Compliance TODAY 27 41

October 2013
a publication of the health care compliance association
Why compliance
matters to the
Loretta Lynch
U.S. Attorney, Eastern
District of New York
See page 16
vs. Medicare
claims audit appeals:
A road less clear
Cornelia M. Dorfschmid
and Lisa Shuman
Sunshine Act reporting:
consulting and
royalty payment
OIG issues
updated guidance
on exclusion:
What it means
for providers
Be part of
the solution:
Stop medical
Stephanie J. Kravetz
Lester J. Perling
Marita Janiga
This article, published in Compliance Today, appears here with permission from the Health Care Compliance Association. Call HCCA at 888-580-8373 with reprint requests.
by Marita Janiga
Be part of the solution:
Stop medical identity fraud
»» Medical identity fraud can be very costly and very risky if patient records are comingled.
»» The lasting effects of medical identity fraud can be mentally taxing.
»» It can take years for a victim’s record to be cleared up.
»» Asking for personal identification during time-of-service can reduce the risk of fraud.
Marita Janiga ([email protected]) is Executive Director of National
Special Investigations & Compliance Hotline, Kaiser Permanente, National
Compliance, Ethics & Integrity Office in Oakland, CA and former Special Agent
in Charge, United States Department of Labor, Office of Inspector General,
Office of Labor Racketeering and Fraud Investigations.
e’ve all seen those television commercials for identity (ID) fraud. They
go something like this: “Your 85-yearold grandmother has been having a ball on her new
mountain bike—at least that’s what it looks like she’s
doing when you review her credit card statement.”
Many people never imagine they
can be a victim of identity fraud or
think of the consequences until it happens to them. Some criminals steal
your identity only to rack up credit
card charges, others can do major
damage. The term identity theft can
also include medical identity theft or
fraud, which can be even more costly
than just buying a new mountain bike.
Medical identity theft
In its “Third Annual Survey on Medical
Identity Theft,” the Ponemon Institute reports
that medical identity theft numbers continue
to rise in the United States and estimated that
in 2012, 1.85 million people were affected by
the crime, at a cost of $41.3 billion.1
Medical identity fraud is of particular
concern to the senior population who are
often specifically targeted by identity thieves.
Medical identity fraud occurs when a person’s
identity is used by someone else to obtain
medical treatment and/or medications. As
previously mentioned, medical identity fraud
can be very costly, leading to higher premiums
and overall healthcare costs.
The Centers for Medicare & Medicaid
Services (CMS) is focusing a lot of attention
on the subject, educating its beneficiaries on
various fraud schemes and how to protect themselves from becoming victims of identity fraud.
CMS literature cautions its beneficiaries to never
give out their Social Security, Medicare, health
plan, and banking numbers or information
to someone they don’t know and to carefully
review their plan statements to ensure that all
the information is correct. Examples of medical identity theft identified by CMS include:
·· Someone other than the member using
a member’s ID card without the member’s
·· A member giving their medical ID card
to someone else to use—often called
“card sharing.”
·· Vendors or providers billing for treatment or service that was never rendered
to a member.
888-580-8373 Compliance Today October 2013
»» Educating beneficiaries on fraud schemes can protect them from becoming victims.
In addition to being costly, the lasting
effects of medical identity fraud can also be
mentally taxing. In November 2012, Tech Blog
ran an article titled “How Medial Identity
Theft Can Give You a Decade of Headaches.”2
The victim, Arnold Salinas, reported that he
knew a lot about the person who stole his
identity—5-foot-9, 190 pounds, liked pizza
and paid for it with forged checks, drove fast
and racked up a lot of speeding tickets, and
worst of all, he was sick and sought medical
care in Salinas’s name. Salinas has been dealing with identity fraud since 2002 and still
fears that he may go to the hospital and be
treated based on the thief’s medical information—a mistake that could potentially cost
him his life.
Preventing and detecting medical identity fraud
Medical personnel can play a key role in
safeguarding patients and personnel from
identity theft by taking the following steps.
·· Follow an ID protocol when registering a
patient or member. This is the best way to
ensure that the right care is being delivered
to the right person.
·· Ask for the patient’s member ID card and
a photo ID card. The best photo ID is a
government-issued card, such as a driver’s
license, a military ID card, a passport, or a
residency card.
·· If a patient has no photo ID, quietly and
privately ask them to provide demographic
information such as date of birth, home
address, phone number, and/or the subscriber’s name on the health plan.
There are many ways to help mitigate
the risks of medical identity fraud. Talk to
your supervisor to see if there are immediate resources readily available for your use.
Be part of the solution. Stop medical identity
fraud before it happens.
1.Ponemon Institute. Third Annual Survey on Medical Identity Fraud.
June 2012. Available at
2.Robertson, Jordan: “How Medical Identity Theft Can Give You a
Decade of Headaches.” Bloomberg News, November 7, 2012. Available
SCCE/HCCA 2012–2013 Board of Directors
Shawn Y. DeGroot, CHC-F, CCEP, CHRC
SCCE/HCCA President | Associate Director, Navigant Consulting, Denver, CO
John Falcetano, CHC-F, CCEP-F, CHRC, CHPC, CIA, CICA
SCCE/HCCA Vice President | Chief Audit/Compliance Officer, Vidant Health,
Greenville, NC
Gabriel L. Imperato, JD, CHC
SCCE/HCCA Second Vice President | Managing Partner, Broad and Cassel,
Fort Lauderdale, FL
Sara Kay Wheeler, JD, CHC
SCCE/HCCA Treasurer | Partner, Attorney at Law, King & Spalding, Atlanta, GA
Urton Anderson, PhD, CCEP
SCCE/HCCA Secretary | Director, Von Allmen School of Accountancy,
Gatton College of Business and Economics, University of Kentucky
Non-Officer Board Member | Senior Vice President and Chief Compliance and
Audit Officer, University of California, Oakland, CA
Frank Sheeder, JD, CCEP
SCCE/HCCA Immediate Past President | Partner, Attorney at Law, DLA Piper,
Dallas, TX
Ex-Officio Executive Committee
Roy Snell, CHC, CCEP-F
Chief Executive Officer, SCCE/HCCA, Minneapolis, MN
Keith Halleland, Esq., CCEP, CHC
SCCE/HCCA Legal Counsel | Halleland Habicht, PA, Minneapolis, MN
Board Members
Deann M. Baker, CHC, CCEP, CHRC
Sutter Care at Home Compliance Officer, Sutter Health, Fairfield, CA
Catherine Boerner, JD, CHC
President, Boerner Consulting, LLC, New Berlin, WI
Brian G. Flood, JD, CHC, CIG, AHFI, CFS
Partner, Husch Blackwell LLP, Austin, TX
Margaret Hambleton, MBA, CPHRM, CHC, CHPC
Senior Vice President, Ministry Integrity, Chief Compliance Officer,
St. Joseph Health System, Orange, CA
Debra Hinson, MBA, RRT, CHC, CCEP, CHRC
President & CEO, Compliance Consultants, Inc., Mineral Bluff, GA
Robert A. Hussar, JD, CHC
Counsel, Manatt, Phelps and Phillips, Albany, NY
Jenny O’Brien, JD, CHC, CHPC
Chief Medicare Compliance Officer, UnitedHealthcare Medicare & Retirement,
Minnetonka, MN
Robert H. Ossoff, DMD, MD, CHC
Assistant Vice-Chancellor for Compliance & Corporate Integrity,
Vanderbilt University Medical Center, Nashville, TN
Daniel Roach, JD
General Counsel, Optum360, San Francisco, CA
Lori Strauss, RN, MSA, CPC, CPC-H, CHC, CHP, CHPC
Chief Corporate Compliance & Privacy Officer, University of Virginia Health
System, Charlottesville, VA
Debbie Troklus, CHC-F, CCEP-F, CHRC, CHPC, CCEP-I
Managing Director, Aegis Compliance and Ethics Center, Chicago, IL
888-580-8373 Compliance Today October 2013
·· Someone using another person’s Social
Security number to obtain a medical ID card.
·· People using a member’s Medicare or health
plan number for reimbursements of services
never received.
·· People calling the member to ask for a
Medicare or health plan number.