Senior Medicare Patrol Referrals Process

Transcription

1 Senior Medicare Patrol Referrals Process Michael Cohen DHSc, JD, PA-C Operations Officer Investigations Branch, Headquarters Office of Inspector General/ Office of Investigations U.S. Department of Health and Human Services Washington, DC Stacey Platte SMP Program Manager Administration for Community Living U.S. Department of Health and Human Services Washington, DC 20201

2 Reminder Briefing is law enforcement sensitive and no portion of this presentation, or the data contained therein, should be re-released without permission from HHS-OIG-OI 2

3 SMP Referrals Approximately 50% of SMP cases must be referred to another agency for follow-up or further action Prior to 2012, SMPs worked directly with OIG/CMS CMS/OIG found cases sent by SMPs were often missing key pieces of information SMPs found they frequently couldn t get updates about case status 3

4 Continued ACL worked with OIG to develop a new referral process to improve accountability and reporting SMP cases are now sent to ACL for triage and clearance before being referred to the OIG for review and, if needed, further referral to CMS or other agencies CMS is legally required to update the OIG about the status/outcome of each case referral 4

5 Referring SMP Cases to the OIG Hotline SMPs enter cases into the SMP Information and Reporting System (SIRS) using efile or SIRS system log-in Select Yes for the Refer to OIG Hotline via ACL field SIRS provides confirmation of the date / time submitted 5

6 ACL Case Review Process An is automatically sent from SIRS to the ACL SMP Mailbox, including the case number ACL s the SMP to confirm receipt ACL uses SIRS to review the referral and compile a brief summary, including next steps ACL team discusses each case and determines whether to refer to OIG, request additional information, or recommend other action 6

7 What Happens Next Each quarter, ACL requests updates from the OIG Hotline about the status of each SMP case referral ACL notifies SMPs about the outcome of each case referral as additional information is provided 7

8 Office of Investigations Overview HHS Programs Served Statistics Explore Why No Feedback? Types of Prosecutions OIG Complaint Routing Hotline Complaint Routing What Happened to my Complaint??? 8

9 Whom Does OIG Serve? Established in 1976 in HHS to combat program waste, fraud, abuse. 73 OIGs. Covers over 100 programs (research grants, IHS, CDC, NIH, FDA, Medicare, Medicaid, AHRQ) 9

10 HHS/Office of Inspector General Office of Audit Services (OAS) Office of Evaluations & Inspections (OEI) Office of Counsel to Inspector General (OCIG) Office of Investigations (OI) 10

11 What is the perception of where my referral goes?? 11

12 From: Instituto de Astrofisica de Canarias 12

13 Investigations take time to develop and involve complex routing of complaints: Have Beneficiary Be Patient 13

14 Options.. 14

15 Hotline Statistics Hotline - Has 8 FTEs and 5 Contractors - Accepts telephone, internet, facsimile, mail - Interface w/ operator; then Operations staff - Handles ALL complaints, not just Medicare - 17,000 electronic, 4000 letters, 120,000 phone - 46% Increase - Second largest Hotline (SSA) 15

16 Why Can t I Find Out About My Referral From OIG? We don t know who is calling Gets aggregated into a national case Cannot disclose a qui tam (whistleblower) Entity is presumed innocent; reputation damage May endanger an undercover agent Some agents don t contact complainant Case conduct takes a different direction 16

17 HHS Office of Investigations Regional Map 17

18 What Kinds of HCF Investigations? Criminal (OIG/OI, DOJ, FBI, FDA, DCIS, NCIS, Postal, DOL) Fraud Civil (OIG, DOJ, FBI, CMS & Contractors) Fraud, Waste, Abuse Administrative (OIG, CMS & Contractors) Waste, Abuse, Mistakes, some Fraud) 18

19 Not a Simple/Linear Process 19

20 OTHER AGENCIES DEA, FDA, STATE LOCAL CASES NATIONAL CASES STRIKE FORCE NATIONAL PROJECT CODES DEPT. OF JUSTICE OIG OFFICE OF COUNCIL EXCLUSIONS OTHER HHS CASES OI AGENTS ASAC CMS CONTRACTORS ZPIC/MEDIC CMS REGIONAL MEDICARE CONGRESS REGIONS / SAC 20

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22 An SMP Case Referral In April 2015, the NJ SMP was contacted by a beneficiary who had recently attended an SMP group education session. Shortly after the session, she received and reviewed her latest MSN. At that time, she noticed that the free genetic testing she had recently received was not free at all Medicare had paid for it, and she was responsible for a portion of the charges, too. 22

23 Genetic Testing Referral After 3 4 days of research, the NJ SMP opened the case in SMART FACTS (April 16) The SMP later used SMART FACTS to refer the case to the OIG Hotline via ACL (April 27) The ACL team reviewed the case details and referred it to the OIG Hotline in early May

24 Genetic Testing Referral Over the next several weeks, the NJ SMP began receiving increasing reports of similar genetic testing schemes Notified Assistant U.S. Attorney and CMS/CPI directly Throughout 2015, the ACL team received numerous referrals of genetic testing-related schemes from SMPs across the country Referred all cases to the OIG Hotline for investigation 24

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26 Case Review: Good Samaritans of America Company sending representatives to low-income house developments, ILFs, and other locations Mostly in New Jersey Performs saliva DNA swabs on the residents Included tests are for STD and pharmacogenomic testing Several complaints over years to Middlesex SMP ACL sent a program alert around the state 26

27 Good Samaritans of America Medicare Summary Notices obtained by SMP, social workers CMS provided these to case agent 27

28 Good Samaritans of America Phony non-profit created to get access to groups of Medicare recipients Claimed they were a trusted non-profit that assisted seniors in navigating federal benefit programs, but only gave publically available info Really just generated lead-lists of Medicare beneficiaries to submit to unnecessary genetic testing Complaint time frame was July

29 Tactics Held ice cream socials Used fear tactics in presentations, including telling seniors they may be vulnerable to heart attacks, strokes, cancer, suicide if not tested Claimed this allows for personalized medicine They immediately obtained swabs without healthcare provider involvement or any determination of medical necessity 29

30 Medical Involvement To get tests authorized, advertisements on Craigslist for providers to sign (mostly PAs) Sent them requisition forms with PHI Providers were paid thousands of dollars per month to sign, although no exam occurred This caused over $1M to be paid to two labs by Medicare Owner Seth Rehfuss obtained commissions of tens of thousands of dollars 30

31 Caught Looking to expand the scheme to 11 other states After referral, developed by HHS/OIG agent Found Rehfuss paid kickbacks to various medical professionals to sign the requisition forms Case is ongoing and involves other potential defendants 31

32 Arrest Rehfuss arrested December 2, 2015 HCF charges carry possible 10 years and up to double damages 32

33 Thank You