Hill Country MHDD Centers

COMPLIANCE & ETHICS

January 2014

Fraud & Abuse

It is essential that all Hill Country MHDD Center employees understand what Health Care Fraud & Abuse is, how to detect it, and how to assist employees, contractors, or agents who may be reporting suspicious activities.

Training Requirements

Hill Country MHDD Center is required by Federal Mandate to make available Fraud & Abuse Training to our employees, contractors, and agents.

This training program provides a general overview of Fraud & Abuse and Compliance regulations, potential fraud indicators, and procedures for reporting fraud and abuse.

Purpose

Health Care Fraud is a crime that has a significant effect on the private and public health care payment system. It is currently costing our government billions of dollars.

Fraud & Abuse accounts for over 10% of annual health care costs.

Impact: *Taxpayers pay higher taxes because of fraud in public programs such as Medicaid and Medicare.

*Employers and individuals pay higher private health insurance premiums because of fraud in the private sector health care system.

Recognizing the serious implications of Fraud, Hill Country MHDD Center’s Fraud & Abuse Program is dedicated to detecting, investigating and preventing all forms of suspicious activities related to possible health insurance fraud and abuse, including any reasonable belief that insurance fraud will be, is being, or has been committed .

Training Overview

This training will provide answers to the following questions: ► What is Fraud and Abuse?

► What are potential Fraud indicators?

► What laws regulate Fraud & Abuse?

► What is a Fraud & Abuse violation?

► How is suspicious activity reported?

► What are the Sanctions and Penalties for Fraud & Abuse violations?

► What are Hill Country MHDD Center’s employees, contractors’ and agents’ responsibilities during an investigation?

Introduction

Hill Country MHDD Center, in compliance with the Office of Inspector General, Insurance Fraud Bureau, and Office of Personnel Management, has put in place a fraud and abuse program designed to meet regulatory requirements and protect consumers, employees, contractors and agents.

Introduction

(cont.)

It is the policy of Hill Country MHDD Center ► To review and investigate all possible allegations of fraud and/or abuse, whether internal or external; ► To take corrective actions for any supported allegations after a thorough investigation; and ► To report confirmed misconduct to the appropriate parties and/or Agencies.

What is Fraud?

Fraud is defined as an intentional perversion of truth for the purpose of inducing another in reliance upon it to part with some valuable thing belonging to him or to surrender a legal right.

It includes any act that constitutes fraud under applicable federal, state, or common law.

What is Abuse?

Abuse is defined as provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to Health programs, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the Health program.

Types of Health Care Fraud

Provider Fraud: ► Providers who deliberately submit claims for services not actually rendered, or bill for higher-priced services than those actually provided.

► Providers of medical equipment and home health services who defraud the Medicare program and private payers, often paying kickbacks to dishonest physicians who prescribe unnecessary products and services.

► Charges are submitted for payment for which there is little or no supporting documentation available, such as progress notes, x-rays or lab results.

Types of Health Care Fraud

(cont.)

Claims or Subscriber Fraud: ► Subscriber/Claim fraud can involve alteration of bills or creation of claims, submission of claims for ineligible dependents, and misrepresentation in response to specific questions on the claim forms.

► Subscriber/Claims fraud can be submitted by anyone.

Examples of potential Fraud, Abuse or Suspicious Activity

Falsifying Claims/Encounters ► Alteration of claim ▪ Super imposed material ▪ White Outs ▪ Erasures ▪ Altered Changes ▪ Different colored inks ► Incorrect Coding ► Double Billing ► Billing for services not rendered ► Misrepresentation of services/supplies ► Substitution for services ► Misspelled Medical terminology ► Treatment of conditions which may suggest a pre-existing condition ► No Provider information on claim ► Diagnosis does not correspond to treatment rendered

Examples of potential Fraud, Abuse or Suspicious Activity

(cont.)

► Delivery of Services ▪ Denying access to services/benefits ▪ Limiting access to services/benefits ▪ Failure to refer for needed services ▪ Over-utilization ▪ Under-utilization ► Consumer Eligibility Fraud ▪ Resource misrepresentation ▪ Ineligible consumer using eligible consumer’s services ▪ Misrepresentation of medical condition ▪ Failure to report third party billing ▪ Eligibility determination issues

Potential Fraud Indicators

► Limited time spent by providers with consumers (under provision of care) ► Frequent referral of consumers (may be indicative of a kickback arrangement) ► Inadequate treatment plan ► Consistently poor outcomes may be a sign of lack of treatment ► Unusual consumer encounter ratios

What laws regulate Fraud & Abuse?

► The Federal False Claims Act (FCA) ► The Stark Law ► The Federal Anti-Kickback Statute ► HIPAA ► Deficit Reduction Act ► Criminal Penalties for Acts involving Federal Health Care Programs ► The False Claims Whistleblower Employee Protection Act ► Administrative Remedies for False Claims and Statements ► And related State Statutes

False Claims Act

Under the False Claims Act (FCA), 31

U.S.C.

§§

3729-3733, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim.

Stark Law

Self-Referral (Stark Law) Statutes, Social Security Act, § 1877, pertains to physician referrals under Medicare and Medicaid.

Referrals for the provisions of health care services, if the referring physician or an immediate family member, has a financial relationship with the entity that receives the referral, is not permitted.

Anti-Kickback Statute

Under the Anti-Kickback Statute, 41 U.S.C., it is a criminal offense to knowingly and willfully offer, pay, solicit or receive any remuneration for any item or service that is reimbursable by any federal health care program.

Penalties many include exclusion from federal health care programs, criminal penalties, jail and civil penalties for each violation.

Anti-Kickback Statute

(cont.)

Examples of Kick-Backs: ► Money ► Discounts ► Gratuities ► Gifts ► Credits ► Commissions Drug companies must document their time and training.

HIPAA

The Health Insurance Portability and

Accountability Act (HIPAA), 45 CFR,

Title II, § 201-250, provides clear definition for Fraud & Abuse control programs, establishment of criminal and civil penalties noncompliance.

and sanctions for

Health Insurance Portability and Accountability Act (HIPAA)



HIPAA is a multi-faceted law meant to streamline the healthcare system in a high technology age.



HIPAA is federal regulation that covers all healthcare providers and their associates.

HIPAA establishes:



Consistent standards for uniform transmission of electronic health care claims.



Standards for securing storage of data.



Most importantly, increases Privacy and

Security.

HIPAA’s “PHI”



“

PHI”- Protected Health Information



All individually identifiable health information transmitted or maintained by a covered entity, regardless of form is protected as highly confidential!

HIPAA: Health Insurance Portability and Accountability Act-

Four

Parts



The Accountability portion of the act created Healthcare crimes: 1.

Healthcare Fraud

“Accepting benefits or payment for benefits under false or fraudulent pretenses, representations, or promises.”

2.

Healthcare Theft or Embezzlement

”Knowingly and willfully taking any money or other assets of a healthcare program for the use of any person other than the rightful owner.”

HIPAA HealthCare Crimes

3. Healthcare False Statements

“to make false representations in connection with the delivery of, or payment for, any healthcare benefit or make any material false, fictitious, or fraudulent statements.”

HIPAA Healthcare Crimes

4. Obstruction of Criminal Healthcare Offense Investigations

“To obstruct in any way the criminal investigation of a healthcare offense whether by failing to produce subpoenaed records or by inducing others to not communicate with criminal investigators.”

HIPAA Privacy Rule:

Written Consent



The Privacy Rule requires written consent by a patient

before covered entities may use or disclose the patient’s protected health information.

HIPAA Privacy Rule:

Minimum Necessary Standard

The Minimum Necessary Standard

requires that covered entities make “reasonable” efforts to limit access to PHI based upon the minimum information necessary to perform a particular role.

HIPAA Privacy Rule:

Right to Request Restrictions



Patients have the right to request their healthcare providers communicate to them by “alternative means” or at “alternative locations.”



Patients have a right to be “de-listed”.



Their name doesn’t have to be on a “patient list.”

Deficit Reduction Act

The Deficit Reduction Act (DRA), Public Law No. 109-171, § 6032, passed in 2005, is designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries. The DRA requires compliance for continued participation in the programs.

The development of policies and education relating to false claims, whistleblower protections and procedures for detecting and preventing fraud & abuse must be implemented.

Criminal Penalties for Acts Involving Federal Health Care Programs

This legislation, 42 U.S.C. § 1128B, 1320a-7b, states that criminal penalties will result in conviction of a felony and a fine of not more than $25,000 and/or imprisonment for not more than 5 years of false statements are knowingly and willfully made for benefits or payments, or misrepresents services or fees to beneficiaries of federal health care programs.

The False Claims Whistleblower Employee Protection Act

Under this legislation, 31 U.S.C. § 3730(h), a company is prohibited from discharging, demoting, suspending, threatening, harassing or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists an investigation of the employer.

Whistleblower Protection Against Retaliation

Whistleblower protection is provided by this federal (and some state) Acts and related statutes that shield employees from retaliation for reporting illegal acts of employers. Under this legislation, 31 U.S.C. § 3730(h),

 

It is illegal for an employer to retaliate against an employee for reporting or participating in an investigation, but . . .

If an employer retaliates anyway, whistleblower protection might entitle employee to file a charge with a government agency, sue the employer, or both.

Administrative Remedies for False Claims and Statements

Under this Act, 31 U.S.C. Chapter 8, § 3801, any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim.

What is a Fraud & Abuse Violation?

Fraud & Abuse Violations occur when a person deliberately uses a misrepresentation or other deceitful means to obtain something to which he/she is not otherwise entitled.

Any employee, contractor, agent or consumer has the right to make a confidential Fraud & Abuse related complaint to the Compliance Department of Hill Country MHDD Centers if he/she feels that there has been suspicious activities.

Sanctions and Penalties for Fraud and Abuse violations

Hill Country MHDD Centers must have and apply appropriate sanctions against any and all employees, contractors, agents, or consumers who fail to comply with the policies and procedures of Hill Country MHDD Centers and/or the requirements of the Federal and State laws and Statutes. The Federal and State government agencies will prosecute these contractors, agents or consumers accordingly.

Sanctions and Penalties for Fraud and Abuse violations (cont.)

Conviction of Fraud & Abuse can carry civil and criminal penalties.

Civil Penalties: ► $5,500 to $11,000 per claim plus up to 3 times the amount of damages Criminal Penalties: ► Felony conviction: 5-20 years in jail ► Misdemeanor conviction: 1 year in jail

Governmental Agencies Enforcing Healthcare Regulations

1.

Offices of Inspector General 2.

Offices of the Attorney General 3.

Department of Justice/FBI 4.

Federal Trade Commission

Federal Trade Commission



FTC ensures that doctors can no longer be treated to expensive dinners at lavish hotels or attend sporting events at the drug company’s expense.



To avoid anti-kickback laws, FTC enforces that drug companies document their time and training. (Kickback is defined as the return of a sum of money or objects already received, typically as the results of pressure, coercion, or secret agreement…

The American Heritage Dictionary- 4 th ed)

Department of Justice (DOJ)



DOJ investigates fraud in nonprofit agencies.



Major reimbursement claim systems are being scrutinized and monitored by the DOJ.



DOJ looks at due diligence, is it done to validate credentials or licenses? If there are too many non credentialed employees, the facility doesn’t meet contract guidelines.

Office of the Attorney General



Office of the Attorney General investigates outpatient psychiatric services



Mental health services in nursing facilities



Improper billing of psychiatric services:



Individual psychotherapy



Psychological Testing



Group Therapy

Program Integrity

The office of Program Integrity was developed to:



Play a key role in getting providers in compliance with Medicare, by identifying errors and problems.



Ask providers for refunds, if it finds the government overpaid.



Work with insurance carriers directly and indirectly to help providers comply with Medicare.

The Office of the Attorney General and the Office of Program Integrity investigates and makes referrals to the DOJ.

Employee, Contractor and Agent Responsibilities

Hill Country MHDD Center employees, contractors, and agents are responsible for understanding: ► Coding Standards ▪ Select appropriate billing code for service rendered ► Hill Country MHDD Centers provider standards ▪ Understand roles and responsibilities as a providers of services ▪ Know licensure responsibilities and restrictions ► Documentation Standards ▪ Hill Country MHDD Centers adheres to internal, national, and state standards for documentation

Our Goal: Elimination Fraud & Abuse

To eliminate fraud and abuse successfully, employees, contractors and agents must work together with Hill Country MHDD Center to prevent and identify inappropriate and potentially fraudulent practices.

This can be accomplished by: ► Monitoring claims submitted for compliance with billing and coding guidelines; ► Education of all employees responsible for medical records ► Reporting to Compliance Officer cases of suspected fraud and abuse.

How does this affect us?



Hill Country governmental authority for agency.

As mentally intellectually MHDDC and is a the ill local local and developmentally disabled individuals in 19 counties, we accept taxpayer money from the state and federal government.



How we do business is closely scrutinized!

To Ensure Compliance with all Federal and State Regulations

We need to follow our Compliance Plan

Compliance Plan



The Office of the Attorney General established the Compliance Program Guidance Guidelines to assist providers in preventing the submission of erroneous claims or engaging in unlawful conduct involving Federal healthcare programs.

Components of an Effective Compliance Program



Conducting internal monitoring and auditing;



Implementing compliance and practice standards;



Designating a compliance officer or contact;



Conducting appropriate training and education;



Developing open lines of communication;



Enforcing disciplinary standards through well publicized guidelines.

Statement of Policy and Open Communication



HCMHDDC Board and Management are committed to providing avenues within which ethical issues may be raised, reviewed, and resolved openly and honestly.



There is an Open Door Policy where employees are free to express their concerns and to exchange ideas without fear of reprisal.

Compliance Officer and Compliance Committee



A Compliance Officer (CO) has been named to ensure state and federal regulations are followed.



The CO is responsible for oversight of the Compliance Committee, including investigations, reporting, and corrective actions.

Gifts and Favors



“An occasional lunch or dinner or gift of limited value.”



“Monetary gifts or favors in attempt to gain influence or advantage”



“Any gift limited in value and consistent with common business courtesies.”



Giving monetary gifts is never acceptable .

Compliance/Monitoring and Auditing



We are committed to complying with all federal and state laws and regulations.



Documentation will follow state and federal guidelines and will be done in a timely manner.



All direct care staff will document according to the TAC guidelines, “after each contact.”



We will conduct audits and other risk evaluations to monitor compliance as stated in our agency policy and procedure manual.

Compliance/Monitoring and Auditing



All staff will be trained in their specialty area.



HCMHDDC will maintain processes to detect Medicaid/Medicare or other third party compliance offenses.



We will initiate corrective action plans.



We will report confirmed fraud and abuse to the appropriate regulatory authorities.



We will respond with appropriate corrective action when employees or contract providers fail to comply.

Accounting and Reporting

 Each employee and contract provider will ensure the integrity of the Center by

accurately

and

truthfully

recording all agency information, accounting, and operational data through strict adherence to established accounting and business procedures.

Corporate Resources



Each employee and contract provider is expected to use corporate resources economically and safeguard corporate assets at all times.

Corporate Code & Media

Hill Country MHDD Center

Electronic Media



All electronic communications systems, including email, internet access, and voice mail are the property of HCMHDDC and are to be used primarily for business purposes.

Electronic Media (con’t.)



As all electronic communication systems and messages generated are the property of HCMHDDC, they are subject to review at any time. You should have no expectation of privacy for any Agency equipment you use.



Use HIPAA guidelines to protect the confidentiality, integrity, and availability of electronic protected health information.

Controlled Substances Focus



The illegal use/abuse or possession of alcohol or any controlled substance in the workplace is unacceptable and will not be tolerated.



These acts are illegal and jeopardize the safety of employees, contract providers, and consumers.



It reduces trustworthiness.

productivity, reliability and

Reporting Misconduct



Bring to your supervisor any violation of this Business Code of Conduct.



Supervisors will suggest an appropriate action.



Reporting will remain confidential unless otherwise required by professional code of conduct, state, and/or federal law.



No employee or contractor will be punished or subjected to reprisal because of good faith reporting

How is suspicious activity reported?

Complaints from agents or consumers: employees, contractors, ► Report all suspicious or potential fraud and abuse activities confidentially to Hill Country MHDDC through your Compliance Officer, Sheree Hess (866) 247-8790, or [email protected]

Consequences for not following Cooperate Compliance



TERMINATION of employment



Referral to Appropriate Authority:



Possible Jail Time and/or Fines

Conclusion



Always Do the Right Thing and you’ll most likely be in compliance with HCMHDDC policies!