1

Medicare Part C and Part D:Fraud, Waste and Abuse Training

Windstone Health Services2015

2

Overview

The Centers for Medicare & Medicaid Services (CMS) requires annual Fraud, Waste and Abuse (FWA) training for organizations providing health services to Part C Medicare Advantage (MA) enrollees. All training must be completed annually.

All entities are required to complete the Attestation of Training Completion.

Organizations must maintain internal training logs and submit copies of the training logs along with required attestations demonstrating that employees received FWA training.

3

FWA requirements…

Organizations contracting directly or indirectly with the federal government are obligated to:Report fraud, waste and abuse;Demonstrate their commitment to

eliminating fraud, waste and abuse; and Implement internal policies and procedures

to identify and combat health care fraud.

4

Best Practices for Preventing FWA

Develop a compliance program. Monitor claims for accuracy – ensure

coding reflects services provided.Monitor medical records – ensure

documentation supports services rendered.

Perform regular internal audits.

Source: National Healthcare Anti-Fraud Association (NHCAA)

5

The SEVEN elements of a compliance plan An effective Compliance Plan includes 7 core elements:1. Written Standards of Conduct: Development and distribution of written

Standards of Conduct and Policies and Procedures that promote the Plan Sponsor’s commitment to compliance and that address specific areas of potential fraud, waste and abuse.

2. Designation of a Compliance Officer: Designation of an individual and a committee charged with the responsibility and authority of operating and monitoring the compliance program.

3. Effective Compliance Training: Development and implementation of regular, effective education and training, such as this training.

4. Internal Monitoring and Auditing: Use of risk evaluation techniques and audits to monitor compliance and assist in the reduction of identified problem areas.

6

The SEVEN elements of a plan (Cont’d)

5. Disciplinary Mechanisms: Policies to consistently enforce standards and address dealing with individuals or entities that are excluded from participating in CMS programs.

6. Effective Lines of Communication: Between the compliance officer and the organization’s employees, managers and directors and members of the compliance committee, as well as first tier, downstream and related entities.

Includes a system to receive, record and respond to compliance questions, or reports of potential or actual non-compliance, while maintaining confidentiality.

7. Procedures for Responding to Detected Offenses and Corrective Action: Policies to respond to and initiate corrective action to prevent similar offenses including a timely, reasonable inquiry.

7

Definitions

Fraud: an intentional act of deception, misrepresentation, or concealment in order to gain something of value.

Waste: over utilization of services (not caused by criminally negligent actions) and the misuses of resources.

Abuse: excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss.

8

Definitions

Examples include: Charging in excess for services or suppliesProviding medically unnecessary services. Billing for items or services that should not be

paid for by Medicare. Billing for services that were never renderedBilling for services at a higher rate than is

actually justified. Misrepresenting services, resulting in

unnecessary cost, improper payments or overpayment

9

FWA Laws: False Claims Act

The False Claims Act:

Enacted in 1863 to fight procurement fraud in the Civil War

The FCA has historically prohibited knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval. Recently amended through the American Recovery and Reinvestment Act of 2009 (ARRA) to expand the scope of liability and give the government enhanced investigative powers

Recently amended through the American Recovery and Reinvestment Act of 2009 (ARRA)-expanding the scope of liability and giving the government enhanced investigative powers

10

FWA Laws: Anti-Kickback Statute

The Anti-Kickback Statute makes it a criminal offense to knowingly and willfully solicit, receive, offer or pay remuneration to induce or reward referrals of items or services reimbursable by the Federal health care program (which includes the Medicare program). Remuneration is defined as the transfer of anything of value,

directly or indirectly, overtly or covertly in cash or in kind. When this happens, both parties are held in criminal liability of the impermissible “kickback” transaction.

Penalties include up to $25,000 or imprisonment of up to five years or both.

Source: 42 USC Section 1320a-7b(b).

11

FWA Laws: Beneficiary Inducement Statute

Beneficiary Inducement Statue prohibits certain inducements to Medicare beneficiaries. i.e. waiving the coinsurance and deductible amounts after determining in good faith that the individual is in financial need; or failing to collect coinsurance or deductible amounts after make reasonable collection efforts.

Red Flag Rule (Identity Theft Protection) requires creditors to implement programs to identify, detect and respond to patterns, practices, or specific activities that could indicate identify theft.

Source: 42 USC Section 1320a-7b(b).

12

FWA Laws:Physician Self-Referral Prohibition Statute (Stark Law)

The Physician Self-Referral Prohibition Statute, commonly referred to as the “Stark Law,” prohibits:

A Physician from referring Medicare patients for certain designated health services to an entity with which the physician or a member of the physician’s immediate family has an ownership/investment interest or with which he or she has a compensation arrangement – unless an exception applies.

An entity from presenting or causing to be presented a bill or claim to anyone for a designated health services furnished as a result of a prohibited referral.

Up to a $15, 000 fine for each service provided. Up to a $100, 000 fine for entering into an arrangement or scheme

Source: 42 USC Section 1395nn

13

Possible Civil and Criminal Penalties

False Claims Act

For each false claim: $5,500-$11,000If the government proves it suffered a

loss, the provider is liable for three times the loss.

14

Reasons to prevent FWA

Tremendous waste of resources

Unnecessary procedures may cause injury or death.

Falsely billed procedures create an erroneous record of the patient’s medical history.

Diluted or substituted drugs may render treatment ineffective or expose the patient to harmful side effects or drug interactions.

Prescription narcotics on the black market contribute to drug abuse and addiction.

15

Other reasons to prevent FWA

Failing to provide medically necessary services.

Marketing schemes such as offering beneficiaries a cash payment as an inducement to enroll in Part D.

Selecting or denying beneficiaries based on their illness profile or other discriminating factors.

Making inappropriate formulary decisions in which costs take priority over criteria such as clinical efficacy and appropriateness.

16

Examples of Potential FWA: Beneficiary

Identity Theft

Doctor Shopping

Improper Coordination of Benefits

17

Examples of Potential FWA: Prescriber

Illegal Payment Schemes

Script Mills

Theft of Prescriber’s Drug Enforcement Agency (DEA) Number or Prescription Pad

Source: Prescription Drug Benefit Manual, Chapter 9 – Part D Program to Control Fraud, Waste and Abuse (Rev.2, 04-25-2006), Section 70.1.7

18

Examples of Potential FWA: Retail Pharmacy

Inappropriate Billing Practices

Prescription Drug Shorting

Dispensing Expired or Adulterated Drugs

Bait and Switch Pricing

Forging or Altering

19

Examples of Potential FWA: Pharmaceutical Manufacturer

Illegal Off-label Promotion

Illegal Usage of Free Samples

Kickbacks, Inducements, Other Illegal Payments

20

Examples of Potential FWA: Wholesaler

Counterfeit, Impure Drugs through Black Market

Resale of Drugs or Black Market

Diverters

Inappropriate Documentation of Pricing Information

21

Partnership for FWA Prevention

Centers for Medicare & Medicaid Services Medicare beneficiaries Medicare contractors Physicians, suppliers, and other providers Quality Improvement Organizations (QIOs) State and federal law enforcement agencies such as:

Office of Inspector General (OIG) of the Department of Health and Human Services (HHS)

Federal Bureau of Investigation (FBI) Department of Justice (DOJ)

Source: CMS Medicare Fraud and Abuse Web-based Training (April 2007)

Prevention and detection of fraud, waste and abuse requires the involvement and collaboration between:

22

Exclusion Lists

Windstone does not contract with practitioners who appear on the Office of Inspector General (OIG) or System of Award Management (SAM) lists.

All Windstone practitioners and employees are checked monthly for these exclusions.

23

Preventing Potential FWA

How can you prevent potential fraud, waste and abuse? Understand your organization’s FWA policies and

procedures, including standards of conduct and report any potential FWA

Get to know your organization’s compliance officer and maintain effective communication

Attend training and education Comply with standards of conduct Conduct internal monitoring and auditing, including

detection through medical review and data analysis Maintain confidentiality of protected health information

(PHI)

24

Reporting FWA

• Everyone has the right and responsibility to report suspected fraud, waste or abuse.

• You may report anonymously and retaliation is prohibited when you report a concern in good faith.

• Take action if you identify a problem.• Remember that you are ultimately responsible for claims bearing your name,

regardless of whether you submitted the claim.

25

Compliance

Windstone ensures compliance with applicable statues, regulations and guidance from:The Federal trade CommissionThe United States Department of Justice,

Anti-Trust Division

26

FWA Resources

Resource Link

Centers for Medicare and Medicaid Services (CMS)

www.cms.hhs.gov

Fraud & Abuse General Information www.cms.hhs.gov/MDFaudAbuseGenInfo

Federal Bureau of Investigation http://www.fbi.gov/

Medicare Learning Network (MLN) www.cms.hhs.gov/MLNGenInfo/

Office of Inspector General Department of Health and Human Services

http://oig.hhs.gov/

Physician Self Referral Law www.cms.hhs.gov/PhysicianSelfReferral

Medicare Managed Care Manual www.cms.hhs.gov/Manuals/IOM/

27

Attestation of Training Completion

Congratulations!You’ve completed the FWA training requirement for calendar year 2015.