Frequently Asked Questions Arkansas SMP
Arkansas SMP - Empowering Seniors To Prevent Healthcare Fraud
What's the Difference Between Medicare and Medicaid?
Medicare is the nation’s largest federal health insurance program, covering nearly 40 million Americans. It is administered by the Centers for Medicare and Medicaid Services (CMS) and pays for health care services for:
- Persons age 65 and over,
- Some people with disabilities under the age of 65, and
- People in end stage renal disease (ESRD) – permanent kidney failure treated with dialysis or a transplant.
Medicare hospital insurance (Part A) pays for limited inpatient care in hospitals, skilled nursing facilities, psychiatric hospitals, hospice, and home health care services. Medicare medical insurance (Part B) helps pay for doctor services, outpatient services, durable medical equipment, and other medical services. These services are the same nationwide.
Medicaid is a joint federal and state health care program, authorized by Title XIX of the Social Security Act, to provide medical care for low-income individuals with limited resources, regardless of age. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.
What is Healthcare Fraud?
Fraud occurs when an individual or organization deliberately deceives others in order to gain some sort of unauthorized benefit.
Medicare or Medicaid fraud occurs when services provided to beneficiaries are deliberately misrepresented, resulting in unnecessary cost to the program, improper payments to providers, or overpayments.
Medicare/Medicaid fraud generally involves billing for services that were never rendered or billing for a service at a higher rate than is actually justified.
Medicare or Medicaid abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards. Doctors, providers, or suppliers bill for items or services that should not be paid for by Medicare or Medicaid.
Healthcare fraud is not just a matter of dollars and cents. Equally important is the serious effect on the quality of care received. For example, a doctor prescribes physical therapy for a patient following a stroke, for an hour of physical therapy three times a week.
HOWEVER, the therapist regularly provides only ten minutes of therapy, BUT bills Medicare for the full hour each time.
Not having the full amount of physical therapy could have led to a loss of function for the patient, which may never have been regained. Medicare beneficiaries can now call the ASMP to report such situations and insure receiving the full physical therapy benefit through another company.
Remember: most health care professionals are honest, trustworthy, and responsible. The goal of this initiative is to weed out the few health care providers who operate with the intention of using Medicare and Medicaid as a pipeline to personal profit. The effort to prevent and detect healthcare fraud is a cooperative one that involves:
- The Centers for Medicare and Medicaid Services (CMS), and the Administration on Aging, Providers of services,
- State and Federal Agencies such as the Department of Health and Human Services Office of the Inspector General (HHS-OIG), the Federal Bureau of Investigation (FBI), the Department of Justice (DOJ), and the Attorney General’s Office,
- Department of Human Services (DHS), Division of Aging and Adult Services (DAAS), and Area Agencies on Aging (AAA),
- Medicare and Medicaid Beneficiaries — This means YOU!
What Healthcare Fraud Is Not
Healthcare fraud is not:
An honest mistake by the provider. Everyone makes mistakes and clerical errors occur all the time. A bill for more time than the patient thinks was spent with the doctor.
Situations where “you just know” something is wrong. A gut feeling that something is wrong cannot be proven without documentation.
Hospital bills that just seem “too high.” Providers are contracted at specific amounts for specific services and/or equipment and bill CMS according to those contracted amounts.
Charges on the Medicare statement for doctors such as anesthesiologists, radiologists, etc. that the beneficiary doesn’t remember seeing. This is not uncommon because these doctors provide specialized services behind the scenes or bill separately from the primary care doctor.
What Does it Cost and Who Pays?
Healthcare fraud affects all Americans. It affects everyone who pays taxes by wasting billions of tax dollars. It affects those who depend on Medicare or Medicaid by diminishing the quality of the treatment they receive.
Loss of money to fraud and abuse means that less money is available for necessary services and programs to assist caregivers. Additionally, poor quality of care can impact a beneficiary's functional level, which may extend his/her need for services.
Higher Medicare costs also result in higher premiums and co-pays.Most Medicare and Medicaid payment errors are simple mistakes by doctors, providers, or suppliers. Most of them provide quality care to their patients and bill the program correctly only for the services they have provided.
However, there are always a few who intentionally cheat these government programs (and in some cases the beneficiaries who are responsible for co-payments) out of millions of dollars annually. The cost is estimated to be over $13 billion annually for Medicare alone. The cost in terms of lost services and poor quality of care is immeasurable.
Who pays? YOU PAY!