP Project Director, is her brother, and it was while they both watched his daughter play soccer that she asked Kevin about SMP and our volunteer activities. After learning about the outreach and education that SMP volunteers do, Terri decided to join the team.
Terri volunteers because she wants to give back to her community and share her knowledge of Social Security and Medicare with others. She also volunteers for Home Health United of Sauk County and the Al Ringling Theatre in Baraboo. Spending time with her family, especially her grandchildren, is a priority for Terri. She also loves to read and quilt.
Thank you, Terri, for joining the team. We are grateful for your willingness to share your expertise with Wisconsin Medicare beneficiaries and caregivers.
2850 Dairy Drive Madison, WI 53718-6742
October 2015 Volume 19, No. 3 Coalition of Wisconsin Aging Groups Elder Law Center
Published and distributed by the Coalition of Wisconsin Aging Groups Elder Law Center. This project was supported, in part by grant #90MP0213, from the U.S. Administration for Community Living, Department of Health and Human Services,
Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
EDITOR AND PROJECT DIRECTOR Kevin Brown
This publication may be reproduced ONLY in its entirety. Permission to excerpt portions must be obtained prior to use.
© 2015 CWAG. All rights reserved.
F r a u d A l e r t !
CMS Launches New Video on Medicare Enrollment Fraud
By Kevin Brown, Wisconsin SMP Project Director
Medicare beneficiaries are particularly vulnerable to the tactics of dishonest brokers during the Open Enrollment Period, which is from October 15 to December 7. The Centers for Medicare & Medicaid Services (CMS) recently released a new video to educate Medicare Advantage and Prescription Drug Plan enrollees, their families, and caregivers about some common Medicare enrollment fraud schemes. The “Lookout for Enrollment Fraud” video, which is five minutes long, teaches viewers how to protect themselves from Medicare enrollment fraud and how to report it if they are victimized by fraudsters. The video addresses some of the typical enrollment fraud tactics of dishonest brokers, such as:
Contacting potential enrollees directly without prior permission.
Pressuring enrollees with false time limits, “limited time offers” or non-existent early bird discounts.
Offering free gifts of more than $15 in value or complimentary items that are given on condition of enrolling in a plan.
Enrolling beneficiaries in plans without their knowledge.
Enrolling only healthy beneficiaries.
Being aware of these common fraud schemes will help beneficiaries keep their confidential
information secure, prevent identity theft, and select the plan that is best for their medical needs and meets their budget. The video also contains valuable information on how individuals can protect themselves from Medicare enrollment fraud. The video is available in both English and Spanish. Please watch the video and share it with others. It is posted to the CMS YouTube channel at
https://www.youtube.com/watch?v=iByQfda5PMo.
Reprinted with permission of the Wisconsin Office of the Commissioner of Insurance
October 14, 2015
Medicare Advantage Open Enrollment Period Starts Early
Check Your Options NowMadison, WI — Insurance Commissioner Ted Nickel reminds Wisconsin seniors that the Medicare open enrollment period begins on October 15 and ends December 7 this year. Medicare open
enrollment allows seniors to look at their existing drug and medical plans and decide whether or not to keep the coverage they have or switch to a new drug or Medicare Advantage plan. Seniors should review their Medicare Advantage and prescription drug plans’ coverage for 2016 now to see if those plans still meet their needs.
“It is important to spend a little bit of time and do an insurance check-up every year. The plan you have this year may not be exactly the same for 2016,” said Nickel. “Plans may change their premiums, deductibles and coinsurance. They may also add or drop physicians and hospitals from their networks or change which drugs they cover.”
People with Medicare are receiving information now from their plans about changes for 2016, including changes to premiums and cost-sharing. They should study this information carefully and determine whether staying with their current plan for 2016 is best for them. During the open enrollment period from October 15 to December 7, 2015, people with Medicare can sign up for any Medicare Advantage or prescription drug plan offered in their area or switch to original Medicare. The federal government has a very useful Web site (Medicare.gov) that will provide information on the Medicare Advantage plans available in an area. They can sign up for a plan from the Web site or contact the plan directly.
When considering a change in Medicare coverage, it is very important to evaluate the cost-sharing provisions of any new plan. Medicare Advantage plans have different deductibles and copayments and those differences can be quite significant. Generally, the higher the cost-sharing, the lower the
premium charged by the plan. However, should an illness occur, out-of-pocket expenses will be greater.
Remember, people with Medicare do not have to change plans unless they choose to.
The cheapest policy may not be the best option. Some things that should be considered when deciding to change or keep one's current plan include:
1. Will the plan allow you to see the providers you want? 2. Will your current doctors accept your coverage?
3. Are there any additional benefits offered? What is the additional charge for those benefits? 4. Will the plan cover the prescription drugs you are currently taking?
5. What are the benefits that are excluded? Would those benefits be covered under an original Medicare supplement policy?
6. What is the total cost to you, including premiums, coinsurance, copayments, deductibles, or other out-of-pocket expenses?
7. How often and by how much can the plan raise your premiums?
8. If you have a specific health condition, is one type of plan better suited to provide the services you need?
Generally, plans that offer you more freedom in choosing providers or that cover additional benefits will cost you more, either in premiums or out-of-pocket expenses.
There are a number of places that seniors can visit for more information about Medicare, their options, and assistance. The Office of the Commissioner of Insurance (OCI) has a number of resources for seniors. Publications including Medicare Part D - Things to Know Before Signing Up and
Wisconsin Guide to Health Insurance for People with Medicare are available on OCI's Web site. Seniors can also go to Medicare's Web site at Medicare.gov for information on this important topic. To compare Medicare Advantage plans or to find out what plans are available in your area, you can:
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, or visit
Medicare.gov on the Web.
Contact the Medigap Helpline at 1-800-242-1060 (Medigap Helpline) or on the Web at
Although Medicare Advantage plans are regulated by the federal government, the Wisconsin Office of the Commissioner of Insurance still regulates insurance agents who sell these products and their actions. If you or someone in your family is a Medicare beneficiary and you have questions regarding agent activity or wish to file a complaint involving an agent, contact OCI at 1-800-236-8517. Further information and complaint forms are also available on the OCI Web site: oci.wi.gov.
DACTP: Beware of IRS and Computer Tech Support Scams
A Department of Agriculture, Trade and Consumer Protection (DATCP) official estimates that 10% of its consumer complaint contacts in the past month were about the IRS scam. “I feel like we’ve talked about these scams until we are blue in the face, but they just keep coming,” said Jerad Albracht, DATCP spokesman. “Over the past month alone, the Consumer Protection Hotline has received 87 inquiries about IRS scams. Put another way, roughly one in every ten phone calls, emails or walk-ins to the hotline was from a consumer asking about these operations.”
According to a recent DATCP consumer alert, “the IRS scam” occurs when: “A scammer who claims to be with the Internal Revenue Service contacts you by phone or email. He claims that you owe back taxes. He demands immediate payment and may threaten you with legal action, jail time, deportation or revocation of your driver’s license.”
Tom Clauder, a retired police officer and former mayor of Fitchburg, recently received a telephone call from someone attempting to perpetrate the IRS scam. Clauder recognized the scam and immediately called his daughters to warn them about it. “The (scammers) called and said, this is the IRS and we have information that you have to call us about right away regarding a problem with your return. I didn’t call back, but I can understand how some people might,” Clauder said.
The goal of a fraudster committing the IRS scam could be either to obtain personal financial
information, like a Social Security number or government tax portal password, so that the con artist can file a false income tax return or to convince individuals that they owe back taxes and must pay them immediately.
Madison Police Department spokesman Joel DeSpain noted that IRS scammers can be successful, “Because a lot of times, they go by sheer numbers. They call a lot of people. And they are successful because these people are very pushy, can be very threatening, and the people they call can be
vulnerable, elderly who may sometimes get confused and fall for them.”
Albrecht stated that the “computer tech scam” is also prevalent currently. “They tell you that they can remove the (nonexistent) virus from your computer for a fee. The call asks you to download software from the Internet that grants them remote access to your system.” Like the IRS scam, the computer tech scam also relies upon fear.
If individuals suspect fraudsters are trying to victimize them with either one of these scams, DATCP recommends that they hang up on the callers or delete their bogus emails.
Medicare Scammers Target Low-Income Beneficiaries in Chicago
Chicago is a Medicare fraud hotspot, and Arlene Gregory, a Chicago resident, is a typical Medicare fraud victim. She is in her 70s, had bladder cancer twice, and walks slowly, sometimes with a limp because of a Baker’s cyst behind one of her knees. She thinks her medical condition made her an easy target for a Medicare con artist.
Last summer, Gregory was approached at her local food pantry by a scammer who introduced herself as “Kim” and claimed that Gregory was eligible to receive free services, like house cleaning. “I fell hook, line and sinker. I was so happy that I could get all these benefits, somebody come in and do my floors,” said Gregory.
However, soon after Gregory started receiving housework help, she started getting unsolicited visits from nurses and a doctor. “I kept telling them, I don’t want a nurse coming out once a week. That’s not necessary. I have my regular home physician. ‘Oh, well you got to have the nurse to be eligible for the other benefits,’” she said.
Gregory was also given durable medical equipment, like a cheap back brace that didn’t fit. Then she received pages and pages of Medicare statements. They showed that the Medicare program had been billed thousands of dollars for services Gregory never received, like physical therapy and psychiatric treatment. After several weeks, Gregory mentioned the unnecessary medical services and products that she had received to her regular doctor. “She like hit the fan. She was very upset. She says, ‘Arlene, these benefits are for people who are homebound,’” Gregory said.
Jeff Jamrosz, a supervisory special agent for the FBI in Chicago, said Gregory’s story isn’t uncommon. Fraudsters often target vulnerable Medicare beneficiaries. “In the low-income area, if you have a high concentration of Medicare beneficiaries with low income, maybe that cash kickback is enough to get it,” he said.
The FBI calls these scammers “marketers.” Jamrosz said marketers will cold call beneficiaries or show up at food pantries – like they did in Gregory’s case – to recruit potential patients. They say, “‘Hey, who has a red, white and blue card?’ Referring to their Medicare card. ‘I’ll give you $50 if you come with me to the doctor.’ And that’s the way in which these patients are found,” he said. The FBI reports that Medicare fraud is quite high despite some strong efforts to curtail it, such as a moratorium on new home health care businesses and stricter sentencing for convicted fraudsters. However, Jamrosz said that scammers are still cashing in and estimated that over a 60-day billing cycle, a home health care con artist can collect $2,500 off a single Medicare beneficiary.
Ultimately, Gregory worked with her doctor and a senior issues organization (Illinois SMP) to resolve the fraudulent billing. If she hadn’t reported the fraud, she may have had trouble getting the services she needed in the future. She still goes to the same food pantry, but she is now more careful about who she talks to and what personal information she shares.
OIG: Nursing Homes Bill Medicare for More Therapy Than Patients Need
On September 30, the U.S. Department of Health and Human Services (DHHS), Office of Inspector General released a report that found that nursing homes regularly billed Medicare for the most expensive level of therapy, regardless of what patients needed. Daniel R. Levinson, the DHHS inspector general, noted that nursing homes have been claiming that more and more of their patients need the highest level of therapy and then provide the patients exactly the amount of therapy required to qualify them for high payments. “Skilled nursing facilities must provide therapy for 720 minutes or more during a seven-day assessment period to bill for ultrahigh therapy,” Levinson said, and they “increasingly provided exactly 720 minutes.”Levinson pointed to claims data as evidence that some nursing homes had abused the Medicare program to increase their revenues. For example, he stated that a Medicare beneficiary received physical therapy treatments for five days a week for five weeks, “even though her medical records indicated that she asked that the therapy be discontinued.” Levinson said these types of extra billings cost Medicare $1.1 billion in 2012-2013.
Medicare classifies nursing home residents into one of 66 groups based on the needs of the patient. Over one-third of the groups are for patients who require physical, occupational or speech therapy. Medicare pays nursing homes more for patients who require the most therapy.
Andrew Slavitt, the acting administrator of the Centers for Medicare & Medicaid Services, did not disagree with the report’s findings. He noted that the current payment structure has an incentive for nursing homes “to provide as much therapy to a resident as that resident can tolerate.” Levinson said that DHHS should consider decreasing Medicare billing rates for therapy in nursing homes. Slavitt agreed, but said Congress would need to provide the agency with “additional statutory authority.” Other entities are also interested in overhauling Medicare’s payment system to nursing homes. In March, the Medicare Payment Advisory Commission said Congress should revamp the system. The commission said that Medicare payments to nursing homes have been at least 10 percent higher than the cost of care for 14 consecutive years. “Therapy payments are not proportional to costs, but instead rise faster than providers’ therapy costs,” the commission said, and Medicare “essentially requires taxpayers to continue to finance the high margins of this industry.”
The Obama administration proposed consolidating Medicare payments for many hip and knee
replacement procedures, which would create incentives for hospitals, surgeons, and nursing homes to coordinate their care. However, Levinson said this would fail to fix Medicare’s payment issues
because the proposed “bundled payments” would be at least partially based upon the current payments nursing homes receive for treating beneficiaries.
The American Health Care Association, a trade group for nursing homes, said it supports efforts to shift Medicare “away from paying providers based solely on their volume of services.” The group says that Medicare should pay a lump sum for a patient’s entire stay in a nursing home, based on their condition and needs. Medicare currently pays nursing homes for each day of care for a patient, and the payments are partially determined by the minutes of therapy provided by a facility.
Reprinted with permission of the U.S. Department of Justice
October 19, 2015
Millennium Laboratories to Pay $256 Million to Resolve False Billing and
Kickback Claims
BOSTON – Millennium Health, formerly Millennium Laboratories, has agreed to pay $256 million to resolve allegations that it billed Medicare, Medicaid, and other federal health care programs for
medically unnecessary drug testing and genetic testing, and provided kickbacks to physicians to induce business. Today’s announcement reflects two False Claims Act settlements between Millennium and the Department of Justice and an administrative settlement agreement between Millennium and the Department of Health and Human Services. Millennium, headquartered in San Diego, Calif., is one of the largest urine drug testing laboratories in the United States.
As part of today’s announced settlements, Millennium has agreed to pay $227 million to resolve False Claims Act allegations that it systematically billed federal health care programs for excessive and unnecessary drug testing from Jan. 1, 2008 through May 20, 2015. (A copy of the United States’ complaint, with exhibits, is available here.) The United States alleged that Millennium caused physicians to order excessive numbers of urine drug tests, in part through the promotion of “custom profiles,” which, instead of being customized for individual patients, were in effect standing orders that caused physicians to order large number of tests without an individualized assessment of each patient’s needs. Millennium’s use of the so-called “custom profile” led to the over-billing of federal health care programs which limit payment to services that are reasonable and medically necessary for the
treatment and diagnosis of an individual patient’s illness or injury. The United States also alleged that Millennium violated the Stark Law and Anti-Kickback Statute by providing physicians with free drug test cups on the express condition that the physicians return the specimens to Millennium for hundreds of dollars’ worth of additional testing.
Millennium has also agreed to pay $10 million to resolve allegations that it submitted false claims to federal health care programs for medically unnecessary genetic testing that was performed on a routine and preemptive basis, without an individualized assessment of need, from Jan. 1, 2012 through May 20, 2015. Routine genetic testing is not medically reasonable and necessary, and therefore does not qualify for Medicare reimbursement.
“Millennium promoted indiscriminate and unnecessary testing that increased medical costs without serving patients’ real medical needs,” said Carmen M. Ortiz, United States Attorney for the District of Massachusetts. “A laboratory which knowingly conducts medically unnecessary testing operates unlawfully and squanders our precious federal health care resources.”
“The Department of Justice is committed to ensuring that laboratory testing, including drug testing, is ordered based on each patient’s medical needs and not for physician or laboratory profit,” said
Benjamin Mizer, Principal Deputy Assistant Attorney General for the Civil Division of the Department of Justice. “Millennium’s promotion of excessive, non-patient specific test ordering—and its test cup giveaways to physicians to increase that ordering—resulted in significant unnecessary costs being imposed upon our nation’s health care programs.”
“When corporations, such as Millennium, bill Medicare for medically unnecessary tests, they threaten the financial integrity of public healthcare programs,” said Special Agent in Charge Harold H. Shaw of
the Boston Division of the Federal Bureau of Investigation. “The FBI hopes this settlement will send a strong message that fraudulent practices by medical labs will not be tolerated.”
In connection with False Claims Act settlements, Millennium has entered into a Corporate Integrity Agreement with the Department of Health and Human Services, Office of Inspector General.
“This company has taken the first step toward demonstrating a commitment to compliance by agreeing to make significant changes to its board of directors,” said Inspector General Daniel R. Levinson of HHS-OIG. “Most of the board will be comprised of new independent members. Under the five-year CIA, OIG will monitor the company’s compliance efforts under this new leadership.”
Today’s announcement also includes a $19 million settlement between Millennium and the Centers for Medicare and Medicaid Services (CMS) to resolve administrative actions regarding Millennium’s claims to Medicare for certain drug test billing codes. These claims were the subject of claim denials and an overpayment action initiated by CMS and its contractors.
The False Claims Act settlements resolve allegations originally brought in lawsuits filed by
whistleblowers under the qui tam provisions of the False Claims Act, which allow private parties to bring suit on behalf of the government and to share in any recovery. The United States filed its False Claims Act complaint on the urine drug testing allegations after intervening in consolidated complaints filed under the qui tam, or whistleblower provisions of the False Claims Act by Mark McGuire, Ryan Uehling, and Omni Healthcare Inc. The genetic testing allegations were also filed in a qui tam complaint filed by Omni Healthcare Inc. In connection with today’s announced settlements, whistleblowers will receive fifteen percent of the federal recovery from the urine drug testing False Claims Act settlement and sixteen and one half percent of the federal recovery from the genetic testing False Claims Act settlement.
The investigation was conducted by the Federal Bureau of Investigation; the Department of Health and Human Services, Office of Inspector General; CMS; the Department of Veterans Affairs, Office of Inspector General; the Office of Personnel and Management, Office of Inspector General; and the United States Postal Inspection Service. The cases were handled by Assistant U.S. Attorneys George Henderson, Abraham George, and Sonya Rao of Ortiz’s Civil Division and Trial Attorneys Douglas Rosenthal and Augustine Ripa of the Justice Department’s Civil Division, Commercial Litigation Branch.
Reprinted with permission of the Federal Trade Commission
October 23, 2015
FTC Testifies On Efforts to Stop Fraud Affecting Older Americans Before House
Subcommittee on Commerce, Manufacturing and Trade
The Federal Trade Commission highlighted to Congress its multi-faceted approach to protecting older Americans from fraud in testimony today before the House Energy and Commerce Committee’s
Subcommittee on Commerce, Manufacturing and Trade.
Testifying on behalf of the agency, Daniel Kaufman, Deputy Director of the FTC’s Bureau of
on combatting technical support and health care related scams. Both of these scams injure older Americans, and fraudsters engaged in these schemes typically fabricate an affiliation with well-known businesses or government agencies to gain consumers’ trust.
The testimony noted the rise in the number of complaints against technical support schemes, reporting that these scams appear to disproportionately affect seniors. From January through August 2015, of the 18,000 people who reported technical support scams and provided their age, 76 percent were over the age of 50, and 56 percent were over the age of 60.
Regarding health care scams, the testimony highlighted how con-artists use false claims of affiliation with the government to trick people into providing their bank account information over the phone and then use that information to take money directly from consumers’ bank accounts.
According to the testimony, all consumers are potential fraud targets, and older Americans are not necessarily defrauded at higher rates than younger consumers. However, the Commission has brought more than 30 cases since 2005 against defendants that have specifically targeted or disproportionately affected older Americans. Frauds that injure older consumers include sweepstakes, prize promotions and lotteries; timeshare sales and re-sales; investments, business opportunities and work-from-home programs; and charitable donations.
The testimony also outlined the FTC’s education and outreach programs that reach tens of millions of people every year. Among them is the recently created “Pass It On” program that provides seniors with information, in English and Spanish, on a variety of scams targeting older consumers. The testimony also noted the agency’s work with the Elder Justice Coordinating Council to help protect seniors, and with the AARP Foundation, whose peer counselors provided fraud-avoidance advice last year to more than a thousand seniors who had filed complaints with the FTC about certain frauds, including lottery, prize promotion, and grandparent scams.
Upcoming Wisconsin SMP Activities
Date Activity County
October 30 SMP Booth-Elderfest-Lancaster Grant
November 2 SMP Booth-Family Caregiver Resource Fair-Eau Claire Eau Claire November 3 SMP Presentation-St. Nazianz Nutrition Site Manitowoc November 3 SMP Presentation-WI Tribal Aging Unit Assn.-Green Bay Brown
November 5 SMP Presentation-Kiel Nutrition Site Manitowoc
November 5 SMP Booth-All Things Senior Expo-Baraboo Sauk November 5 SMP Booth-Alzheimer’s Fall Education Conf.-Green Bay Brown November 6 SMP Booth-Caregiver Resource Fair-Montello Marquette November 9 SMP Presentation-High Ridge Manor-New Berlin Waukesha November 11 SMP Presentation-Valders Nutrition Site Manitowoc November 13 SMP Presentation-Birchwood Highlands-Weston Marathon November 16 SMP Presentation-Manitou Manor Nutrition Site Manitowoc November 18 SMP Presentation/Booth-Poverty Matters! Conf.-Pewaukee Waukesha
We are always looking for opportunities to support our colleagues in the aging network. Please contact Wisconsin SMP and let us know about upcoming events in your area.
ATTENTION: All of You with Email…
In an effort to save paper, postage and be “volunteer friendly,” we will email issues of the
Fraud Alert! to those who have email. Please contact Kevin Brown at [email protected] and give him your email address to add to our list. Thank you!
For more information, contact: Kevin Brown, SMP Project Director
Coalition of Wisconsin Aging Groups Elder Law Center 2850 Dairy Drive – Suite 100
Madison, WI 53718-6742
Phone: 800/488-2596 608/224-0606 Email: [email protected]
You can also access our publication by visiting our web site www.wisconsinsmp.org
Or you can visit the Coalition of Wisconsin Aging Groups web site www.cwag.org
Click on Publications then click on Wisconsin Senior Medicare Patrol (SMP) and scroll down and click on the edition you wish to view.
Wisconsin SMP
Coalition of WI Aging Groups 2850 Dairy Drive Ste. 100 Madison WI 53718