Transcript Fraud, Waste, and Abuse (FWA) Training Program

Fraud, Waste, and Abuse
(FWA) Training Program
for
First Tier, Downstream, and
Related Entities
UPDATED 4/19/2011
Purpose
 MTM is providing this training for many reasons:
• The Centers for Medicare and Medicaid Services (CMS) has
handed down new rules regarding Fraud, Waste and Abuse
(FWA) that must be followed by not only MTM, but also MTM
First Tier, Downstream and Related Entities (transportation
providers, drivers and office staff).
• Not only does CMS require this training, MTM Clients do as
well.
• We all have a responsibility to help make sure FWA does not
happen and to report it if we suspect it is happening, without
fear of reprisal.
Purpose (Continued)
 This training will give you the basic information necessary to
understand what FWA actually is and what your obligations are
if you suspect FWA is taking place.
 By knowing the basics of FWA and what to do if we suspect it is
happening, not only are we in compliance with CMS and MTM
Client requirements; we are helping reduce the potential for
future FWA to take place.
 By being on the look-out for FWA, we are all taking care of
Federal monies that are given to the Medicaid and Medicare
programs for people that rely on Medicaid and Medicare to get
their medical treatments.
Topics
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Definitions for Fraud, Waste and Abuse (FWA)
Why MTM is doing this FWA training
Applicable Federal laws dealing with FWA
What the obligations are for everyone involved
Examples of “member” FWA
What MTM can do to get resolution in a situation where
“member” FWA is suspected
• Examples of First Tier, Downstream and Related Entities
FWA
Topics (Continued)
• What MTM can do to get resolution in a situation where
FWA is suspected by the First Tier, Downstream and
Related Entity
• Who is responsible for identifying FWA?
• Who is responsible for monitoring and auditing FWA at
MTM?
• How to prevent FWA
• Methods for reporting FWA
• Protection for whistle blowers
What is Fraud?
 An intentional deception or misrepresentation
made by a person with the knowledge that the
deception could result in some unauthorized benefit
to himself or some other person. It includes any act
that constitutes fraud under applicable Federal and
State law.
What is Waste?
 Over-utilization of services, or other practices that
result in unnecessary costs. Waste is generally not
considered to be caused by criminally negligent
actions but rather the misuse of resources.
What is Abuse?
 Provider practices that are inconsistent with sound
fiscal, business, or medical practices, and result in an
unnecessary cost to the Medicaid/Medicare
program, or in reimbursement for services that are
not medically necessary or that fail to meet
professionally recognized standards for healthcare. It
also includes Covered Member practices that result
in unnecessary cost to the Medicare/Medicaid
program.
Training Importance
 MTM does business with both Medicare and Medicaid Clients. These
Clients are required by the Centers for Medicare and Medicaid
Services (CMS) to conduct FWA training with the Clients’ first tier,
downstream, and related entities (in short, their sub-contractors, like
MTM).
 With MTM Clients being regulated to train their first tier, downstream,
and related entities, MTM must do the same with MTM first tier,
downstream, and related entities (transportation providers, drivers,
and office staff). In effect, because MTM Clients are being regulated
by CMS, so too is MTM and any MTM sub-contractors.
 Documentation of the annual FWA training (for MTM staff and MTM
first tier, downstream, and related entities) must be maintained and
must be available to CMS and/or MTM Clients whenever requested.
Training Requirements
 Applicable laws and regulations (federal & state specific).
 The obligations of first tier, downstream, and related entities to have appropriate
policies and procedures in place that address FWA.
 The types of FWA that may occur with Covered Members.
 Possible resolutions to Covered Member FWA.
 The types of FWA that may occur in first tier, downstream, and related entities.
 Possible resolutions to first tier, downstream, and related entity FWA.
 The process for reporting suspected FWA in first tier, downstream, and related
entities.
 The protections for employees of first tier, downstream, and related entities who
report suspected FWA.
Laws and Regulations
 Suspected violations of the False Claims Act; 31 U.S.C. §3729 of
the False Claims Act
 Suspected violations of the Stark Law
 Suspected violations of the AntiKickback Statute
 Suspected marketing violations, including inducements
 Any act identified in any act defined in 18 U.S.C. Chapter 47,
especially §1001 and §1035
 Health Insurance Portability and Accountability Act (HIPAA)
 Any/all state specific laws and regulations that address Medicaid
and Medicare Fraud, Waste and Abuse (FWA).
Your Obligations
 Have policies and procedures in place regarding FWA.
 Comply with all policies and procedures that are developed and
amended from time to time by MTM that are relative to FWA.
 Acknowledge that payments made to them consist of federal
and state money and they can/will be held civilly and/or
criminally liable in the event of nonperformance,
misrepresentation, FWA of services rendered to MTM and its
Clients.
 Immediately refer all information regarding suspected or
confirmed FWA by MTM riders to MTM.
Examples of Member FWA
 Changing, forging, or altering any of the following:
 Prescriptions
 Medical Records
 Referral Forms
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Lending of an insurance card to another person
Using transportation services for non-medical services
Misrepresentation of eligibility status
Identity theft
Resale of medications to others
Medication stockpiling
Doctor shopping
Resolution Options for Member FWA
 Adding a note to the Covered Member’s permanent
file, instructing Customer Service Staff on setting
future trips.
 Adding the Covered Member’s name to a list a
frequent abusers so all of the Covered Member’s
trip requests will be monitored and case managed in
an effort to prevent future FWA.
 Reporting the issue to the designated State or
County Medicaid office or to the MTM Client.
Examples of Provider FWA
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Falsifying credentials
Billing for services not rendered
Inappropriate billing
Double billing, up-coding and unbundling
Collusion among providers
 Providers agreeing on minimum fees they will charge and accept
 Falsifying information that has been submitted through
a prior authorization or other formulary oversight
mechanism in order to justify coverage
Resolution Options for Provider FWA
 Recovering trip cost
 Providing Transportation Provider Education
 Making a recommendation for an audit of the
transportation provider’s trip records
 Establishing a Corrective Action Plan (CAP)
 Disciplinary action against the First Tier, Downstream,
and Related Entities
 Dismissal from the MTM network of the First Tier,
Downstream, and Related Entities
Who is responsible for identifying FWA?
 All MTM employees and Board of Directors
 All MTM First Tier, Downstream, and Related Entities
(transportation providers, drivers, office staff, etc.)
Who monitors FWA at MTM?
 All reported incidents of FWA are reported to the Quality
Management Department.
 A Compliance Auditor investigates each reported
incident of FWA.
 The Compliance Auditor notes the results of the
investigation into the Covered Member’s file.
 Any FWA reported against a first tier, downstream, and
related entity is handled in the same manner.
 MTM reports all incidents of FWA to its Clients on a
monthly basis.
Preventing FWA
 Preventing FWA before it happens is critical.
 First Tier, Downstream, and Related Entities
(transportation providers, drivers, and office staff),
as it relates to MTM riders only, should report any
incidents they suspect of being FWA to MTM’s
Quality Management Department as soon as
possible.
Preventing FWA
 MTM staff should be diligent and watch carefully for
signs of FWA:
 Deny a trip if it seems “suspect”
 Push the trip request up the internal chain of command to a
Team Lead
 Contact the Client (insurance company) and get their guidance
 Report the suspicious activity to the Quality Management
Department for investigation
Reporting
 Contact the Quality Management Department at
MTM:
 1-866-436-0457
 Try to include the following information:
 Subject (s) of FWA.
 Subject (s) identification information.
 Description of FWA.
 Any other important information.
Reporting Protections
 “Whistle blower”s are offered certain protections
against retaliation under the False Claims Act.
 Employees who are discharged, demoted, harassed,
or otherwise confront discrimination in furtherance
of such an action or as a consequence of whistle
blowing activity are entitled to all relief necessary to
make the employee whole.
Conclusion
 You have been given more knowledge about what FWA really is
and why it is important to be on the look-out for cases of
suspected FWA.
 You now have the tools necessary to feel confident in reporting
any suspected FWA, without fear of reprisal.
 You understand why MTM is requiring this training.
 You know that everyone is responsible for reporting FWA.
 You know that preventing FWA is critical – stop it before it
happens or gets out of hand.
 You know that you are protected by Federal laws if you report
FWA.