Fraud, Waste & Abuse Training

Course Objectives1. Theregulatoryrequirement

2. Thescopeoffraud,waste&abuse

3. Theobligationalresponsibilitiesofallthoseinvolved

4. Howtogoaboutreportingfraud,waste&abuse

5. Thelawssurroundingfraud,waste&abuse

6. Theconsequencesofcommittingfraud,waste&abuse

Why do I have to take this course?

PertheCenterforMedicareandMedicaidServices(CMS),allpartiesinvolvedwithreceivingordeliveringCMSsanctionedservicesarerequiredtogothroughatrainingonstatute,regulationsand

policiesthatgovernallCMSprograms.

Everyyearmillionsofdollarsareimproperlyspentduetofraud,waste,andabuse.Itaffectseveryone…includingYOU.Thistrainingwillhelpyoutodetect,correct,andpreventfraud,waste,

andabuse.

Youarepartofthesolution.

Where does everyone fit in?Programparticipants:

Company:Provider

Clients:Enrollee

FieldStaff:Employee

You

AsapersonwhoprovideshealthoradministrativeservicestoaPartCorPartDenrolleeyouareeithera:

•PartCorDSponsorEmployee•FirstTierEntity

Examples:PBM,aClaimsProcessingCompany,contractedSalesAgent

•DownstreamEntityExample:Pharmacy

•RelatedEntityExample:EntitythathasacommonownershiporcontrolofaPartC/DSponsor

What do I have to do?v Followallappropriatestatutory,regulatory,andotherPartCorPartDrequirements,includingadoptingandimplementingyouremployer’scomplianceprogram.

v Reportanyviolationsoflawsthatyoumaybeawareof.

v FollowHHHC’sCodeofConductthatexplainsyourcommitmenttostandardsofconductandethicalrulesofbehavior.

Prevention

How do I prevent Fraud, Waste & Abuse?v UnderstandwhatFraud,Waste&Abuseare

v UnderstandindicatorsofFraud,Waste&Abuse

vMakesureyouareuptodatewithlaws,regulationsandpolicies

v Ensuretimecardsareaccurateandproperlydocumented

v Verifyinformationprovidedtoyou

v Beonthelookoutforsuspiciousactivity

What is Criminal Fraud?Knowinglyandwillfullyexecuting,orattemptingtoexecute,aschemeorartificetodefraudany

healthcarebenefitprogram;ortoobtain,bymeansoffalseorfraudulentpretenses,representations,orpromises,anyofthemoneyorpropertyownedby,orunderthecustodyor

controlof,anyhealthcarebenefitprogram.

18UnitedStatesCode§1347

What does that mean?Intentionallysubmittingfalseinformationtothegovernmentoragovernmentcontractorin

ordertogetmoneyorabenefit.

Example: Youdon’tdeliverservicestoaclient,butyouchartontoyourtimecardthatservicesweredeliveredbyyoutotheclient.

What is Waste?Touse,consumeandspendunnecessarilythroughthoughtlessnessorcarelessness.

Example: Takingcompanysuppliedequipment(likegloves),whenyoustillhaveagoodsupplyonhandorusingthesuppliedequipmentcarelessly.

What is Abuse?Givinginformationordocumentationregardingservicesinawaythatimproperlyusesprogramresourcesforpersonalgainorbenefit.Abusecanhappenwithnointentionaldeceptionorintentionalmisrepresentation.

Example: Notutilizingservicetimecorrectlyandreportingthatmoretimeisneededorthattimeisnotenoughtocareforaclient,whenclientisreceivingsufficienttimeneededforrequiredcares.

Detection

Indicators for Fraud, Waste & Abuse?ForProviders:Youshouldlookforthefollowing:v Employeeperformingunnecessarytasks

v Theemployeechartingincorrectly

v Clientand/oremployeesignaturesdonotmatchsignaturesonhand

v Employeechartingtimeswhenclientisnotavailable

v Employeechartingfortimeswhenemployeeisnotavailable

Indicators for Fraud, Waste & AbuseForClients:Youshouldlookforthefollowing:v Homehealthvisitsthatyourdoctorordered,butthatyoudidn’tget.v Visitsbyhomehealthstaffthatyoudidn’trequestandthatyoudon’tneed.v Billsforservicesandequipmentyounevergot.v Fakesignatures(yoursoryourdoctor’s)onmedicalformsorequipmentorders.v Pressuretoacceptitemsandservicesthatyoudon’tneedorthatMedicaredoesn’tcover.v ItemslistedonyourMedicareSummaryNoticethatyoudon’tthinkyougotorused.v Homehealthservicesyourdoctordidn’torder.Thedoctorwhoapproveshomehealthservicesforyoushouldknowwhoyouare,andshouldbeinvolvedinyourcare.Ifyourplanofcarechanges,makesurethatyourdoctorwasinvolvedinmakingthosechanges.

v AhomehealthagencythatoffersyoufreegoodsorservicesinexchangeforyourMedicarenumber.TreatyourMedicarecardlikeacreditcardorcash.NevergiveyourMedicareorMedicaidnumbertopeoplewhotellyouaserviceisfree,andtheyneedyournumberfortheirrecords.

Indicators for Fraud, Waste & Abuse

ForEmployees:Youshouldlookforthefollowing:v Clientabusingservicesprovidedtothem

v Clientmakinganyarrangementswherepaymentissharedinexchangefornodeliveryofservices.

v Clientorcompanyrequestingthatyouworkatlocationsoutsideofcareplan

v Clientorcompanyrequestingforservicesthatareoutsideofcareplan

Reporting

Reporting Fraud, Waste & Abuse

Donotbeconcernedaboutwhetheranactisoffraud,waste,orabuse.Itisyourresponsibilitytoreportanyconcernstoyourcomplianceofficer.Thecomplianceofficerwillinvestigateandmaketheproperdetermination.

Everyoneisrequiredtoreportsuspectedinstancesoffraud,waste,andabuse.Youremployer’sCodeofConductandEthicsshouldclearlystatethisobligation.Employersmaynotretaliateagainstyouformakingagoodfaitheffortinreporting.

What do I do?Thinkcarefullyabouttheallegationandtheinformationyouhaveavailablethatcanhelpusdeterminewhethermismanagementorcriminalconducthasbeencommitted.Toprocessyourallegations,wewillneedyoutoprovideasmuchinformationaspossibleregardingthesuspectandvictim.Yourinformationshouldinclude:vWhocommittedthewrongdoing(person,companyororganization)?vWhatexactlydidtheindividualorentitydo?vWheredidtheactivitytakeplace?vWhendidithappen?vHowwastheactivitycommitted?vDoyouknowwhythepersoncommittedthewrongdoing?vWhoelsehasknowledgeofthepotentialwrongdoing?

Reporting Fraud, Waste & AbuseWithoutsufficientinformationwemaybeunabletoactonyourallegation.Themoreinformationyoucanprovide,thebetterchancewehaveofdeterminingwhetherany

wrongdoinghasbeencommitted.Weareveryinterestedintheinformationyouhavetoprovideregardingwaste,fraud,abuse,mismanagementormisconduct.

Ifyouhaveanyquestionsorneedadditionalinformation,pleasecallourcomplianceofficer.

ComplianceOfficer:Shoua MouaContactNumber:651-262-5510

Reporting Fraud, Waste & AbuseYoucanalsoreportanyconcernsto:

vMinnesotaDepartmentofHumanServicev ProviderFraud:651-431-2650(TollFree)800-657-3750v RecipientFraud:800-627-9977

v CentersforMedicare&MedicaidServicesv RegionalOffice:312-886-6432

v OfficeoftheAttorneyGeneralv Local:651-296-3353(TollFree)800-657-3787v 1-800-HHS-TIPS(1-800-447-8477)

Laws & Regulation

Civil Fraud/Civil False Claims ActProhibits:v Presentingafalseclaimforpaymentorapproval;

vMakingorusingafalserecordorstatementinsupportofafalseclaim;

v ConspiringtoviolatetheFalseClaimsAct;

v Falselycertifyingthetype/amountofpropertytobeusedbytheGovernment;

v Certifyingreceiptofpropertywithoutknowingifit’strue;

v BuyingpropertyfromanunauthorizedGovernmentofficer;and

v KnowinglyconcealingorknowinglyandimproperlyavoidingordecreasinganobligationtopaytheGovernment.

Civil False Claims Act Damages and Penalties

v Thedamagesmaybetripled.CivilMoneyPenaltybetween$5,000and$10,000foreachclaim.

v Ifconvicted,theindividualshallbefined,imprisoned,orboth.Iftheviolationsresultedindeath,theindividualmaybeimprisonedforanytermofyearsorforlife,orboth.

18UnitedStatesCode§1347

Anti-Kickback StatuteProhibits:v Knowinglyandwillfullysoliciting,receiving,offeringorpayingremuneration(includinganykickback,bribe,orrebate)forreferralsforservicesthatarepaidinwholeorinpartunderafederalhealthcareprogram(whichincludestheMedicareprogram).

42UnitedStatesCode§1320a-7b(b)

Anti-Kickback Statute Penalties

vFineofupto$25,000,imprisonmentuptofive(5)years,orbothfineandimprisonment.

Stark Statute(Physician Self-Referral Law)Prohibits:v Aphysicianfrommakingareferralforcertaindesignatedhealthservicestoanentityinwhichthephysician(oramemberofhisorherfamily)hasanownership/investmentinterestorwithwhichheorshehasacompensationarrangement(exceptionsapply).

42UnitedStatesCode§1395nn

Stark Statute Damages and PenaltiesMedicareclaimstaintedbyanarrangementthatdoesnotcomplywithStarkarenotpayable.Uptoa$15,000fineforeachserviceprovided.Uptoa$100,000fineforenteringintoanarrangementorscheme.

ExclusionvNoFederalhealthcareprogrampaymentmaybemadeforanyitemorservicefurnished,ordered,orprescribedbyanindividualorentityexcludedbytheOfficeofInspectorGeneral.

42U.S.C.§1395(e)(1)

42C.F.R.§1001.1901

HIPAAvHealthInsurancePortabilityandAccountabilityActof1996(P.L.104-191)

vCreatedgreateraccesstohealthcareinsurance,protectionofprivacyofhealthcaredata,andpromotedstandardizationandefficiencyinthehealthcareindustry.

vSafeguardstopreventunauthorizedaccesstoprotectedhealthcareinformation.

vAsanindividualwhohasaccesstoprotectedhealthcareinformation,youareresponsibleforadheringtoHIPAA.

Consequences

Consequences of Committing Fraud, Waste, or Abuse

vHealthInsurancePortabilityandAccountabilityActof1996(P.L.104-191)

vCreatedgreateraccesstohealthcareinsurance,protectionofprivacyofhealthcaredata,andpromotedstandardizationandefficiencyinthehealthcareindustry.

vSafeguardstopreventunauthorizedaccesstoprotectedhealthcareinformation.

vAsanindividualwhohasaccesstoprotectedhealthcareinformation,youareresponsibleforadheringtoHIPAA.

Government Resourcesv NationalBenefitIntegrityMEDIC:http://www.healthintegrity.org/html/contracts/medic/index.html

v StopMedicareFraud:http://www.stopmedicarefraud.gov

v ThePatientProtectionandAffordableCareAct:http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

v ComplianceGuidanceforMedicare+ChoiceOrganizations:http://oig.hhs.gov/fraud/docs/complianceguidance/111599.pdf

v OfficeoftheInspectorGeneral,ComplianceProgramGuidancefortheHealthcareIndustry:http://oig.hhs.gov/compliance/compliance-guidance/index.asp

v FederalSentencingGuidelines:http://www.ussc.gov/Guidelines

v FraudAlerts,BulletinsandOtherGuidancefromtheOIG:http://oig.hhs.gov/compliance/alerts/index.asp

v FalseClaimsAct:http://www.justice.gov/jmd/ls/legislative_histories/pl99-562/pl99-562.html

v HealthInsurancePortabilityandAccountabilityAct(HIPAA):http://aspe.hhs.gov/admnsimp/pl104191.htm

v Anti-KickbackStatute(seesection1128B(b)):http://www.ssa.gov/OP_Home/ssact/title11/1128B.htm#f

v StarkLaw(PhysicianSelf-Referral):https://www.cms.gov/PhysicianSelfReferral/