Nevada SMP – Senior Medicare Patrol Volunteer

Position Summary:

The goal of the Nevada SMP program is to use the skills of adult volunteers to reach Medicare and Medicaid beneficiaries across the state of Nevada with the SMP message: Protect, Detect, Report.  Nevada SMP volunteers empower beneficiaries to prevent, detect, and report healthcare fraud by providing outreach and education on health care fraud in their communities.

SMP volunteers  work  through  the State  of  Nevada  Aging  and  Disabilities  Services Division to provide consumer education, one-on-one counseling, and informal advocacy in the area of Medicare/Medicaid fraud and abuse, through the program’s collaboration and partnership  with various  government  agencies including  but not  limited  to: CMS – Centers for Medicare & Medicaid Services, SHIP – State Health Insurance Assistance Program, GovCHA– Governor’s Office for Consumer Health Assistance and Salud En Acción for Hispanic outreach.

Duties: Volunteers may participate in one or more of the following activities depending on their level of training and preference:

• Act  as  a  consumer  education  resource  for  Medicare/Medicaid  beneficiaries  and community  members  and  with  an  emphasis  on  detecting  possible  healthcare fraud, waste, or abuse.
• Educate  beneficiaries  to  critically  review  their  Medicare  Summary  Notices  or Insurance  Explanation  of  Benefits  statements  enabling  them  to  spot  suspicious activity.
• Take complaints from beneficiaries, referring unresolved disputes to the Nevada

SMP Program Officer or Program Assistant when appropriate

• Give public presentations to community groups on fraud and abuse.
• Staff display tables at fairs and community events.
• Provide  one-on-one  counseling  to  individual  beneficiaries  (at  libraries,  senior centers, etc.).
• Reply to phone calls from the public to the Nevada SMP.
• Answer hotline calls (forwarded from SMP office).
• Promote  awareness  of  the  Nevada  SMP – Senior  Medicare  Patrol,  a  Medicare fraud prevention program.
• Submit  monthly  reports  (mileage,  event  tracking  forms,  etc.)  and  complaint referrals as needed to the SMP staff.
• Other projects related to the promotion of the SMP mission.

SMP FOUNDATIONS TRAINING: VOLUNTEER MANUAL

SMP Glossary of Terms

ADMINISTRATION ON AGING (AOA) – An agency of the U.S. Department of Health and Human Services. AoA is a focal point and advocacy agency for older persons and their concerns at the Federal level. AoA works closely with its nationwide network of State and Area Agencies on Aging (AAA) to plan, coordinate, and develop community-level systems of services that meet the unique needs of individual older persons and their caregivers.

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) – A health care provider or supplier may give a person a notice called an “Advance Beneficiary Notice of Noncoverage” (ABN). This notice says Medicare probably (or certainly) won’t pay for some services in certain situations. If the person chooses to get the items or services listed on the ABN, they will have to pay if Medicare doesn’t. There are specific requirements for how and when ABNs must be issued.

ASSIGNMENT – In the Original Medicare Plan, “assignment” means a doctor or supplier agrees to accept the Medicare-approved amount as full payment. If you are in the Original Medicare Plan, it can save you money if your doctor accepts assignment. You still pay your share of the cost of the doctor's visit.

CAPITATED PAYMENT – The health care provider is paid a fixed amount of money by an insurer for all of their patients. The amount doesn’t change regardless of whether the patient visits the doctor. If a patient requires a lot of care and it isn’t well managed by the doctor, he/ she can use more services than the doctor gets paid for.

CARRIER – Carriers process some Part B claims. Contracts will be transitioning from Carriers to MACs.

CATASTROPHIC COVERAGE -- Once beneficiaries reach their plan’s out-of-pocket limit, they automatically get “catastrophic coverage” which means that they only pay a small coinsurance amount or copayment for the drug for the rest of the year.

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) – The Federal agency responsible for the Medicare and Medicaid programs.

1-800-MEDICARE or www.cms.hhs.gov.

COINSURANCE -- An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

COPAYMENT -- An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage.

COMPLAINTS – Allegations of errors, fraud, and abuse.SMP FOUNDATIONS TRAINING: VOLUNTEER MANUAL

COMPLEX ISSUE – The Office of the Inspector General (OIG) performance measure definition of a complex issue is: “inquiries that generally require the SMP staff or volunteer to obtain beneficiary personal identifying information and detailed information related to the issue, complaint, or allegation in order to conduct further investigation or referral.” Complaints, defined by the OIG as allegations of errors, fraud, and abuse, are one type of complex issue.

COORDINATION OF BENEFITS CONTRACTOR (COB) – COBs identify the health benefits available to a Medicare beneficiary and coordinate the payment process to prevent mistaken payment of Medicare benefits. The COB program involves the collection, management, and reporting of other insurance coverage. www.cms.hhs.gov/medicare/cob.

COVERAGE GAP (“DONUT HOLE”) - After a beneficiary and a Part D drug plan have spent a certain amount of money for covered drugs, the beneficiary must pay almost all costs out-of-pocket for prescriptions up to a yearly limit (see Catastrophic Coverage, below). Some plans offer coverage in this gap for generic prescriptions (not name brand). Effective January 1, 2011, if a person reaches the donut hole, they will automatically get a 50% discount on covered brand-name drugs and biologics and a 7% discount on generic drugs until they reach the catastrophic coverage phase. Each year they will pay less for prescription drugs in the donut hole until the donut hole is eliminated in 2020.

DEDUCTIBLE -- The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or your other insurance begins to pay.

DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) – HHS is the Federal agency that houses the Centers for Medicare & Medicaid Services, the Administration on Aging, and the HHS Office of the Inspector General. www.hhs.gov

DIAGNOSIS RELATED GROUP (DRG) - A system to classify hospital cases. Patients within each category are similar clinically and are expected to use the same level of hospital resources. DRGs are used to determine how much Medicare will pay.

DURABLE MEDICAL EQUIPMENT (DME) – Certain medical equipment that is ordered by a doctor for use in the home. Examples are walkers, wheelchairs, or hospital beds. DME is paid for under both Medicare Part B and Part A for home health services.

DURABLE MEDICAL EQUIPMENT MEDICARE ADMINISTRATIVE CONTRACTOR (DMEMAC) – DMEMACs process some Part B and DME, Prosthetics, Orthotics and Supplies (DMEPOS) claims.FOUNDATIONS TRAINING: VOLUNTEER MANUAL

END-STAGE RENAL DISEASE (ESRD) – Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.

FISCAL INTERMEDIARY (FI) – FIs process some Part A bills and services, hospital care and skilled nursing care. Contracts will be transitioning from FIs to MACs.

FORMULARY - The list of drugs that a Medicare Part D drug plan will cover. The formulary varies depending on the Part D plan.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) Pub L. 104-191(also called Kennedy-Kassebaum) – This law created privacy protections for transmitting individual health care data, expanded health insurance coverage, and expanded the capacity for Federal prosecution of health care fraud.

MEDICAID – A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

MEDICARE – The Federal health insurance program for people 65 years of age or older, certain younger people with disabilities or ALS, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes

called ESRD).

MEDICARE ADMINISTRATIVE CONTRACTORS (MAC) – MACs are responsible for administration of Part A and Part B Medicare fee-for-service claims.

MEDICARE ADVANTAGE (MA) PLANS – MAs offer a managed care model of Medicare. A list of MA plans is available at www.medicare.gov.

MEDICARE DRUG INTEGRITY CONTRACTOR (MEDIC) – MEDICs are responsible for benefit integrity, medical review, data analysis, and related provider education and beneficiary outreach specifically for the Part D (prescription drug) program.

MEDICARE SUMMARY NOTICE (MSN) – A notice a beneficiary gets after the doctor or provider files a claim for Part A or Part B services in Original Medicare. It explains what the provider billed for, the Medicare-approved amount, how much Medicarepaid, and what a beneficiary may be billed for.

OFFICE OF THE INSPECTOR GENERAL (OIG) – The agency within the U.S.Department of Health and Human Services responsible for the investigation of suspected fraud and abuse and performing audits and inspections of HHS programs. The OIG has authority to levy certain sanctions and Civil Monetary Penalties.

OLDER AMERICANS ACT – Congress passed the Older Americans Act in 1965 to help each state develop a comprehensive and coordinated network that provides services, opportunities, and protections for older Americans to help them maintain health and independence in their homes and to be able to continue to function as a part of their community.

ORIGINAL MEDICARE - Original Medicare is one of the health coverage choices as part of Medicare. Original Medicare is run by the Federal government and provides your Part A and Part B coverage. Beneficiaries will have Original Medicare unless they choose to join a Medicare Advantage health plan (Part C). With Original Medicare, they can also join a Medicare Prescription Drug Plan (Part D) to add drug coverage, and/or they can buy a Medigap (Medicare Supplement Insurance) policy (sold by private insurance companies) to help fill the gaps in Part A and Part B coverage.

PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA or ACA)–Federal statute signed into law on March 22, 2010. The laws focus on reform of the private health insurance market, provides better coverage for those with pre-existing conditions, improves prescription drug coverage in Medicare, provides new tools to fight fraud and extends the life of the Medicare Trust fund by at least 12 years.

PREMIUM -- The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

PROGRAM SAFEGUARD CONTRACTOR (PSC) – PSCs are responsible for benefit integrity, medical review, data analysis, and related provider education and beneficiary outreach.

QUALITY IMPROVEMENT ORGANIZATION (QIO) – Contact the QIO with questions or complaints about the quality of health care paid for by Medicare.

REGIONAL HOME HEALTH INTERMEDIARY (RHHI) – RHHIs process some Part A claims: home health care and hospice.

SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM (SHIP) – Every state, territory, and the District of Columbia has a Senior Health Insurance Assistance Program (SHIP). They are sometimes referred to by different names and acronyms e.g., SHIBA, SHICK, Georgia Cares. The SHIPs are funded by CMS to provide information, assistance and counseling to Medicare beneficiaries – www.medicare.gov.

SIMPLE INQUIRY – The Office of the Inspector General (OIG) performance measure definition of a simple inquiry is: “Brief contact initiated by the consumer and/or beneficiary that is resolved with minimal time and research or review.” Simple inquiries typically do not require individual demographic or private personal information, such as a Medicare number or information about a medical condition.

SMART FACTS – The Seniors Medicare Assistance and Reporting Tool for Fraud And Complaint Tracking System). SMART FACTS is the web-based electronic tool for SMP management, tracking, and reporting of program outcomes to AoA and to the Office of the Inspector General (OIG).

SOCIAL SECURITY ADMINISTRATION (SSA) – SSA is the Federal agency responsible for enrollment in Medicare, provides information about signing up for Extra Help with Part D benefits and about Social Security benefits. www.ssa.gov

SOCIAL SECURITY CREDITS (previously called Quarters of Coverage) – As you work and pay taxes, you earn credits that count toward your eligibility for future Social Security benefits. You can earn up to 4 credits/year. Most people need 40 credits to qualify for benefits; fewer credits are needed to qualify for disability or survivors’ benefits. www.socialsecurity.gov.

The Nevada Senior Medicare Patrol (SMP) educates Nevadans on how to detect and report healthcare fraud in Medicare and Medicaid in order to protect these vital healthcare programs for the future.

Every year the Medicare system is drained of billions of dollars as a result of fraud, waste, errors and abuse - almost $134 MILLION in Nevada in 2008 alone!  The Nevada SMP is funded and supported by the U.S. Administration on Aging, and works closely with the Centers for Medicare and Medicaid Services.  There is an SMP in every state whose mission is to educate Medicare beneficiaries and their caretakers to become critical health care consumers, enabling them to identify suspicious situations or billings so that we can increase the chance that the Medicare system is solvent for future generations.

Examples of Abuse can include, but are not limited to:

• Billing for services different than actually provided
• Providing and billing for unneccessary procedures or services
• Overcharging for services
• Billing for a service or procedure provided by an assistant at a level that by regulation may only be charged by a doctor
• Billing for a higher level of service than what was actually provided (i.e. billing the level allowed for a new patient when actually the beneficiary is an existing patient)

Examples of Fraud can include, but are not limited to:

• Billing for services not received
• Billing non-covered services as covered services (i.e. billing routine nail care as foot surgery)
• Offers of "FREE" or medically unnecessary services and then billing Medicare

Medicare beneficiaries play a vital role in detecting these instances of abuse and we rely on them to report the errors to the Medicare system.

Here are some ways to protect yourself and the system:

• Protect your Medicare number!  In the wrong hands, it is a license to steal.  Unless you need it for a doctor's visit, leave your Medicare card at home, in a safe place.
• Record your doctor's visits in a Personal Healthcare Journal, which is available from the Nevada SMP program.
• Carefully review your quarterly Medicare Summary Notice and/or your Explanation of Benefits (from another insurance company). Check the dates of service to make sure there are no duplicate billings for services received and verify that the billing is for a service that you did receive.
• Don't be influenced by advertising for services, medications, or products.  Educate yourself and make your own decisions.

We are responsible for helping citizens across our state to identify issues to protect themselves and their loved ones from being victimized. We do this in a number of ways.

• We deliver presentations for interested parties to educate them on the signs of fraud, waste and abuse.
• We also recruit senior professional volunteers from the community to help. These dedicated seniors work at healthcare fairs, one-on-one counseling sessions and by networking with the state's senior service provider system to get our message into the community.
• We provide resources and referrals to other senior support agencies and non-profits in the state.
• Finally, we maintain a statewide, TOLL-FREE hotline (888-838-7305) so that Nevada beneficiaries have a local resource to resolve and/or investigate these complicated issues.

The Nevada SMP is here to help you! Please call us if:

• You suspect fraud, errors, waste or abuse to Medicare
• You are a retired professional senior who would be interested in volunteering.
• You are a member of a senior group, law enforcement agency or other interested community group that would like a presentation.

Our statewide, toll-free number is 1-888-838-7305.  We can also be reached by email at sdshott@adsd.nv.gov

Contact:
Mary Matiya, SMP Project Officer
1820 E. Sahara Ave, Ste 205
Las Vegas NV 89104