Transcript Document

Medicare Advantage and Medicare
Part D Required Fraud, Waste and
Abuse Training
2009
Introduction
The Centers for Medicare & Medicaid Services (CMS) requires
Medicare Advantage Organizations (MAO) to have policies and
procedures to identify and address Fraud, Waste and Abuse
(FWA) in the delivery of health care services through the
Medicare Advantage benefit.
CMS also requires the MAO to have a procedure in place to
facilitate FWA training and education for vendors and
providers.
SOURCE: Prescription Drug Benefit Manual, Chapter 9 - Part D Program to Control Fraud, Waste and Abuse as well as part 42 of the Code of
Federal Regulations sections 422.503 and 423.504.
2
Our Commitment
Empire Blue Cross Blue Shield (Empire) and subsidiaries,
must ensure that all delegated and external entities implement
fraud, waste and abuse training for all personnel who deal
directly with our Medicare members or who view Protected
Health Information (PHI) in any capacity.
We must establish training requirements and communication to
our first tier, downstream and related entities of which we have
a contractual relationship.
SOURCE: Federal Register – Part V Department of Health and Human Services, 42 CFR 422 and 423.
3
How Does this Effect You?
As an entity that contracts with Empire, on behalf of
our Medicare Advantage members, your office must
meet the new education and training requirements
outlined in the contract addendums sent earlier this
year.
4
Requirements
In order to ensure we are in compliance with the CMS regulations, we
are providing three avenues for you to fulfill the training requirements.
1.
Provide your own internal FWA and
compliance training, and complete the
attestation form via our online attestation
with United Mail. You will need to enter
User ID: EmpireBCBS and Password:
fwatrain
Click Here
2.
Take the training through LearnSomething, Inc.
Click Here
3.
Continue through this presentation as your
FWA training, and complete the attestation
form at the end of this presentation.
Click Here
5
Providing Your Own Internal FWA Training
Providing your own internal FWA and compliance
training will require that the training is acceptable per
the regulations found in 42 CFR 422.504(b)(4)(vi)(c)
and 423.504(b)(4)(vi)(c), as well as the learning
objectives listed on the next page.
6
Providing Your Own Internal FWA Training
FWA Training Learning Objectives
• Laws and regulations including the False Claims Act, AntiKickback Statute and HIPAA
• Identify processes for reporting fraud, waste and abuse to the
Medicare Advantage and Part D plan sponsors
• Information on protections for employees who report
suspected fraud, waste and abuse
• Identifying fraud, waste and abuse
Click Here for
the Attestation
7
LearnSomething, Inc.
If your practice does not have a training program and using the
Empire training is not an option for you, the National Health
Care Antifraud Association (NHCAA), in conjunction with the
Blue Cross and Blue Shield Association (BCBSA), has
launched an online Fraud, Waste and Abuse General
Compliance Training Course.
8
LearnSomething, Inc.
This course was developed in collaboration with
LearnSomething, Inc., a leading producer of customized,
multimedia training and learning management solutions. This
online training program was specifically developed to help
Medicare Advantage first tier and downstream contractors
meet CMS compliance requirements.
You can access the online training via the course portal at
www.wellpoint.learnsomething.com. This course is reasonably
priced, with volume discounts available and can be purchased
through this link.
9
Fraud, Waste and Abuse
Training
Empire Blue Cross Blue Shield
Fraud, Waste & Abuse Training
The following slides provide learning objectives, regulations,
definitions, relevant laws and examples of potential FWA and
prevention plans.
At the conclusion of this presentation, an authorized
representative from your organization will need to complete the
attestation statement.
11
FWA Training Outline
• Identify Who Needs to Take the Training
• Identify Fraud, Waste and Abuse
• Who Can Commit Fraud?
• Laws and Prohibitions
• Compliance Programs
• Reporting Suspected Fraud & Abuse
• Attestation Statement
• Additional Sources and Finding More Information
• Acronyms and Glossary
12
Who Needs to Take the
Training?
Who Needs to Take the Training?
The Prescription Drug Benefit Manual, Chapter 9
states that these requirements are related to all first
tier, downstream, and related entities.
14
First Tier Entity
The First Tier Entity is any party that enters into a written
arrangement acceptable to CMS with a sponsor or applicant to
provide administrative services or health care services for a
Medicare eligible individual under Part D.
First Tier Entity Examples
• Pharmacy Benefits Manager (PBM)
• Contracted hospital
• Clinics
• Physicians and non-physician practitioners
SOURCE: Prescription Drug Benefit (PDB) Manual, Chapter 9 – Part D Program to Control Fraud, Waste and Abuse; 42 CFR 422.503 and 423.504
15
Downstream Entity
The Downstream Entity is any party that enters into a
written arrangement, acceptable to CMS, below the level
of the arrangement between a sponsor and a first tier
entity. These written arrangements continue down to the
level of ultimate provider of both health and administrative
services.
Downstream Entity Examples
• Pharmacies
• Marketing firms
• Quality assurance companies
• Claims processing firms
• Billing agencies
SOURCE: Prescription Drug Benefit (PDB) Manual, Chapter 9 – Part D Program to Control Fraud, Waste and Abuse; 42 CFR
422.503 and 423.504
16
Related Entity
A Related Entity is any entity that is related to the sponsor by
common ownership or control and
• performs some of the Sponsor’s management functions under
contract or delegation, or
• furnishes services to Medicare enrollees under an oral or
written agreement; or leases real property, or
• sells materials to the Sponsor at a cost of more than $2,500
during a contract period.
SOURCE: Medicare Managed Care Manual (MCM) Chapter 11- Medicare Advantage Application Procedures and Contract Requirements
17
Identifying Fraud, Waste &
Abuse
What is Fraud?
Fraud is the intentional misrepresentation of data for financial
gain.
Fraud happens when an individual knows or should know that
something is false and makes a knowing deception that could
result in some unauthorized benefit to themselves or another
person.
SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN)
19
What is Waste?
Waste is the extravagant, careless or needless expenditure of
healthcare benefits or services that results from deficient
practices or decisions.
SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN)
20
What is Abuse?
Abuse involves payment for items or services where there was
no intent to deceive or misrepresent but the outcome of poor
insufficient methods results in unnecessary costs to the
Medicare program. Abuse may include:
• Billing for a non-covered service.
• Misusing codes on the claim.
• Inappropriately allocating costs on a cost report.
SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN)
21
Who Can Commit Fraud?
Who Commits Fraud and Abuse?
Many individuals and organizations can potentially commit
fraud including:
• Beneficiaries
• Physicians, nurses and other healthcare providers
• Pharmacies
• Laboratories
• Pharmaceutical manufacturers
• Durable Medical Equipment (DME) Providers
• Hospitals
• Pharmacy Benefit Managers (PBMs)
• Employees of health plans
• Home Health Agencies
SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN)
23
Beneficiary Fraud
Examples of fraud committed by beneficiaries of a federal
program may include:
• Identify theft
• Resale of drugs on black market
• Falsely reporting loss or theft of drugs to receive replacements
• Doctor shopping
SOURCE: PDM Manual Chapter 9, Part 70.1.7
24
Provider Fraud
Fraud can be found in some day-to-day operations within any
medical practice. Some forms of fraud may include:
• Billing for items or services not rendered or not provided as claims.
• Submitting claims for equipment or supplies and services that are not
reasonable and necessary.
• Double billing resulting in duplicate payments.
• Unbundling.
• Failure to properly code using coding modifiers or up-coding the level
of service provided, inappropriate use of place of service codes.
• Altering medical records.
SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN); Medicare Physician Guide: A Resource for Residents, Practicing
Physicians, and Other Health Care Professionals, Tenth Edition.
25
Pharmacy Benefit Manager (PBM) Fraud
Fraud committed by a PBM may include:
• Unlawful remuneration in order to steer a beneficiary toward a
certain plan or drug, or for formulary placement. Includes
unlawful remuneration from vendors beyond switching fees.
• Not offering a beneficiary the negotiated price of a Part D drug.
SOURCE: Prescription Drug Benefit Manual, Chapter 9 – Part D Program to Control Fraud, Waste and Abuse
26
Fraud Committed by Plan Sponsors and
Medicare Advantage Organizations
Plan Sponsors and MAOs may commit fraud by:
•
Making payments for excluded drugs.
•
Conducting marketing schemes.
•
Offering beneficiaries a cash payment as an inducement to enroll.
•
Unsolicited door-to-door marketing.
•
Enrollment of beneficiaries without their consent.
•
Stating that a marketing agent/broker works for or is contracted with the Social
Security Administration or CMS.
•
Misrepresenting the product being marketed as an approved Part D Plan when
it actually is a Medigap policy or non-Medicare drug plan.
•
Requiring beneficiaries to pay up front premiums.
SOURCE: Prescription Drug Benefit Manual, Chapter 9 – Part D Program to Control Fraud, Waste and Abuse
27
Laws, Statutes and Prohibitions
False Claims Act
A person is in violation of the False Claims Act if they have:
• Purposefully supplied false information on an application for a
Medicare benefit or payment or for use in determining the right to any
such benefit or payment;
• Known about, but did not disclose, any event affecting the right to
receive a benefit;
• Knowingly submitting a claim for a physician service that was not
rendered by a physician or
• Supplied items or services and asked for, offered, or received a
kickback, bribe or rebate.
Under the 42 U.S.C section 1320a-7b(a), if an individual participates
in an activity above, they will be found guilty of a felony and upon
conviction shall be fined a maximum of $50,000 per violation or
imprisoned for up to five years per violation or both.
SOURCE: Chapter 6 Protecting the Medicare Trust Fund
29
Anti-Kickback Statute
The Anti-Kickback Statute, 42 U.S.C. §1320a-7b(b), prohibits
offering, soliciting, paying, or receiving remuneration for
referrals for services that are paid in whole or in part by 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.
SOURCE: Medicare Fraud & Abuse Resource Reference, January 2009; 42 U.S.C. 1320-7b(b).
30
Anti-Kickback Statute
An arrangement will be deemed to not violate the AntiKickback Statute if it fully complies with the terms of a safe
harbor issued by the Office of the Inspector General (OIG).
Arrangements that do not fit within a safe harbor and thus do
not qualify for automatic protection may or may not violate the
Anti-Kickback Statute, depending on their facts.
SOURCE: Medicare Fraud & Abuse Resource Reference, January 2009; 42 U.S.C. 1320-7b(b).
31
Whistle Blower Provision
Under the Whistle Blower or qui tam provision of the False
Claim Act, any individual who has knowledge of a false claim
may file a civil suit on behalf of the U.S. Government and may
share a percentage of the recovery realized from a successful
action.
32
Physician Self-Referral “Stark” Prohibition
The physician self-referral prohibition commonly known as the
“stark law”, prohibits physicians from referring Medicare
patients for certain designated health services (DHS) to an
entity where the physician or member of the physician’s
immediate family has a financial relationship.
SOURCE: www.cms.hhs.gov/PhysicianSelfReferral; Medicare Fraud & Abuse Resource Reference, January 2009
33
Physician Self-Referral “Stark” Prohibition
In 2003, Congress amended section 1877 by establishing an
18-month moratorium (in effect from 12/08/03 – 06/07/05) on
physician referrals to certain specialty hospitals in which the
referring physician has an ownership or investment interest.
Under the moratorium, specialty hospitals cannot fill or submit
claims to anyone for DHS furnished as a result of a referral
that is prohibited under the moratorium.
On June 7, 2005, CMS instituted a temporary suspension on
the processing of specialty hospital applications for
participation in the Medicare program.
SOURCE: www.cms.hhs.gov/PhysicianSelfReferral; Medicare Fraud & Abuse Resource Reference, January 2009
34
Health Insurance Portability and
Accountability Act (HIPAA)
The Administrative Simplification provisions of the HIPAA of
1996 (HIPAA, Title II) required the Department of Health and
Human Services (HHS) to establish national standards for
electronic health care transactions and national identifiers for
providers, health plans, and employers.
It also addressed the security and privacy of health data. As
the industry adopts these standards for the efficiency and
effectiveness of the nation's health care system will improve
the use of electronic data interchange.
35
Legal Actions
A provider, supplier or health care organization that has
been convicted of fraud may receive a significant fine,
prison sentence or be temporarily or permanently
excluded form the Medicare program or other Federal
health care programs, and in some states, lose their
license. Failure to comply with fraud and abuse laws may
result in:
• Investigations referred to the OIG
• Civil Monetary Penalties that can result in up to $10,000 per
violation and exclusion from the Medicare program
• Denial or revocation of a Medicare Provider Number
• Suspension of payments
SOURCE: Chapter 6 Protecting the Medicare Trust Fund
36
Compliance Programs
What is a Compliance program?
A compliance program is a series of internal controls and
measures that will ensure that the sponsor follows applicable
laws and regulations that govern Federal programs, like
Medicare.
38
Implementing a Compliance Program
The adoption and implementation of a compliance program
significantly reduces the risk of fraud, abuse and waste in the
health care setting, while providing quality of services and care
to patients.
39
Implementing a Compliance Program
Organizations contracting directly or indirectly with the federal
government are obligated to:
• report fraud, waste and abuse and
• demonstrate their commitment to eliminating fraud, waste and
abuse and
• implement internal policies and procedures to identify and
combat heal care fraud.
SOURCE: National Healthcare Anti-Fraud Association (NHCAA)
40
Preventing Fraud
CMS follows four parallel strategies to prevent fraud and
abuse:
1. Preventing fraud through effective enrollment and through
education for physicians, providers, suppliers and
beneficiaries.
2. Early detection through Medical Review (MR) and data
analysis.
3. Close coordination with partners, including contractors, the
MEDIC and law enforcement agencies
4. Applying fair and firm enforcement policies.
SOURCE: CMS Medicare Fraud and Abuse MLN Web Based Training
41
Implementing a Compliance Program
The expectations for an organization’s compliance program
includes:
• Written policies, procedures, standards of conduct and a plan to
identify and respond to fraud, waste and abuse issues.
• Designation of a compliance officer and compliance committee.
• Effective training and education to all staff and new employees
• Effective lines of communication.
• Enforcement of standards through disciplinary guidelines.
• Internal monitoring and auditing procedures.
• Procedures to ensure prompt response and corrective action for
detected offenses
SOURCE: National Healthcare Anti-Fraud Association (NHCAA); Office of the Inspector General (OIG)
42
Reporting Fraud & Abuse
Our Position
Empire believes the vast majority of providers and groups are
honest and share our interest in deterring health insurance
fraud. However, a relatively small group of people may take
advantage of Empire and our policyholders. When someone
takes advantage of Empire, that person also takes advantage
of you.
44
Special Investigations Unit (SIU)
That's why Empire has a Special Investigations Unit (SIU) to
detect, analyze, investigate and refer for prosecution any
alleged fraudulent practices by providers, members, groups,
brokers and Empire associates.
MISSION
"To protect the integrity of the healthcare system we
serve through the detection and prosecution of those
parties responsible for fraud against Empire and its affiliated
companies."
45
Where to Report Fraud
Our Special Investigations Unit consists of investigators and
auditors from Indiana, Kentucky, Ohio, Connecticut, Maine,
New Hampshire and Colorado/Nevada. Our investigators have
various backgrounds which includes law enforcement and
claims administration.
Review and print the next slide for your local SIU phone
number.
46
Reporting Fraud in the East Region
California (888) 231-5044
Colorado (800) 377-2227
Connecticut (800) 258-3258
Georgia (800) 831-8998
Indiana (877) 283-1524
Kentucky (800) 866-1186
Maine (800) 285-7424
Missouri (888)451-1155
Nevada (800) 377-2227
New Hampshire (800) 203-3738
New York (800) ICFRAUD
Ohio (800) 848-9276
Virginia (800) 368-3580
Wisconsin (800) 377-2227
ALL OTHER STATES
National Blue Cross Blue Shield
Anti-Fraud Hotline (877) 327-BLUE
47
Where Can You find More
Information?
Where to Find More Information
Resource
Link
Centers for Medicare and Medicaid
Services (CMS)
www.cms.hhs.gov
Medicare Managed Care Manual and
Medicare Prescription Drug Benefit
Manual
www.cms.hhs.gov/Manuals/IOM/
Chapter 6 – Protecting the Medicare
Trust Fund
www.cms.hhs.gov/MLNProducts/dow
nloads/Chapter6.pdf
Fraud & Abuse General Information
www.cms.hhs.gov/MDFraudAbuseGe
nInfo
Part D Prescription Drug Benefit
Manual
www.cms.hhs.gov/PrescriptionDrugC
ovContra/12_PartDManuals.asp#Top
OfPage
49
Where to Find More Information
Resource
Link
Compilation of the Social Security
Laws
www.ssa.gov/OP_Home/ssact/compssa.htm
Federal Register citations 42 CFR
422.50342, 422.50442, CFR
423.50442 and 423.505
www.cms.hhs.gov/quarterlyprovideru
pdates/downloads/cms4124fc.pdf
Medicare Learning Network (MLN)
www.cms.hhs.gov/MLNGenInfo/
Medicare Fraud and Abuse Brochure
www.cms.hhs.gov/MLNProducts/dow
nloads/081606_Medicare_Fraud_and
_Abuse_brochure.pdf
Health Insurance Portability and
Accountability Act (HIPAA)
http://www.cms.hhs.gov/EducationMa
terials/02_HIPAAMaterials.asp#TopO
fPage
50
Where to Find More Information
Resource
Link
Office of Inspector General (OIG)
www.oig.hhs.gov
Reporting Fraud to the OIG
www.oig.hhs.gov/fraud/hotline/
Physician Self Referral Law
www.cms.hhs.gov/PhysicianSelfRefe
rral
Social Security Administration
www.ssa.gov/oig/guidelin.htm
Federal Bureau of Investigation
http://www.fbi.gov/
Office of Inspector General
Department of Health and Human
Services
http://oig.hhs.gov/
51
Where to Find More Information
Resource
Link
Office of Inspector General
Office of Personnel Management
www.opm.gov/
Office of Inspector General
U.S. Postal Service
http://www.uspsoig.gov/
U.S. Postal Inspection Service
http://www.usps.gov/postalinspectors
Food and Drug Administration
Department of Health and Human
Services
http://www.fda.gov/
Office of Inspector General
Department of Labor
http://www.dol.gov/
Other Partners
National Health Care Anti-Fraud
Association
http://www.nhcaa.org
52
Where to Find More Information
Resource
Link
Other Partners
National Health Care Anti-Fraud
Association
http://www.nhcaa.org
Coalition Against Insurance Fraud
http://www.insurancefraud.org
Association of Certified Fraud
Examiners
http://www.acfe.com/home.asp
53
Attestation Statement
Congratulations!
This concludes the Fraud, Waste and Abuse and Compliance
training requirement for calendar year 2009.
We ask that an authorized representative attest to the
completion of this or an internal FWA training. Failure to do so
could result in the loss of the organization’s contract to provide
Medicare Part C & D services.
The attestation statement is critical for us to ensure that all of
our first tier, downstream and delegated entities are taking an
FWA training.
55
Training Documentation
Please note that you must be able to submit records of training logs
documenting employee participation in the training upon request.
Review the example of a training log below.
Employee Name
– PRINT
Employee
Signature
Name of Training
(Anthem)
Date of Training
Manager’s Initials
56
Attestation
By clicking on the link below and completing the required fields, you are
certifying that you are the authorized representative of your organization
having responsibility directly or indirectly for all employees, board members,
officers, contracted personnel, contracted providers/practitioners,
contractors, sub-contractors and vendors affiliated with your organization
who have direct or indirect contact with the Medicare business, have
completed a Medicare Fraud, Waste & Abuse General Training as mandated
by the Centers for Medicare & Medicaid Services (42 CFR §
422.503(b)(4)(vi)(C), § 423.504(b)(4)(vi)(C)).
IMPORTANT NOTICE: Without clicking on the link we
will not be able to verify that your organization has
completed the Fraud, Waste and Abuse training.
Click Here for
the Attestation
LOGON: You will need to enter User ID: EmpireBCBS
and Password: fwatrain
57
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue
Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols
are registered marks of the Blue Cross and Blue Shield Association.
58