The Role of Medicare Representatives

As a participant in a health and/or drug plan underwritten or administered by CommunityCare, there are a number of things you can do to help identify and prevent health care fraud. You should, however, first be aware of certain guidelines concerning Medicare and the unique role it plays with respect to fraud, waste and abuse. Individuals working for or with Medicare are not permitted to:

• Come to your home uninvited to sell or endorse any Medicare related product
• Enroll you into a prescription drug plan over the telephone, unless you initiate the call
• Ask for bank account or other personal information over the phone
• Ask for payments over the phone or Internet
• Seek premium payments up front or before you have been billed
• Call a beneficiary after he/she has asked not to receive additional calls
• Call before 8 a.m. or after 9 p.m.
• Offer a gift worth more than $15 or a cash payment as an incentive to enroll in a plan

With these guidelines in mind, here are some of the more common fraudulent schemes and other practices that may give rise to fraud, waste or abuse:

Telemarketing Scams

A new telemarketing scam has been identified; the caller claims that the Member has not been accepted by a specific insurance company under the Affordable Care Act (ACA). They advise that the ACA is going to put cash in their checking account for medical expenses. They ask for the last 4 digits of your Social Security Number, bank account, and routing number. CommunityCare will never contact you requesting the above information. The Affordable Care Act (ACA) does not deposit funds in your bank account. Don't be a victim!

Call from Fake HHS OIG Hotline

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently confirmed that the HHS OIG Hotline telephone number is being used as part of a telephone spoofing scam targeting individuals throughout the country. These scammers represent themselves as HHS OIG Hotline employees and can alter the appearance of the caller ID to make it seem as if the call is coming from the HHS OIG Hotline 1-800-HHS-TIPS (1-800-447-8477). The perpetrator may use various tactics to obtain or verify the victim’s personal information, which can then be used to steal money from an individual’s bank account or for other fraudulent activity. HHS OIG takes this matter seriously. We are actively investigating this matter and intend to have the perpetrators prosecuted.

It is important to know that HHS OIG will not use the HHS OIG Hotline telephone number to make outgoing calls and individuals should not answer calls from 1-800-HHS-TIPS (1-800-447-8477). We encourage the public to remain vigilant, protect their personal information, and guard against providing personal information during calls that purport to be from the HHS OIG Hotline telephone number. We also remind the public that it is still safe to call into the HHS OIG Hotline to report fraud. We particularly encourage those who believe they may have been a victim of the telephone spoofing scam to report that information to us through the HHS OIG Hotline 1-800-HHS-TIPS (1-800-447-8477) or spoof@oig.hhs.gov. Individuals may also file a complaint with the Federal Trade Commission 1-877-FTC-HELP (1-877-382-4357).

$299/$379 Scam

With the advent of Medicare Part D (also known as the Medicare prescription drug program), anti-fraud agencies have received a growing number of complaints concerning what has become known as the "$299 Ring." In this scam, an individual claiming to be associated with Medicare will call your home and offer to help enroll you in a prescription drug plan for a "small fee," generally $299 or $379. The caller may then ask for personal information, such as your Social Security, bank account or credit card number. If you receive such a call, do not give out any information and do not send any money. Instead, tell the caller not to contact you again and hang up the phone. Remember, legitimate Medicare representatives are not permitted to ask you for any personal information if they initiate the call and cannot solicit or take payment information over the phone.

Inappropriate Billing

When you obtain prescription drugs under your health plan, you should only be charged for the specific drug you have received. You should not be charged for drugs that are not listed on your physician's prescription or for any orders you never picked up. Each time you receive an Explanation of Benefits (EOB) form from CommunityCare, review the form and make sure that the prescriptions listed match those your doctor prescribed and that you actually received. If you received a generic drug, your pharmacist should not charge you for a brand name drug. In addition, except for any applicable copayment or coinsurance, your pharmacist should not bill you for a drug that is covered by your plan.

Falsification of True Out of Pocket (TrOOP) Expenses

Under Medicare's prescription drug plan, your True Out-of-Pocket Costs (TrOOP) are the portion of your expenses that count toward your annual Medicare drug plan threshold (also called the "donut hole"). The amount of the threshold may change each year, and determines when a person's catastrophic prescription drug coverage starts. Only certain expenses count toward TrOOP, so if you are unsure whether or not an expense should be counted toward your TrOOP, contact one of our customer service representatives. You should not attempt to manipulate your TrOOP costs in order to bridge the coverage gap (or donut hole) and reach catastrophic coverage before you are truly eligible. This may be viewed as fraud and could lead to an investigation.

Drug Shorting

If your pharmacist is unable to fill your entire prescription at one - for example, because of a short supply - your pharmacist should inform you and make arrangements to provide you with a partial amount of the prescription, and then provide you the remainder as soon as possible at no additional expense. However, if your pharmacist intentionally provides you less than the prescribed amount without letting you know, or fails to provide you with the balance of a partially filled prescription, but bills your drug plan for the full amount, he/she may have committed fraud, and you should contact Customer Service at (918) 594-5200 to let us know.

Prescription Splitting

If you present a single prescription form to your pharmacist, you should receive your prescription in a single order and only be billed once. Your pharmacist should also receive only one dispensing fee each time a prescription is filled or refilled. The pharmacist should not intentionally split a single prescription into two or more separately billed orders. This should not be confused with tablet splitting, which permits a pharmacist to fill a prescription at a higher dosage so that the patient can split the medication (typically a scored tablet) in half. Some plans encourage tablet splitting, when appropriate, because the patient receives a double supply of the medication for a lower out-of-pocket cost. You should call your plan to see if tablet splitting is permitted.

Coordination of Benefits

Coordination of benefits is the process insurers use to determine which plan pays first when a person is covered under more than one insurance plan at the same time. The coordination process is governed by state or federal law, and ensures that your health care provider is not overpaid. When using your prescription drug plan, you should always inform your doctor or pharmacist if you are covered by more than one insurance plan. This will help your provider know which plan to bill in order to comply with your coverage guidelines. You should not try to conceal information about additional coverage in order to lower the payments you personally make because this might be viewed as an attempt to commit fraud.

Duplicate Coverage

If you are covered by both a prescription drug plan and a separate Medicare Part B (medical insurance) plan, there may be additional issues that arise because of duplicate coverage. When you receive your Explanation of Benefits (EOB) form, you should check to ensure that your doctor or pharmacist has not billed both plans for the same prescription order. Additionally, if you pick up a prescription from your pharmacy and take the medication to an office visit for your doctor to administer, you should check your EOB to make sure your doctor has only billed your plan for the administration of the drug and not for the cost of the drug itself. In that situation, your pharmacy should be the only one charging you for the cost of the drug.

If you are covered by multiple plans and are unsure which plan should be billed in any situation, call our customer service number to be sure that you, your doctor and your pharmacist submit your claims to the appropriate plan.

Other Schemes and Scams

In addition to the specific schemes and issues above, fraud may include:

• Someone asking you to sell your Medicare prescription drug card
• Someone offering you cash or a gift worth more than $15 to sign up for a plan
• Someone asking you to get drugs for them using your Medicare prescription card
• An individual calling your home to enroll you over the phone or to ask for payments

How You Can Help

First, treat your health insurance card with the same level of care and security given to a debit or credit card. If your insurance card, Social Security number or other personal information is ever lost or stolen, immediately report the matter to our customer service department using the phone number on your ID card.

In addition, pay close attention to all EOB forms and be sure to review them to ensure that you have been properly charged for any costs associated with your prescription drug plan. If you need help reviewing your EOBs, seek the assistance of a family member or trusted friend, or call our customer service department.

How to Report Fraud

If you believe that you have been the victim of health care fraud, report the matter to CommunityCare directly by calling the Compliance Hotline at 918-594-5343, or by writing our Compliance Officer at Two West Second Street, Tulsa, OK 74103. Calls to the compliance hotline may be made anonymously; however, if you choose to remain anonymous, CommunityCare’s ability to investigate your compliant may be adversely affected. You may also report fraud by calling our customer service department or by sending a letter to CommunityCare’s grievance and appeals department:

CommunityCare
Attn.: Grievance and Appeals Coordinator
P.O. Box 3249
Tulsa, OK 74101

CommunityCare's Compliance Hotline: 918-594-5343

Customer Service, Tulsa: (918) 594-5200

Customer Service, Statewide toll-free: 1-800-278-7563

Customer Service, TTY/TDD: toll-free: 1-800-722-0353