Transcript Slide 1

2012 Fraud, Waste and Abuse
Downstream Training
Preferred Care Partners
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Definition of First Tier, Downstream and
Related Entities
o First Tier Entity – means any party that enters into a written arrangement
acceptable to CMS with a sponsor or applicant to provide administrative or
healthcare services for a Medicare eligible individual under Part D (hospital, provider,
PBM).
o Downstream Entity – means any party that enters into a written arrangement,
acceptable to CMS, below the level of a First Tier arrangement (pharmacy, claim or
billing company).
o Related Entity – means 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; Furnishes services to Medicare members 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. 42 CFR 422.2 & 423.4
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Have You Been Trained?
Detecting and preventing fraud, waste and abuse (FWA) is the responsibility of
everyone, including employees, members, physicians, vendors, subcontractors,
hospitals, brokers, agents and other persons who may be subject to federal or
state laws relating to FWA. The Centers for Medicare and Medicaid Services (CMS)
requires that all employees who work or contract with Medicare Advantage
Programs (MA) and or Medicare Prescription Drug Programs (PDP) meet annual
compliance and education training requirements with respect to Fraud, Waste
and Abuse.
Specifically, the compliance regulation states that these contractors mentioned
above must have a compliance plan, which addresses measures to detect, correct,
and prevent fraud, waste and abuse; and consist of training, education, and
effective lines of communication between the compliance officer and the
organization’s employees, managers, and directors in regards to Fraud, Waste and
Abuse.
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Preferred Care Partners’ Commitment
Preferred Care Partners 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. To meet this
obligation we have established training requirements and communicate
this to our first tier, downstream and related entities for which we have
a contractual relationship.
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This Training Will Cover:
o Obligations of first tier, downstream, and related entities to have appropriate
compliance program, policies and procedures in place to address FWA
o Who Commits Fraud, Waste and Abuse
o Definitions of Fraud, Waste and Abuse
o Types of Fraud, Waste and Abuse that can occur in first tier, downstream and
related entities
o Healthcare Fraud Laws and Regulations
o HIPAA Privacy and Security Laws and Regulations
o Your Responsibilities
o Process/ Duty to report FWA
o Protections for employees/entities who report suspected FWA
o Training Documentation
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Compliance Program
Preferred Care Partners and their first tier, downstream and related entities are obligated to have a Compliance Program to
guard against potential fraud, waste, and abuse. The plan must include:
(1) Written policies, procedures, and standards of conduct articulating the organization's commitment to comply
with all applicable Federal and State standards
(2) The designation of a compliance officer and compliance committee
(3) Effective training and education between the compliance officer and the MA/Part D plan sponsor's employees,
managers and directors, and the MA/Part D plan sponsor's first tier, downstream, and related entities
(4) Effective lines of communication between the compliance officer, members of the compliance committee, the
MA/Part D plan sponsor's employees, managers and directors, and the MA/Part D plan sponsor's first tier,
downstream, and related entities
(5) Enforcement of standards through well-publicized disciplinary guidelines
(6) Procedures for internal monitoring and auditing
(7) Procedures for ensuring prompt responses to detected offenses and development of corrective action initiatives
relating to the organization's contract as a MA/Part D plan sponsor
By the terms of your contract with Preferred Care Partners you must have and maintain an effective compliance program.
Be aware and knowledgeable about laws applicable to fraud, waste and abuse. Effectively educate and train employees,
downstream and related entities about fraud, waste and abuse, at least annually. Maintain effective lines of communication
with Preferred Care Partners’ compliance officer about potential fraud, waste and abuse. Maintain records to effectively
track completion of education and training regarding fraud, waste and abuse either through your organization’s own
training or through the material provided here. Provide or make available fraud, waste and abuse training to your partners
(first tier, downstream, and related entities) to ensure that Medicare business partners are aware of their obligation.
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Who Commits Fraud, Waste and Abuse?
Many individuals and organizations can potentially commit fraud including:
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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
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Definitions of
Fraud, Waste and Abuse
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What is Fraud?
Fraud is an intentional deception or misrepresentation that the individual
knows to be false or does not believe to be true, and makes knowing that
the deception could result in some unauthorized benefit to himself/herself
or some other person.
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What is Waste?
Waste is the extravagant, careless, or needless expenditure of funds or
consumption of property that results from deficient practices, system
controls, and wrong decisions.
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What is Abuse?
Abuse describes provider practices that are inconsistent with generally accepted
business or medical practices and that result in an unnecessary cost to the
Medicare program or in the reimbursement for goods or services that are not
medically necessary or that fail to meet professionally recognized standards for
health care/ or recipient practices that result in unnecessary cost to the Medicare
program.
Many times abuse appears quite similar to fraud except that it is not possible to
establish that abusive acts were committed knowingly, willfully, and intentionally.
Although these types of practices may initially be categorized as abusive in nature,
under certain circumstances they may develop into fraud if there is evidence that
the subject was knowingly and willfully conducting an abusive practice.
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Fraud, Waste, and Abuse in our Healthcare
System
The National Healthcare Anti-fraud Association (NHCAA) cites an average of 3 percent
(at the low end) and 10 percent (at the high end) of healthcare spending is lost due to
fraud. That’s between $67 Billion and $230 Billion lost each year to fraud, waste or
abuse. That estimates to between $184 million and $630 million dollar loss per day,
and this number is expected to increase every year as healthcare costs rise.*
Healthcare fraud is believed to be the second largest white-collar crime in the United
States. It is often mistaken for a victimless crime, but it affects everyone. Fraud causes
insurance premiums to rise, and victims may be put through unnecessary or unsafe
procedures. Victims of identity theft may find their insurance information used to
submit false claims. This is a staggering cost, and we are committed to battling these
unnecessary expenditures every step of the way.
*The National Healthcare Anti-fraud Association (NHCAA). “Anti-Fraud Resource, Consumer Info & Action”; available at:
http://www.nhcaa.org/eweb/DynamicPage.aspx?webcode=anti_fraud_resource_centr&wpscode=ConsumerAndActionInfo
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Types of
Fraud, Waste and Abuse
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Beneficiary Fraud
Examples of fraud committed by beneficiaries may include:
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Identify theft
Resale of drugs on the black market
Falsely reporting loss or theft of drugs to receive replacements
Doctor shopping
False and inaccurate information to Medicare/Medicaid
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Provider Fraud
Fraud can be found in some day-to-day operations within any medical
practice. Some forms of fraud may include:
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Billing for items or services not rendered or not provided
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
Kickbacks
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Pharmacy Benefit Manager (PBM) Fraud
Fraud committed by a PBM may include:
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Unlawful remuneration in order to steer a beneficiary toward a
certain plan or drug, or for formulary placement.
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Not offering a beneficiary the negotiated price of a drug.
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Pharmacy Fraud
o Forgery: bogus prescriptions, bogus
invoices
o No prescription - phantom billings
o Overstating cost or billing for a
commercially available product
when compounding the
product (e.g., inhalation drugs)
o Altering prescriptions (+ Drugs,
Quantity, Refills)
o Dispensing samples or expired
drugs
o Shorting quantity dispensed with full
billings
o Using a single dose vial for
multiple prescriptions and
billings
o IOU - partial fills for full billings
o Over billed quantities
o Billing one drug and dispensing
another
o Returns to stock not credited
o Authorized refills billed but not
dispensed
o Ignoring payer of last resort
policy
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Healthcare Fraud
Laws and Regulations
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The False Claims Act
The False Claims Act (FCA) prohibits knowingly filing a false or fraudulent
claim for payment to the government, knowingly using a false record or
statement to obtain payment on a false or fraudulent claim paid by the
government, or conspiring to defraud the government by getting a false or
fraudulent claim allowed or paid. See 31 U.S.C. 3729(a) of the Act for
additional details, exclusions, and statutory exceptions.
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False Claims Act Examples & Fines
A person is in violation of the False Claims Act if they have:
o 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;
o Known about, but did not disclose, any event affecting the right to receive a
benefit;
o Knowingly submitting a claim for a physician service that was not rendered by
a physician or
o 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.
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Civil and Criminal False Claims Act
(42 U.S.C. §1320a-7b(a))
It is a crime for any person or organization to:
o Knowingly present, or cause to be presented, a false or fraudulent claim for payment
or approval by the federal government; or
o Knowingly make, use, or cause to be made or used a false record or statement to
influence the payment of a false or fraudulent claim.
NOTE:
Unlike the Anti-Kickback Statute, no proof of specific intent to defraud is required by the
False Claims Act. The person submitting a claim does not need to have actual knowledge
that the claim is false. Anyone who acts in reckless disregard or in deliberate ignorance of
the truth or falsity of the information can also be found liable under the False Claims Act.
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Fraud Enforcement & Recovery Act of 2009
(“FERA”)
Signed into law May 20, 2009.
o Amends the False Claims Act.
o Makes it illegal to “knowingly conceal or knowingly and improperly avoid” an
obligation to repay federal funds that have been paid in error, even if the
erroneous payment was not caused by the submission of a false record or
statement.
Expands the definition of “claim” to include:
o Demands for payments made by subcontractors to companies receiving federal
funds.
o Any request for money made to any “recipient” of funds provided, in whole or
in part, by the government, “to advance a Government program or interest.”
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Anti-Kickback Statute
The Anti-Kickback Statute, 42 U.S.C. §1320a-7b(b), prohibits the following actions:
Soliciting or receiving, offering, paying remuneration for referrals of Medicare or
Medicaid patients, or referrals for services or items which are paid for, in whole or in
part, by Medicare or Medicaid. Soliciting or receiving, offering or paying remuneration
in return for purchasing, leasing, ordering, or arranging for, or recommending
purchasing, leasing, or ordering any goods, facility, service, or item for which payment
may be made in whole or in part, by Medicare or Medicaid. Discounts, rebates, or
other reductions in price may violate the anti-kickback statute because such
arrangements induce the purchase of items or services payable by Medicare or
Medicaid.
The statute ascribes criminal liability to parties on both sides of an impermissible
“kickback” transaction.
However, certain arrangements are clearly permissible if they fall within a “safe
harbor.”
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What is Remuneration?
The transfer of anything of value, directly or indirectly, overtly or covertly
in cash.
When this happens, both parties are held in criminal liability of the
impermissible “kickback” transaction.
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Physician Self-Referral
“Stark” Prohibition
Physician Self-Referral Prohibition Statute
o Commonly referred to as the “Stark Law.”
o Prohibits physicians 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 a financial relationship – unless an exception
applies.
o Prohibits an entity from presenting or causing to be presented a bill or claim to
anyone for a designated health service furnished as a result of a prohibited
referral.
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Stark Joint Venture Agreement Changes effective October 1, 2009
Under Arrangement Agreements. CMS finalized changes to the definition of "entity" that will prohibit
physician ownership of entities that provide services to hospitals "under arrangements." Under the
revised definition of "entity", a person or entity is considered to be furnishing DHS if the person or
entity either "performs" the DHS or presents a claim or causes a claim to be presented to Medicare for
the DHS.
Per Click leases CMS revised the space and equipment lease exceptions, the fair market value
exception, and the indirect compensation arrangements exception under Stark to prohibit per-unit of
service rental charges for space and equipment to the extent that such charges reflect services
provided to patients referred between the parties. This change will effectively prohibit physicianowned leasing companies from entering into per-click leases with hospitals and other designated
health services entities. CMS stated that the new prohibition also applies when the physician is the
lessee. However, CMS is not prohibiting per-click arrangements involving non-physician-owned lessors
to the extent that these lessors do not refer patients for DHS. CMS also clarifies that it is not
prohibiting per-click payments to physician lessors for services rendered to patients who were not
referred to the lessee by the physician lessors. The Rule also prohibits the use of compensation
arrangements for the rental of space or equipment that are based on a percentage of revenue
attributable to the services performed or business generated in the leased office space or in the use of
leased equipment, whether the arrangement is a direct or indirect financial arrangement.
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Stand in Shoes Doctrine Affects
o Ancillary Services Joint Ventures (e.g. ambulatory surgery centers, diagnostic imaging
facilities, specialty hospitals, etc.)
o Physician Medical Director Management relationships
o Exclusive Specialty Services contracts
Phase III "stand in the shoes" rules, effective January 1, 2008, required physicians to
stand in the shoes of "physician organizations" ("POs") with which they had a financial
relationship. As defined, a PO is generally considered as any organization primarily
engaged in providing physician services. Financial relationships between the PO and
DHS entities are analyzed if such relationships are direct between a physician and the
DHS entity. These relationships must therefore meet a direct compensation exception
under the Stark. In 2009 the stand in the shoes doctrine changed in three ways: (i)
modifies types of financial relationships between physicians and POs subject to the
rule; (ii) alters the application of the physician "stand in the shoes" rules to academic
medical centers; and (iii) declines to implement to the so-called “entity stand in the
shoes” doctrine that had previously appeared in the 2008 Medicare Physician Fee
Schedule.
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Intermediate Sanctions
It is important that to understand these regulations since violations can result
in civil and federal penalties.
CMS can impose intermediate sanctions on our Plan Sponsors for:
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Engaging in discriminatory practices
Providing false information to CMS
Imposing excessive premiums on members
Inappropriately disenrolling or refusing to re-enroll an individual
Failing to provide a beneficiary with medically necessary items or services that
are required under law or contract
o Employing or contracting with any health care provider that is excluded from
participation in the Medicare program
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The OIG Exclusion
The Department of Health and Human Services Office of Inspector General
(OIG) is legally required to exclude from participation in all Federal Health
Care programs individuals and entities convicted of the following types of
criminal offenses:
o Medicare or Medicaid fraud
o Patient abuse or neglect
o Felony convictions for other health related fraud, theft, or other
financial misconduct
o Felony convictions for unlawful manufacture, distribution, prescription
or dispensing of controlled substances
The OIG has discretion to exclude on several other grounds, including
misdemeanor convictions related to the list above.
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The OIG Exclusion (cont.)
• If a Provider is excluded by OIG from participation in Federal Health Care
programs, then Medicare, Medicaid, TRICARE and/or VA will not pay for
items or services furnished, ordered or prescribed by the excluded provider.
• Excluded providers may not bill directly for treating Medicare and Medicaid
patients, nor may their services be billed indirectly through an employer or a
group practice.
• The online database may be accessed at:
http://oig.hhs.gov/fraud/exclusions.asp
• The List of Excluded Individuals/Entities (OIG) contains just the exclusion
actions taken by the OIG.
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.
HIPAA
Privacy & Security
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The Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA),
addresses the right to privacy for an individual patient’s medical records.
Privacy Rule: Defines protected health information and provides individuals
more control over how their health information is used and disclosed.
Security Rule: Establishes controls for safeguarding the integrity, availability
and confidentiality of private information. The Office for Civil Rights is
responsible for implementation and enforcement of the privacy and security
regulations.
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WHAT DOES HIPAA PROTECT?
Patient information such as medical office patient charts, hospital records, radiographs,
lab work and testing procedures are considered Protected Health Information (PHI). It also
protects information that is maintained by a health care provider or health plan. HIPAA
protects a patient’s right to access and make changes to their PHI.
WHAT INFORMATION IS PROTECTED?
Protected information includes identification of a patient by name, social security number,
birth date or address. It includes all data in a patient’s medical record such as health
status, diagnosis, treatment information and test results. Information relative to provisions
for or payment of health care is also protected.
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What Is Considered PHI?
o Names, Addresses
o All elements of dates directly related to an individual, including birth date,
admission date discharge date, date of death
o Telephone or Fax number
o E-Mail Address
o Medical Record Number
o Health Plan Beneficiary Number
o Account Numbers
o Certificate/License Number Vehicle Identifier and Serial Numbers (License
plates)
o Device Identifiers & Serial Numbers
o URL, IP Addresses
o Biometric Identifiers (finger and voice prints)
o Full-Face Photos and Comparable Images
o Any other unique identifying number, characteristic or code
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SECURITY OF DATA
SAFEGUARDING PROTECTED HEALTH INFORMATION (PHI) - A covered
entity must have administrative, technical and physical safeguards in
place to protect the privacy of Protected Health Information from the
intentional or unintentional use or disclosure.
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HIPAA’s 2009 HITECH ACT
Health Information Technology for Economic and
Clinical Health
HITECH Act introduced several new security provisions including:
o time frame requirement to notify members and Health and Human
Services (HHS) of Protected Health Information (PHI) security breaches;
o new stricter HIPAA regulations regarding business associates and
enforcement of penalties;
o restrictions on the sale and marketing of PHI;
When a breach occurs, a covered entity must notify each individual whose
unsecured PHI has been, or is reasonably believed by the covered entity to have
been breached, accessed, acquired, used or disclosed as a result of such breach.
A covered entity must notify HHS and the media in the event of a breach of
unsecured PHI involving 500 or more individuals. A business associate must notify
the covered entity of any breach of unsecured PHI.
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Violation of PHI & PHI Breach Disclosures
For knowingly obtaining or disclosing identifiable health information relating to an
individual in violation of the Rule:
o Up to $50,000 & 1 year imprisonment
o Up to $100,000 & 5 years if done under false pretenses
o Up to $250,000 & 10 years if intent to sell, transfer, or use for
commercial advantage, personal gain or malicious harm
Preferred Care Partners must notify the Secretary of Health and Human Services of all
unauthorized disclosures of PHI; and follow the required process of notification to the
individual, client, business associate and when indicated, the media.
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HIPAA AUDITS
The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) is
responsible for privacy and security enforcement under Health Insurance Portability and
Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical
Health (HITECH) Act provisions. OCR has announced that it is initiating compliance
audits beginning November, 2011, as authorized by the HITECH Act. This action
precedes the imminent release of the Final HIPAA/HITECH Act Privacy, Security, Breach
Notification, and Enforcement Rules, expected before the end of 2011, and will
strengthen enforcement and accountability for compliance with existing and
forthcoming Rule modifications. To avoid the consequences of potential penalties for
non-compliance, covered entities and business associates must now pay immediate
attention to conducting a new or reviewing an existing risk assessment of threat and
vulnerability to protected health information (PHI), mitigating identified risks through
privacy and security safeguard policies and procedures, training their workforce
members to safeguard privacy and security of PHI, and documenting those actions in
writing.
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Record Retention
Documentation such as medical, professional, financial and
business records must be maintained for at least 10 years from
the date of service.
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Your
Responsibilities
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Duty to Report
Everyone within your organization, including owners, directors, vendors and
contractors have a duty to comply with all laws and regulations and to report
violations.
o You do not have to be certain that a violation has occurred in order to
report suspected wrongdoing.
o Retaliating against anyone who reports a suspected violation is prohibited
by Company policy.
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Fraud
If you suspect any potential case of fraud, waste or abuse related to Medicare you may report it to our
Fraud Hotline number 1- 866- 678- 8822. All reports are confidential and may be anonymous.
Our website address is: http://www.mypreferredcare.com/english/aboutus/fraud.aspx
You may also report fraud via email: [email protected]
http://www.mypreferredprovider.com/medicare/en/provider-resources/report-fraud.aspx
Suspected cases of Medicare fraud may also be reported directly to the Health and Human Services
Office of the Inspector General in writing or by phone:
1-800-HHS-TIPS (1-800-447-8477)
TTY: 1-800-377-4950
Mail:
Office of the Inspector General
Department of Health and Human Services
Attention: HOTLINE
PO Box 23489
Washington, DC 20026
CMS: 1-800-MEDICARE
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Whistle Blower Protections
Qui Tam Actions: The FCA contains whistleblower or qui tam provisions that allow individuals
who become aware of fraud against the government to sue on behalf of the government. A
person who brings a qui tam action that a court later finds was frivolous may be liable for fines,
attorney fees and other expenses.
Non retaliation Policy: Preferred Care Partners does not retaliate against any employee or
entity that reports suspected fraudulent insurance activities.
o Preferred Care Partners ensures that identities are protected for individuals reporting in
good faith alleged acts of fraud and abuse.
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Penalties for Violating Medicare Civil Monetary Penalties
(CMPs) (42 U.S.C. §1320a-7a)
Penalties range from $10,000 to $50,000 per violation and includes exclusion from the Medicare
program for a minimum of five years or more, these are:
o Presenting a claim that the person knows or should know is for an item or service that was not
provided or is false or fraudulent or for which payment may not be made.
o Making false statements or misrepresentations on application or contracts to participate in Federal
Health Care programs.
o Violation of the Medicare assignment provisions
o Violation of a Medicare physician or supplier agreement
o Violation of assignment requirement for certain diagnostic clinical laboratory tests
o Violation of requirement of assignment for nurse-anesthetist services
o Refusal of any supplier to provide rental Durable Medical Equipment (DME) supplies without charge
after rental payments may no longer be made
o Physician billing for assistants at a cataract surgery without prior approval of the Quality
Improvement Organization (QIO)
o Hospital unbundling of outpatient surgery costs
o Hospital and responsible physician “dumping of patients” based upon their inability to pay, or lack
of resources.
o False or misleading information expected to influence a discharge decision
o Violations of the Anti-Kickback statute and/or Stark Law.
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RESOURCES
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Centers for Medicare and Medicaid Services (CMS)
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Medicare Managed Care Manual and Medicare Prescription Drug Benefit Manual
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CMS Prescription Drug Manual – Chapter 9:
www.cms.hhs.gov
www.cms.hhs.gov/Manuals/IOM
http://www.cms.gov/manuals/downloads/Pub100_18.pdf
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Fraud & Abuse General Information www.cms.hhs.gov/MDFraudAbuseGenInfo
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Office of Inspector General (OIG) www.oig
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Physician Self Referral Law www.cms.hhs.gov/PhysicianSelfReferral
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Social Security Administration www.ssa.gov/oig/guidelin.htm
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Office of Inspector General Department of Health and Human Services
http://oig.hhs.gov
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HIPAA http://www.hhs.gov/ocr/privacy hhs.gov
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Training Documentation
You are accountable and responsible for ensuring Compliance
o
Companies like Preferred Care Partners that have contracts with the federal government must
ensure that their employees, owners, directors, vendors and contractors are knowledgeable about
all laws and regulations that apply to their business in order to ensure that no documentation or
certification prepared by those employees and provided to the government is considered to be
knowingly false.
o
Please note that you must be able to submit records of training logs documenting employee
participation in the training upon request.
Thank you for completing Preferred Care Partners Fraud, Waste and Abuse Training.
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