Health Care Fraud Prevention and Enforcement Efforts Result in Record Breaking Recoveries Totaling Nearly $4.1 Billion in 2011

Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius recently released a new report showing that the government’s health care fraud prevention and enforcement efforts recovered nearly $4.1 billion in taxpayer dollars in the 2011 Fiscal year. This is the highest annual amount ever recovered from individuals and companies who attempted to defraud seniors and taxpayers or who sought payments to which they were not entitled.

These findings were released in the annual Health Care Fraud and Abuse Control Program (HCFAC) and are a direct result of President Obama making the elimination of fraud, waste and abuse a top priority in his administration. The success of this joint effort would not be possible without the Health Care Fraud Prevention & Enforcement Action Team (HEAT), which was created in 2009 to prevent fraud, waste and abuse in the Medicare and Medicaid Programs. Their efforts to crack down on the perpetrators who are abusing the system and costing millions of American taxpayers billions of dollars has been quite successful.

“This report reflects unprecedented successes by the Departments of Justice and HHS in aggressively preventing and combating health care fraud, safeguarding precious taxpayer dollars and ensuring the strength of our essential health care programs,” said Attorney General Holder. ” We are committed to the ongoing pursuit of accountability and helping the American people at a time when budgets are tight.”

CMS Daily Digest Bulletin

IT’S ABOUT TIME!. The above report demonstrates just how much fraud, waste and abuse exists. Not all health care providers are unscrupulous—many are. Therefore, it is vitally important that you arm yourself with good advice. You can do this by educating yourself about your health plan options, as well as your benefits and responsibilities.

Do you know what your Out-of-Pocket-Expenses will be for 2012? Do you know what Medicare pays vs. what you are responsible for financially? Take a minute to ask yourself how much you spent on your health care costs last year. Do you think that it will be the same for 2012? It might not be. Medicare has made quite a few changes for 2012. An increase in your Part A & Part D deductibles could have an impact on your healthcare costs.

How has Medicare and the newly developed fraud prevention programs been so successful? It’s actually quite brilliant, but simple in its origin. During 2011, Health Care Fraud Prevention & Enforcement Action Team (HEAT) and the Medicare Fraud Strike Force expanded local partnerships and helped educate Medicare beneficiaries about how to protect themselves against fraud. The departments hosted a series of regional fraud prevention summits across the country, provided free compliance training for providers and other stakeholders, and sent letters to state attorneys general urging them to work with the Department of Health and Human Services (HHS). Additionally, federal, state, and local law enforcement officials mounted a substantial outreach campaign to educate seniors. Such community-based fraud prevention programs have brought awareness to the Medicare community and Medicare healthcare providers alike.

The strike force teams use advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes along with chronic fraud by deceitful individuals masquerading as health care providers or suppliers. In 2011 alone, strike force operations charged a record 323 defendants, who allegedly billed the Medicare program more than $ 1 billion. Strike force teams secured 172 guilty pleas, convicted 26 defendants at trial and sentenced 175 to prison. With their help, federal prosecutors were able to file criminal charges against a total of 1,430 defendants for health care fraud related crimes…”Fighting fraud is one of our top priorities and we have recovered an unprecedented number of taxpayer dollars,” said Secretary Sebelius. ” Our efforts strengthen the integrity of our health care programs, and meet the President’s call for a return to American values that ensure everyone gets a fair shot, everyone does their fair share, and everyone plays by the same rules.”

CMS Daily Digest Bulletin

The federal government, along with the Centers for Medicare and Medicaid Services (CMS) has made substantial improvements in cracking down on Medicare/Medicaid fraud and abuse, but it is still not enough. We applaud them for their efforts. With 80 million seniors turning 65 over the next twenty years, their efforts are still very much in demand. As the number of beneficiaries grows, their job becomes even more necessary and important. We can participate in this effort by educating others and ourselves about how to understand and thus make better health plan decisions.

Managed Care Consultants can be your educational partner and informational resource. There is no selling of any kind. We provide you the forum to ask your questions and get answers from Qualified Licensed Health Plan Professionals. We seek to understand your needs and provide clarity in the sometimes-confusing world of senior health plans. We work for you, not the health plan provider. Contact Calvert Louden at

By Managed Care Consultants Posted in Medicare

MA-DP Deadline Quickly Approaching

Medicare Advantage Disenrollment Period, deadline is quickly approaching.
The MADP, which begins January 1st and runs until February 14th and replaces the Open Enrollment Period, is an opportunity for beneficiaries to return to Original Medicare. It is not an additional enrollment period nor is it an opportunity for Medicare Advantage members to switch to different MA Plans.
Allowable Actions during the MADP:

People enrolled in an MA-PD plan may disenroll from the MA-PD and will have the opportunity to enroll in a standalon Prescription Drug Plan (PDP). Important: MA-PD members who enroll in a standalone PDP during this period will be automatically disenrolled from their current MA-PD and will not have the option of enrolling in another Medicare Advantage Plan.

Members who are in a Medicare Advantage only plan may request disenrollment from the MA plan and will then receive a Special Election Period (SEP) to enroll in a PDP standalone plan. The SEP is available from the time the disenrollment request is made until the member enrolls in a PDP or after February 14, whichever comes first.

Members who have both a standalone MA and a standalone PDP may disenroll from the MA plan, but may not make a change to their current standalone PDP.

A beneficiary who disenrolls from an MA or MA-PD plan using the opportunity afforded by the MADP may enroll in a Medicare Supplement policy upon returning to Original Medicare. However, using the MADP does not give the beneficiary guaranteed issue rights under federal law to prevent health-based underwriting of the Med Supp policy. In some cases, State Medigap laws may offer additional guaranteed issue rights to beneficiaries who are affected by the MADP.

Members who have a standalone PDP, but are not enrolled in an MA plan may not make any change to their current PDP plan and may not enroll in an MA plan.

People with Original Medicare who are not enrolled in any Part C Medicare Advantage plan have no options under MADP to make any change in their Medicare coverage.

Note: The effective dates of the MA disenrollment under the MADP and the PDP enrollment under the coordinating Part D SEP do not have to be the same. If a beneficiary disenrolls from an MA plan, he or she has until the end of the SEP (February 14th) to enroll in a PDP. Thus an individual could disenroll from an MA plan in January (effective February 1) and not choose a PDP until February (effective March 1). However, the individual must make a PDP election by the end of this SEP or wait until the next valid Part D election period in order to enroll in a PDP. In all cases, the effective date for the enrollment in a PDP may not precede the date of the MA disenrollment.

” Simplify Your Healthcare Management.”

Medicare. How many seniors that are enrolled understand its benefits? ….. Not as many as you think. For a program established by this government FOR its seniors, they sure don’t make it easy for them to understand how to make the most of their healthcare options. The government and independent providers refer beneficiaries to Medicare to inquire about coordination of benefits between health plans and retiree benefit programs. Questions such as: “Who pays for which services first?” and “How much will I pay?” This referral system would work except for one, lousy problem…… Beneficiaries are left to remain on hold until they decide to hang up.

For what it’s worth, I think it’s important to understand, and applaud Medicare and Social Security for trying to be efficient in streamlining the customer service aspect of their business. By implementing automated systems beneficiaries can opt out of waiting for a live agent and just follow the prompts to get the desired answers to their questions. Initially that sounds great, but what if the beneficiary has a special circumstance? As in most instances when beneficiaries reach out, their questions require a full and thorough explanation, therefore making the computer-generated system ineffective. So where are the beneficiaries left to seek advice from now? Social workers at Retirement Communities, Skilled Nursing Facilities (SNF), and Human Resources departments of Employer Retiree Plans are all viable resources. They are educated enough to answer these questions. Unfortunately, however, those resources end up spending the majority of their time filing claims forms for the beneficiary. So who is left making sure the individuals understand how their Medicare options work and how Medicare coordinates benefits with their current or prospective health, employer or retiree plans? Anybody???

Would it be callous to associate this frustration to a rat trapped in a maze? I understand that may seem a bit cold, but it is really quite accurate. The answers for seniors are available but only after exhausting every avenue, which has their own fair share of obstacles and hurdles, making the process akin to the rat lost in a maze. This only frustrates beneficiaries, confusing them even more and overall makes matters worse.

What good is a system if its own beneficiaries cannot access it efficiently?

Herein, lies the problem. Many may say the responsibility of maintaining one’s own healthcare management falls upon oneself. Agreed. Individuals should not have to rely on others to make their important healthcare decisions due to the inaccessibility of designated resources. Beneficiaries want to be aware and cognizant of the options available to them and how to make the most of their choices so they can meet their individual healthcare needs. The “Designated Resources,” used to handle the inquiries about Medicare health plans, both Medicare and Social Security, respectively, are incapable of handling the demands of 80 million seniors. And so, millions go without ever fully understanding how Medicare, an integral part of their healthcare that contributes to their well being, truly works. This lack of direction, with regards to healthcare management, can be very dangerous.

Millions of beneficiaries enroll into healthcare plans without completely understanding how it affects their financial responsibility. They enroll into plans expecting a level of coverage that is different than what the insurance company will provide. Or worse yet, the beneficiaries’ projected Out-of-Pocket-Expenses for the year are far greater than forecasted. Where will the additional income come from? One begs to question where the lack of communication occurred….

The 21st century consumer market place demands delivery upon receipt. If you pay for something, you expect to get something else in return; that particular mindset is warranted. In insurance, for example, those things can be customer service, specific coverage and to pay when they, the insurance company, say they will (claims).

As a consumer, one would like to place blame on one faction versus the other, but a lack of communication could very well have stemmed from both the insurance company and the consumer. The insurance provider can make a contract so confusing, that the consumer doesn’t bother to read it all. And, well,…. just that. The consumer fails to read the ENTIRE contract or Summary of Benefits, (SOB), for those of us in the insurance industry. Therefore beneficiaries are confused as to their responsibility upholding a contract they do not understand. Hence, misunderstandings occur leaving beneficiaries confused and frustrated.

Misconceptions and misinterpretations of shared responsibility plans can lead to unwarranted claims as well. This is a major contributor to what ties up the claims departments. Claims that shouldn’t be filed are, and the one’s that should take precedence are held up, slowing down the efficiency of distributing claim payouts where they need to go. As I’m sure we can all infer, unfortunately now the individuals that are in dire need of that payout have to wait.

The insurance industry is a business, and therefore beneficiaries should approach the task of choosing a viable health plan based on their needs in the same manner, analytically and cost-effectively. By gaining a better understanding of how cost-sharing plans actually work, beneficiaries can more effectively forecast their annual Out-of-Pocket-Expenses and budget accordingly. If they are cognizant of what Medicare covers versus what they don’t cover, they are now aware, or at least in a better position to make the necessary adjustments to bear the financial responsibility, (in theory).

So then what’s the solution? Good question. What seniors need is for someone to provide an ACCESSIBLE resource within establishments and communities that will allow them easy access to the answers for their healthcare management questions. Managed Care Consultants is “THAT” resource.

Managed Care Consultants provides many different forms of educational services to the retirement community of your establishment. Through seminars, consultations, blogs and emails retirees of your institution will have 24-hour access to the answers they seek. Qualified health professionals are committed to consulting with beneficiaries about the different scenarios they may encounter when dealing with coordinating benefits between Medicare, Healthcare providers and Retiree and/or Employer plans.