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American Behavioral

2009 Health Provider Compliance and Fraud, Waste and Abuse (FWA) Training 1

Why Do We Have Compliance Training?

 To improve services for American Behavioral members  To define expected conduct from providers, members and American Behavioral associates  To provide guidance on making right decisions  To quickly identify and resolve compliance concerns  To assist in meeting laws, regulations and accreditation standards  To avoid legal and financial penalties 06/11/09 2

The American Behavioral Compliance Mission

 To direct our business in an ethical manner and in accordance with all regulations and accreditation standards  To foster open, honest and timely communication between American Behavioral and our providers  To integrate compliance as an essential part of daily operations  To promote the cooperative relationship between American Behavioral and our providers 06/11/09 3

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The Ultimate Goal

Developing controls and educating providers, members, and associates in order to reduce the amount of fraudulent, wasteful or abusive activities 4

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The American Behavioral Code of Conduct

 Be honest  Know the applicable American Behavioral guidelines, policies and procedures  Ask questions  Admit mistakes  Report concerns 5

Fraud, Waste and Abuse (FWA)

 FWA is a nationwide problem that affects everyone either directly or indirectly  National estimates project that billions of dollars are lost due to fraud, waste and/or abuse, resulting in increased health care costs and increased cost for coverage  We have the responsibility to prevent, detect and eliminate FWA 06/11/09 6

Definition of Fraud

A person intentionally misrepresents information, knowing that the misrepresentation could benefit himself/herself or some other person The most common kind of health care fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of payable benefits 06/11/09 7

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Definition of Waste

Performing functions in a manner requiring more resources than are necessary, i.e. using or billing for more supplies, technology or hours than are required 8

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Definition of Abuse

Refers to practices that may directly or indirectly cause financial loss to payers of insurance or health care benefits. Abuse often involves administering unnecessary services, improper billing or providing products or services that are not consistent with accepted practices 9

Limited Examples of FWA

 Fraud: Submitting false claims for health care services that were not provided or filing a claim for more complicated service than the service performed  Waste: Unnecessary spending or use of office supplies, technology, resources  Abuse: Billing for services/supplies that are not medically necessary or providing care that is not consistent with accepted medical practices 06/11/09 10

Examples of Provider Health Care Fraud and Abuse

 Billing for services that were not provided  Double billing: Duplicate submission of a claim for the same service  Misrepresenting the service provided  Up-coding: Charging for a more complex or expensive service that was actually provided  Billing for a covered service when the service actually provided was not covered 06/11/09 11

Examples of Provider Health Care Fraud and Abuse (cont.)

 Kickbacks: Receiving payments or other benefits for making a referral  Ordering excessive or inappropriate testing  Brief or intermediate-length visits coded as lengthy or comprehensive visits  Regularly waiving co-pays or co-insurance for patients, but filing with the insurance company for reimbursement 06/11/09 12

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Examples of Member/Client Health Care Fraud and Abuse

 Using a member ID card that does not belong to that person  Adding someone to a policy that is not eligible for coverage, i.e. a grandchild  Failing to remove someone from a policy when that person is no longer eligible, i.e. a former spouse 13

Examples of Member/Client Health Care Fraud and Abuse (cont.)

 Doctor shopping: Visiting several doctors to obtain multiple prescriptions/services  Providing false employer group and/or group membership information 06/11/09 14

Which Laws Regulate FWA?

The Anti-Kickback Statute

and of prohibited activities include:

The Stark Law

are federal laws that prohibit someone from knowingly or willfully offering, paying or receiving anything of value for a referral. Examples • • • Waiving a co-pay or deductible for reasons other than real financial hardship (or allowable exceptions) Accepting a payment that is different from fair market value as a means to obtain more business Demanding or requesting a kickback (i.e. gifts, cash, write-offs, free supplies for referring patients to specific providers) Failure to comply can result in fines, jail and/or exclusion from state health programs, Medicare or Medicaid 06/11/09 15

False Claims Act

 The

False Claims Act

is a Federal law that prohibits a provider from knowingly submitting false, fictitious, or fraudulent claims to obtain payment from federal or state programs  Knowingly and/or willfully making a false statement about a claim is a

federal felony.

Penalties can include significant fines, jail time and/or exclusion from participation in federal and state programs.

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Criminal Activity (Self-Disclosure)

 Felony convictions or other criminal activity (other than minor traffic violations) occurring prior to or during a provider’s contract with American Behavioral must be self-disclosed  The provider agrees to notify American Behavioral within seven (7) days of the loss, restriction or recommended adverse action against his or hospital privileges or license 06/11/09 17

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Debarment or Exclusion

The Office of the Inspector General (OIG) and the General Services Administration (GSA) maintain a list of individuals and entities that have been debarred or excluded from working with federal or state health programs. At the time of the initial credentialing or re credentialing process, American Behavioral reviews and verifies that the individual or entity is not on that list As with other criminal activities, American Behavioral requires self-disclosure of any information related to debarment, exclusion or any activity that prevents a provider from working directly or indirectly with Medicare, Medicaid or state health programs 18

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Confidential Information

 Compliance with HIPAA regulations is mandatory, and the confidentiality of records, documents and business practices must be maintained  Protected Health Information (PHI) and other member information must be appropriately safeguarded This information includes paper, electronic records and oral communication  PHI should only be shared if the disclosure is specifically allowed by HIPAA 19

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Monitoring and Auditing

 Everyone is obligated to monitor compliance activities and follow all policies and procedures  Any area of suspected non-compliance should be reported immediately  American Behavioral will review claims and other data submitted by each provider as an internal monitoring and auditing control 20

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Prevention Tips: Teach American Behavioral Members to be Aware

 Review each

Explanation of Benefits

to ensure the accuracy of the name of the provider, dates of service and types of services reported  Protect his or her insurance card and personal information at all times  Count his or her pills each time they pick up a prescription  Be wary of all advertisements that claim “free” treatments 21

Prevention Tips: Teach American Behavioral Members to be Aware (cont.)

 Check providers’ credentials with the appropriate state licensing board. If a member is unsure of a provider’s credentials, tell them to ask American Behavioral  Members should report all suspected fraud and abuse to the Quality Department at American Behavioral 205-868-9633 06/11/09 22

What To Do Once Suspected Fraud or Abuse is Reported

Research the following to see if the allegation against a particular provider is substantiated:  Research the provider throughout all billings  Research pre-billing and post-billing reviews of the provider  Research submission and payment of claims  Query provider history  Review contract or benefit language 06/11/09 23

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Potential Investigation/Corrective Actions

 A pre-payment investigation may be warranted  Additional documentation may be requested from the provider before claims payment  Possible recovery of over-payments may be recommended. The decision to enact this recommendation would come from upper administration and/or corporate legal counsel  Mandatory retraining  Contract suspension and/or contract termination 24

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Getting Assistance or Reporting a Potential Violation

   Obtain assistance from a supervisor. (Take the route in which you feel most comfortable. If you suspect your immediate supervisor of FWA, go to the Quality Department or another trusted member of management) American Behavioral Quality Department 205-868-9633 Report suspicious practices involving Medicare or other federal programs to the Office of the Inspector General (OIG) Hotline 1-800-368-5779 All reports will be investigated. Unless required by law, the reporter will remain anonymous if requested. There will be no retribution for reports made in good faith 25

Summary

 Fraud: When a person misrepresents information, knowing that the misrepresentation could benefit himself/herself or some other person  Waste: Using more resources than necessary to complete a task  Abuse: When an associate, vendor, provider or contractor furnishes products or services that are inconsistent with accepted practices or that are clearly not reasonable or necessary 06/11/09 26

Summary (cont.)

Compliance:

The material and policies in this training are mandatory. Ethical behavior can never be sacrificed in the pursuit of other objectives American Behavioral is committed to the highest standards of ethics and compliance. Everyone is responsible for their own conduct and behavior. If you are not sure about potential compliance or FWA issues,

ask

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Summary (cont.)

Fraud and abuse are

serious problems

. Report suspected fraud and abuse

as soon as possible

.

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Summary (cont.)

Remember The Ultimate Goal:

Developing controls and educating providers, members, and associates in order to reduce the amount of fraudulent, wasteful or abusive activities 29

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Questions?

Contact Debbie Garvin, Quality Officer at 1-877-660-6646 x 633 30