Transcript Slide 1

Blue Cross of Idaho
Medicare Advantage Provider
Fraud, Waste and Abuse
Training
Fall 2009
Training Objectives
• Recognize laws and concepts affecting
fraud, waste and abuse (FWA)
• Increase awareness of FWA
• Use identification techniques in the work
environment
• Report Medicare FWA concerns
Background (continued)
In December 2007, the Centers for Medicare & Medicaid
Services (CMS) published new Medicare Advantage (MA)
and Part D regulations that became effective January 1,
2009.
These regulations require MA and Part D Plan Sponsors—
such as Blue Cross of Idaho —to apply their training
requirements and “effective lines of communication” to
those entities we partner with “to provide services in the MA
and Part D programs.” Those entities include providers who
have contracted with Blue Cross of Idaho to provide
services to our MA members.
Federal Register, pp. 68700-68741, December 5, 2007
Definitions
Fraud: The intentional use of deception for unlawful
gain or unjust advantage.
Waste and abuse: Incidents or practices that are
inconsistent with sound fiscal, business, or medical
practices and result in unnecessary costs to the
Medicare program. This includes costs for services
that are not medically necessary or that fail to meet
professionally recognized standards.
Federal and state authorities
Many federal government agencies play a part in the
oversight of federal health care programs including:
• The Office of Inspector General (OIG) – An agency of the
Department of Health and Human Services (HHS) whose mission is to
protect the integrity of the HHS programs, as well as the health and
welfare of the beneficiaries of those programs.
• Department of Justice
• Centers for Medicare & Medicaid Services (CMS) – the
agency that administers the Medicare program, which provides health
insurance for more than 43 million elderly and disabled Americans.
CMS is part of HHS.
• Office of the State Attorney General
Federal False Claims Act (FCA)
The FCA (31 U.S.C. §§3729-3733) establishes liability
under a number of circumstances. Some examples
include any person or entity who:
• knowingly presents or causes a false claim to be
presented to the federal government for payment or
approval;
• knowingly makes, uses, or causes to be made or used, a
false record or statement material to a false or fraudulent
claim;
• knowingly conceals and/or improperly avoids or
decreases an obligation to pay or transmit money or
property to the federal government;
• conspires to commit a violation of the liability sections of
the Act.
FCA Penalties
Penalties of the FCA include:
• Civil penalties between $5,000 –$11,000 plus three times
the total damages per claim;
• Possible exclusion from Medicare and Medicaid;
• Possible criminal prosecution.
Examples of FCA Violations
Two examples of provider activity that may
constitute a FCA violation are:
• Billing for services that were not rendered.
• Upcoding—billing for a service that was not
rendered simply because the coding generates
more income than the correct billing for the
service that was actually rendered.
Anti-Kickback Statute (AKS)
• The AKS 42 U.S.C. §§1320a-7b) provides criminal
penalties for individuals or entities that knowingly
and willfully offer, pay, solicit, or receive
remuneration in order to induce or reward the
referral of business payable or reimbursable under
the Medicare or other federal health care
programs.
• The individual or entity may be excluded from
participation in Medicare or other federal health
care programs.
Beneficiary Inducement Law
The Beneficiary Inducement Law:
• Prohibits offering a remuneration that a person
knows, or should know, is likely to influence a
beneficiary to select a particular provider,
practitioner, or supplier;
• Creates liability of civil monetary penalties of up to
$10,000 for each wrongful act.
Examples of AKS Violations
Two examples of provider activity that may constitute
violations of the AKS are:
• Taking money from pharmaceutical representatives in
exchange for promising to prescribe that company’s
drugs over others.
• Only referring Medicare patients to one physical therapy
practice, in exchange for receiving money from that
practice for such referrals.
Exclusion Lists
• OIG has the authority to exclude individuals or
organizations from participating in Medicare,
Medicaid, and other federal programs.
• Exclusion reasons include:–conviction of fraud or
abuse;
–default on federal student loans;
–controlled-substance violations;
–licensing board actions.
Exclusion List Screening
• OIG:
• GSA:
• No payment will be made by any federal health
care program for any items or services furnished,
ordered, or prescribed by an excluded individual or
entity.
• Individuals must be checked at the time of hire and
annually thereafter. No excluded individual or entity
may provide goods or services reimbursed by a
federal health care program.
Record Retention
• Providers must maintain service, prescription,
claim, and billing records for ten years.
• Records are subject to CMS or contractor audit.
Examples of Potential Provider FWA
1. A physician prescribes medications for his mother, a
Part D member, and fills the prescriptions for his own
use.
2. A Durable Medical Equipment (DME) provider
submits false claims to an MA plan for payment of
DME supplies that were never provided to a plan
member.
3. A physician submits claims to an MA plan for
services that were not rendered, or rendered in an
incomplete manner.
Examples of Potential Plan Sponsor FWA
1. A Part D plan sponsor participates in marketing
schemes such as offering beneficiaries a cash
payment as an inducement to enroll in Part D,
enrolling beneficiaries without their consent, and
using unlicensed agents.
2. A MA plan fails to provide medically necessary MA
services required by law while continuing to report
claims experience to CMS for those services.
3. A Part D plan sponsor denies Part D members their
right to appeal plan denials
Examples of Potential Beneficiary FWA
1. After obtaining the drugs through his Part D
coverage by falsely reporting loss and by feigning
illness to obtain the drugs from multiple providers,
the beneficiary sells the drugs on the street.
2. A beneficiary utilizes false identification to enroll in
an MA plan.
3. A Part D member submits false pharmaceutical drug
receipts to his Part D plan for payment.
FWA Prevention
The federal government strongly encourages providers to
develop and implement voluntary compliance programs, as
effective tools in detecting and preventing fraud, waste, and
abuse perpetrated against the federal government’s health
care programs.
Elements of a compliance plan include:
• Written policies and procedures;
• Compliance Officer and Compliance Committee;
• Effective training and education;
• Effective lines of communication;
• Internal monitoring and auditing;
• Well-publicized disciplinary guidelines;
• Corrective actions, when needed; and
• Comprehensive FWA program.
Reporting FWA Concerns
Blue Cross of Idaho
Medicare Advantage Compliance Officer
Jane Lindsay (208) 387-6949
Fraud and Abuse Hotline
800-682-9095
CMS
1-800-MEDICARE
HHS OIG
1-800-447-8477
All reports are kept confidential and callers may remain
anonymous.
Conclusion
Thank you for completing the MA Compliance
Training Session for Medicare Advantage
Providers at Blue Cross of Idaho.
If you have any questions regarding this
presentation, please contact the Blue Cross of
Idaho Medicare Advantage Officer or your provider
representative.