Senior Medicare Patrol, Beneficiaries on the Lookout for Fraud

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Original story posted on: July 6, 2012

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You know to be aware of disgruntled employees who can turn into whistleblowers, but be ready for another type of watchdog looking for fraud: Senior Medicare Patrol (SMP) members and Medicare beneficiaries.

In 2011, SMP had a 14-percent increase in the number of volunteers over the year before, bringing the total to almost 5,700, according to a June HHS Office of Inspector General (OIG) report. The SMP saw a 45-percent increase in the number of Medicare beneficiaries who attended group education sessions, from 298,097 in 2010 to 431,128 in 2011.

Some of the SMP efforts have modest financial results – about $19,283 in Medicare funds were recovered in 2011 and cost avoidance totaled $247,850 – but SMP members reported two “large-dollar cases” to contractors. In one case, the Medicare contractor is seeking to recover $2.9 million in overpayments from a provider, the OIG report stated.

Those numbers could grow. The report showed 39 states, the District of Columbia, Guam and the Virgin Islands referred other cases for further action. Georgia referred cases involving more than $4 million for further action, while California, Delaware, Michigan, Nebraska, New Mexico, Texas and Utah referred cases totaling at least $100,000 each.

For more information on the SMP and its results, visit http://oig.hhs.gov/oei/reports/oei-02-12-00190.asp.

2 RAC Issues Approved in May Posted

Recovery auditors (RACs) posted two issues last week that were approved in May. HealthDataInsights, the RAC for Region D, posted an issue about multi-use vial waste for Herceptin. CGI, the RAC for Region B, posted an issue about outpatient Bevacizumab (Avastin) services. See the chart below for more information.

Physician

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Multi-use vial wastage: Herceptin (Trastuzumab)

5/25/12

RAC Region D

Multi-use vials are not subject to payment for discarded amounts of drug or biological. Per the manufacturer label, J9355 Injection, Trastuzumab, 10 mg (Herceptin) is only supplied in a multi-use vial. Providers should only bill the units associated with the dose administered to the patient.

CMS Pub. 100-02 chapter 15; CMS Pub. 100-04 chapter 17; Herceptin approved package insert 1-18-2008, FDA website; CDC safe practices for medical injections FAQs; questions about multi-dose vials

Outpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Outpatient Bevacizumab (Avastin) services

5/25/12

RAC Region B

Bevacizumab (Avastin) represents 10 mg per unit and should be billed one unit for every 10 mg per patient. Claims for J0150 should be submitted so that the billed units represent the administered units, not the total number of milligrams.

CMS Change Request 5718 dated Sept. 14, 2007; OIG report A-09-10-02019; NGS article about Avastin related to LCD 25820 (A46095)

About the Author

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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Karen Long

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