Fraud, Waste, & Abuse Training

Transcription

1 Fraud, Waste, & Abuse Training Training for all Healthcare Employees

2 What We ll Cover Today Today s Objec=ves Objec'ves: Provide an overview of general health care fraud, waste and abuse Iden'fy various types of healthcare fraud Iden'fy who is responsible for comba'ng fraud, waste and abuse Understand how to report suspected health care fraud, waste and abuse Understand protec'ons when repor'ng suspected fraud, waste and abuse Recognize relevant laws related to fraud, waste and abuse

3 Fraud, Waste & Abuse Training Requirements Fraud, Waste, and Abuse (FWA) training is required for all employees who work for or contract with Medicare Part C Medicare Advantage Programs (MA) or Part D Medicare Prescription Drug Programs (PDP) Training is required for.

4 FWA Training Requirements Pharmacy Benefit Managers (PBMs) Pharmacies and pharmacists Brokers and agents Vendors & subcontractors such as claims processing firms Hospitals Primary care providers Specialists Ancillary providers Den'sts Medical Coders Note: list is not all-inclusive

5 Medicare

6 Medicare Part A Hospital Insurance Medically necessary Hospital, Skilled Nursing Facility, Home Health and Hospice Care Part B Medical Insurance Medically necessary doctors services, preventa've care, durable medical equipment (DME), hospital outpa'ent services, laboratory tests, x- rays, mental health care, and some home health and ambulance services

7 Medicare Part C Medicare Advantage MCO s through HMO s and PPO s provide Medicare benefits. May be offered at different pricing, includes all of Part A and B coverage, and may also get Part D benefits if chosen Part D Outpa=ent Prescrip=on Drug Insurance Drug coverage provided by private insurance companies that have contracts with Medicare

8 PACE Program PACE = Program of All- inclusive Care for the Elderly Medicare and Medicaid Program Meet needs in community instead of nursing home or other care facility Care and services in the home and PACE centers Must be: 55 or older Living in the service area of a PACE organiza'on In need of nursing home care (as deemed by state) Able to live safely in the community with PACE help

9 En==es First Tier En=ty Any party that enters into a wri\en arrangement, acceptable to CMS, with a sponsor or applicant to provide administra've services or health care services for Medicare eligible individual under the MA or Part D programs Examples include (but are not limited to) pharmacy benefit managers (PBMs), hospitals and physicians

10 En==es Downstream En=ty Any party that enters into a wri\en arrangement, acceptable to CMS, with persons or en''es involved in the MA or Part D benefit, below the level of the arrangement between a sponsor and a first 'er en'ty These wri\en arrangements con'nue down to the level of the ul'mate provider of both health and administra've services Examples include (but are not limited to) pharmacies and claims processing firms

11 En==es Related En=ty Any en'ty that is related to the Sponsor by common ownership or control and: 1. Performs some of the Sponsor s management func'ons under contract or delega'on 2. Furnishes services to Medicare enrollees under an oral or wri\en agreement; or 3. Leases real property or sells materials to the Sponsor at a cost of more than $2,500 during a contract period

12 The Complexity and Size of The System

13 Centers for Medicare & Medicaid Services (CMS) Federal agency with oversight of Medicare, Medicaid, and Children s Health Insurance Program (CHIP) Over $800 Billion spent each year on these programs (19% of total federal budget) Over 100 Million beneficiaries Covers 1 in 4 Americans

14 Medicare Each Work Day, Medicare: Pays over 4.4 Million claims To 1.5 Million providers Worth $1.1 Billion Each Month, Medicare: Receives almost 19,000 provider enrollment applica'ons Each year, Medicare: Pays over $430 Billion For more than 45 Million beneficiaries

15 Medicaid Each Year, Medicaid: (na'onally) Pays over 2.5 Billion claims For more than 54 Million beneficiaries In 56 state and territory- administered programs By 2014, Americans who earn less than 133% of the poverty level (approximately $29,000 for a family of 4), will be eligible to enroll in Medicaid 8.8 Million (18%) of Medicaid beneficiaries are dual eligible meaning they also qualify for Medicare coverage

16 Center for Program Integrity Affordable Care Act enacted March 23, 2010 HHS Secretary Sebelius realigns CMS into 5 centers, crea'ng the Center for Program Integrity (CPI) CPI consolidates Medicare and Medicaid program integrity Move away from pay and chase approach and toward a focus on prepayment preven'on efforts Increase public and private coopera'on

17 Program Integrity

18 Program Integrity Partners

19 Program Integrity Partners

20 FFS Program Environment

21 A/B Administra=ve Contractors

22 DME Administra=ve Contractors

23 Home Health Administra=ve Contractors

24 ZPIC Map

25 RAC Jurisdic=ons

26 MEDIC Part C & D Benefit Integrity Program integrity for Medicare Parts C and D Na'onal Jurisdic'on Coordinates program integrity efforts of Plans Law enforcement educa'on and support Inves'gators responsible for assigned areas (live in or near assigned areas) 20 office located in: St Augus'ne, Miami, Atlanta, Greensboro, New Orleans, Dallas, Houston, San Antonio, McAllen (TX), Denver, Kansas City, San Diego, Los Angeles, Easton (MD), Plymouth (PA), New Jersey, Boston, Chicago, Detroit, and Sea\le

27 Recognizing Fraud, Waste & Abuse

28 Health Care Fraud Health Care Fraud is inten'onally, or knowingly and willfully a4emp'ng to execute a scheme to falsely obtain money from any health care benefit program¹ ¹Defined in Title 18, US Code 1347 Medicare Fraud: is purposefully billing Medicare for services that were never provided or received.

29 Abuse in the Health Care System Abuse involves ac5ons that are inconsistent with accepted, sound medical, business or fiscal prac5ces. Abuse directly or indirectly results in unnecessary costs to the Medicare program through improper payments.¹ Fraud is dis'nguished from abuse in that, in the case of fraudulent acts, there is clear evidence that the acts were commi\ed knowingly, willfully and inten'onally; or with reckless disregard. Abuse is uninten=onal

30 Waste in the Health Care System Waste: to use up or spend without real need, gain or purpose; squander¹ ¹Websters New World Dic'onary, Third College Edi'on Experts estimate that 30% of the $2.3 trillion spent on health care is wasted, meaning it could be eliminated without reducing the quality of patient care.

31 Be Encouraged Most Medicare payment errors are simple mistakes and are not the result of physicians, providers, or suppliers trying to take advantage of the Medicare system. The vast majority of physicians, providers, and suppliers who serve people with Medicare are commi\ed to providing high quality care to their pa'ents and to billing the program only for the payments they have earned.

32 However. There are a few individuals who are intent on abusing or defrauding Medicare, chea'ng the program (and in some cases the people with Medicare who are liable for co- payments) out of millions of dollars annually. Medicare fraud takes a lot of money every year from the Medicare program. People with Medicare pay for it with higher premiums. ¹ ¹ h\p://

33 Examples of Ways Fraud, Waste & Abuse Can Occur

34 Examples of Fraud, Waste & Abuse For Health Plans: Failure to provide medically necessary services Marke'ng schemes such as offering beneficiaries a cash payment as an inducement to enroll Selec'ng or denying beneficiaries based on their illness profile or other discrimina'ng factors Inappropriate formulary decisions in which costs take priority over criteria such as clinical efficacy and appropriateness

35 Examples of Fraud, Waste & Abuse For Providers: Bundling and unbundling Billing for services not rendered or supplies not provided Misrepresen'ng who rendered the service Rent- a- pa'ent scheme Misrepresen'ng the date services were rendered or the individual who received the services

36 Examples of Fraud, Waste & Abuse For Providers: Altering claim forms, electronic claim records or medical documenta'on Solici'ng, offering or receiving a kickback, bribe or rebate Theu of a prescriber s Drug Enforcement Agency (DEA) number, prescrip'on pad or e- prescribing log- in informa'on Prescrip'on drug switching Illegal remunera'on schemes, such as selling prescrip'ons

37 Examples of Fraud, Waste & Abuse For Brokers: Enrolling a beneficiary without their knowledge or consent Encouraging a member to dis- enroll Offering beneficiaries a cash payment as an inducement to enroll Sta'ng the broker works for or is contracted with the Social Security Administra'on or CMS Misrepresen'ng the plan being marketed (i.e. enrolling a beneficiary in a MA- PD plan when they wanted a PDP)

38 Examples of Fraud, Waste & Abuse For Pharmacies: Prescrip'on splivng Prescrip'on drug shor'ng Dispensing expired or adulterated prescrip'on drugs True Out- of- Pocket (TrOOP) manipula'on Bait and switch pricing Prescrip'on forging or altering Inappropriate billing prac'ces such as: Billing for brand when generics are dispensed Billing non- covered prescrip'ons as covered items Billing for prescrip'ons that are never picked up

39 Examples of Fraud, Waste & Abuse For Pharmacy Benefit Managers (PBMs): Unlawful remunera'on, such as remunera'on for steering a beneficiary toward a certain plan or drug or for formulary placement Inappropriate formulary decisions where cost takes precedence over clinical efficacy and appropriateness Prescrip'on drug switching Prescrip'on drug splivng or shor'ng Failure to offer nego'ated prices

40 Examples of Fraud, Waste & Abuse For Pharmaceu=cal manufacturers: Inappropriate documenta'on of pricing informa'on Kickbacks, inducements, and other illegal remunera'ons Inappropriate rela'onships with prescribers Illegal off- label promo'on Illegal usage of free samples

41 Examples of Fraud, Waste & Abuse For Wholesalers: Counterfeit and adulterated drugs through black and grey market purchases including fake, diluted, expired and illegally imported drugs Diver'ng drugs - brokers illegally gain control of discounted medicines intended for places such as nursing homes and AIDS clinics; mark up the prices and move them to small wholesalers before being sold to consumers Inappropriate documenta'on of pricing informa'on

42 Examples of Fraud, Waste & Abuse For Medicare Beneficiaries: ID card sharing Misrepresenta'on of status Doctor shopping Resale of drugs on the black market Prescrip'on forging or altering Iden'ty theu

43 Improper Referrals and Services Can lead to: Overu'liza'on of resources Increased costs Corrup'on of medical- decision- making Pa'ent steering Unfair compe''on

44 Who is Responsible for Comba=ng Fraud, Waste & Abuse?

45 Who is Responsible for Comba=ng FWA? EVERYONE

46 Who is Responsible for Comba=ng FWA: CMS is taking strong ac'on to combat fraud and abuse of the system in key areas: CMS goal is to make sure Medicare only does business with physicians, providers, and suppliers who will provide people with Medicare with high quality services¹ CMS contracts with private organiza'ons called Medicare Drug Integrity Contractors (MEDICSs) to assist in the management of CMS audits, oversight, and an'- fraud and abuse efforts ¹ h\p://

47 Who is Responsible for Comba=ng FWA: The cooperative effort to prevent and detect fraud includes State and Federal Agencies such as: ü the Department of Health and Human Services Office of the Inspector General ü the Federal Bureau of Investigation ü the Department of Justice

48 Who is Responsible for Comba=ng Health Plans FWA: All plan sponsors are required to have a comprehensive plan to detect, correct and prevent fraud, waste and abuse¹ Medicare Advantage organiza'ons and Part D Sponsors are required to provide FWA training and educa'on to all first 'er, downstream and related en''es² ¹42 C.F.R (b)(4)(vi)(H) ²72 Fed. Reg. 233 (2007)

49 Who is Responsible for Comba=ng FWA: Brokers and Agents are responsible for marke'ng products in accordance with applicable federal and state laws, including state licensing laws and CMS policy Providers and Vendors are ul'mately responsible for billing bearing their name; providers and vendors and their employees are required to complete the FWA training and submit the a\esta'on Beneficiaries are encouraged by CMS to report suspected fraudulent ac'vity

50 Who is Responsible for Comba=ng FWA: All first tier, downstream and related entities are obligated to have appropriate polices and procedures to address fraud, waste and abuse

51 Repor=ng Fraud, Waste & Abuse

52 Repor=ng Fraud, Waste & Abuse Fraud, Waste & Abuse is a very serious matter. Find out who you should report these concerns to within your own organization.

53 Repor=ng Fraud, Waste & Abuse Centers for Medicare & Medicaid Services (CMS) Suspicions of fraud or abuse may also be reported to Medicare s Customer Service Center at MEDICARE ( ) For ques'ons about billing procedures, billing errors, or ques'onable billing prac'ces contact your Medicare Contractor. You can find FI and Carrier contact informa'on, including toll- free telephone numbers, at h4p:// CallCenterTollNumDirectory.zip on the CMS website.

54 Repor=ng Fraud, Waste & Abuse U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) If you have iden'fied billing prac'ces that cause you to suspect poten'al fraud or abuse, call the OIG s Na'onal Hotline at HHS- TIPS ( )

55 Repor=ng Fraud, Waste & Abuse U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) By Fax: By E- Mail: By TTY: By Mail: Office of Inspector General Department of Health and Human Services A\n: HOTLINE 330 Independence Ave., SW Washington, DC 20201

56 Non- Retalia=on for Repor=ng FWA Good faith repor'ng of suspected Fraud, Waste & Abuse is accepted and expected behavior Anyone who in good faith reports a viola=on is referred to as a whistleblower and is protected from any retalia=on by the Company A number of laws contain whistleblower protec'on - one of which is the False Claims Act

57 Relevant Laws

58 The False Claims Act The False Claims Act is also known as the Lincoln Law because it was passed under the administra'on of President Lincoln in It prohibits: 1. Knowingly presen'ng, or causing to be presented a false claim for payment or approval; 2. Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim. 3. Conspiring to commit any viola'on of the False Claims Act. 4. Falsely cer'fying the type or amount of property to be used by the Government; 5. Cer'fying receipt of property on a document without completely knowing that the informa'on is true; 6. Knowingly buying Government property from an unauthorized officer of the Government, and; 7. Knowingly making, using, or causing to be made or used a false record to avoid, or decrease an obliga'on to pay or transmit property to the Government.

59 The False Claims Act (b) for these purposes the terms "knowing" and "knowingly" mean that a person: (1) has actual knowledge of the informa'on (2) acts in deliberate ignorance of the truth or falsity of the informa'on; or (3) acts in reckless disregard of the truth or falsity of the informa'on, and no proof of specific intent to defraud is required The False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false

60 The False Claims Act The Act does not require proof of intent to defraud the government. Prosecu'on may occur on a wide variety of ac'ons to include: Falsifying treatment plans or medical records to maximize payments Duplicate or double billing Unlawfully giving health care providers inducements in exchange for referrals Physician billing for services provided by interns, residents, and fellows in a teaching hospital (where no physician exam/evalua'on was performed)

61 The False Claims Act The False Claims Act includes a qui tam provision which allows people not affiliated with the government to file ac'ons on behalf of the government. This is also known as whistleblowing Allows any person with actual knowledge of allegedly false claims to the government to file a lawsuit on behalf of the government Under the False Claims Act, the Department of Jus'ce (DOJ) may pay rewards to anyone who reports fraud against the federal government in an amount between 15% and 30% of what is recovered based on the whistleblowers informa'on. (Approximately $1.1 Billion recovered from whistleblower lawsuits)

62 Viola=ons of False Claims Act 3 times the amount suffered by the government plus mandatory civil penalties between $5,500 & $11,000 per claim An example may be a physician who submits a bill to Medicare for medical services he or she knows has not been provided

63 Civil Monetary Penal=es Law The Civil Monetary Penal=es Law authorizes the imposi'on of substan'al civil money penal'es against an en'ty that engages in ac'vi'es including, but not limited to: (1) knowingly presen'ng or causing to be presented, a claim for services not provided as claimed or which is otherwise false or fraudulent in any way; (2) knowingly giving or causing to be given false or misleading informa'on reasonably expected to influence the decision to discharge a pa'ent; (3) offering or giving remunera'on to any beneficiary of a federal health care program likely to influence the receipt of reimbursable items or services; (4) arranging for reimbursable services with an en'ty which is excluded from par'cipa'on from a federal health care program; (5) knowingly or willfully solici'ng or receiving remunera'on for a referral of a federal health care program beneficiary; or (6) using a payment intended for a federal health care program beneficiary for another use. 42 U.S.C. 1320a- 7a. From OIG website, h\p://oig.hhs.gov/fraud/enforcement/cmp/index.asp (last accessed Apr. 30, 2012).

64 Civil Monetary Penal=es Law CMS may impose civil monetary penal=es when: A person presents, or causes to be presented, a claim for an item or service not provided as claimed A claim is for an item or service that is false or fraudulent A physician s service was provided by a person who was not a licensed physician, whose license had been obtained through misrepresenta'on, or who improperly represented to a pa'ent that he or she was a cer'fied specialist An item or service was furnished by an excluded person

65 Civil Monetary Penal=es Law Penalties range between $10,000 & $50,000 per violation h\p://oig.hhs.gov/compliance/physician- educa'on/ index.asp

66 Civil Monetary Penal=es Law The OIG is authorized to seek different amounts of CMPs and assessments based on the type of viola'on at issue. See 42 CFR For example, in a case of false or fraudulent claims, the OIG may seek a penalty of up to $10,000 for each item or service improperly claimed, and an assessment of up to three 'mes the amount improperly claimed. 42 U.S.C. 1320a- 7a(a) In a kickback case, the OIG may seek a penalty of up to $50,000 for each improper act and damages of up to three 'mes the amount of remunera'on at issue (regardless of whether some of the remunera'on was for a lawful purpose). 42 U.S.C. 1320a- 7a(a) From OIG website, h\p://oig.hhs.gov/fraud/enforcement/cmp/index.asp (last accessed Apr. 30, 2012).

67 An=- kickback Statute The an'- kickback statute makes it a criminal offense to knowingly or willfully offer, pay, solicit, or receive any remunera=on to induce or reward referral of items or services reimbursable by a Federal health care program Remunera'on includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind Medicare Fraud & Abuse Resource Reference Remunera5on is payment, compensa'on, wage, benefit or salary; typically a monetary payment for services rendered, as in an employment or contractual agreement

68 An=- kickback Statute The federal An'- Kickback Statute ( An'- Kickback Statute ) is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business. See 42 U.S.C. 1320a- 7b. The An'- Kickback Statute is broadly draued and establishes penal'es for individuals and en''es on both sides of the prohibited transac'on. Convic'on for a single viola'on under the An'- Kickback Statute may result in a fine of up to $25,000 and imprisonment for up to five (5) years. See 42 U.S.C. 1320a- 7b(b)

69 An=- kickback Statute In addi'on, convic'on results in mandatory exclusion from par'cipa'on in federal health care programs. 42 U.S.C. 1320a- 7(a) Absent a convic'on, individuals who violate the An'- Kickback Statute may s'll face exclusion from federal health care programs at the discre'on of the Secretary of Health and Human Services. 42 U.S.C. 1320a- 7(b) The government may also assess civil money penal'es, which could result in treble damages plus $50,000 for each viola'on of the An'- Kickback Statute. 42 U.S.C 1320a- 7a(a)(7)

70 The Stark Law The Physician Self- Referral Prohibi=on Statute (commonly referred to as the Stark Law): prohibits physicians from referring Medicare pa'ents for certain designated health services (DHS) to an en'ty with which the physician or member of the physician's immediate family has a financial rela=onship with the en=ty unless an excep'on applies prohibits an en'ty from presen'ng or causing to be presented a bill or claim to anyone for a DHS furnished as a result of a prohibited referral Medicare Fraud & Abuse Resource Reference

71 The Stark Law Three important ques'ons: 1. Is there a referral from a physician for a designated health service (DHS)? 2. Does the physician (or immediate family member) have a financial rela'onship with the en'ty providing the DHS? 3. Does the financial rela'onship fit an excep'on? Source: OIG

72 The Stark Law Penal=es For Self- Referral Viola'ons: Payment denial Monetary penal'es (fines) Exclusion Source: OIG

73 Stark Compliance Tips 1. Meet a Stark Law excep'on 2. Document financial rela'onships with referring physicians 3. Use systems to ensure properly structured payments 4. Avoid Lease creep problems 5. Review produc'vity bonuses 6. Gius can implicate the Stark Law also Source: OIG

74 Relevant Laws The an'- kickback statute and the physician self- referral law are two important fraud and abuse authori'es Viola'ons of these laws can result in nonpayment of claims, civil monetary penal'es, exclusion from the Medicare program, and liability for the submission of false claims to the government Viola'on of the an'- kickback statute may addi'onally result in imprisonment and criminal fines

75 Advisory Opinions In certain situa'ons, upon formal request, the HHS Office of Inspector General may issue an advisory opinion with respect to the an5- kickback statute or OIG s other fraud and abuse authori'es, and CMS may issue an advisory opinion with respect to the physician self- referral prohibi'on Advisory opinions are legal opinions issued to one or more reques'ng par'es about the applica'on to a party s exis'ng or proposed business arrangements of either the fraud and abuse provisions within the OIG s scope of authority or the physician self- referral prohibi'on within CMS scope of authority

76 Advisory Opinions A CMS or OIG advisory opinion is legally binding on HHS and the reques'ng party or par'es, but no person or en'ty can rely on an advisory opinion issued to another party A party that receives a favorable advisory opinion is protected from CMS or OIG administra've sanc'ons so long as the arrangement at issue is conducted in accordance with the facts submi\ed to the CMS or OIG Medicare Fraud & Abuse Resource Reference

77 Exclusions & Debarment Individuals or en''es that par'cipate in or bill a Federal health care program may not employ or contract with an excluded or debarred individual or en'ty No payment will be made by any Federal health care program for any items or services furnished, ordered, or prescribed, directly or indirectly, by an excluded or debarred individual or en'ty

78 Exclusions The OIG has the authority to exclude individuals and en''es from par'cipa'on in Medicare, Medicaid, and other Federal health care programs The excluded individual or en'ty cannot be paid, directly or indirectly, by the Federal health care programs, for any items or services they provide Two types: Mandatory Permissive May affect any individual or en'ty May be a defined 'me period or indefinite in length

79 Exclusions & Debarment Federal health care programs include Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan) OIG List of Excluded Individuals/En''es (LEIE): hjp://exclusions.oig.hhs.gov/search.html General Services Administra'on (GSA) database of excluded individuals/en''es: hjp://epls.arnet.gov/

80 OIG List of Excluded Individuals The HHS Office of Inspector General is responsible for excluding individuals who have par'cipated or engaged in certain impermissible, inappropriate, or illegal conduct The OIG s List of Excluded Individuals and En''es (LEIE) provides informa'on on all individuals and en''es currently excluded from par'cipa'on in the Medicare, Medicaid, and all other Federal health care programs The LEIE, along with other informa'on pertaining to OIG exclusions, can be found at: h4p://oig.hhs.gov/fraud/exclusions.html

81 GSA List of Excluded Individuals The GSA is responsible for maintaining an index of individuals and en''es that have been excluded throughout the U.S. Government from receiving Federal contracts, subcontracts, and from Federal financial and non- financial assistance and benefits GSA s Excluded Par'es List System (EPLS) can be found at: h4p://epls.arnet.gov

82 Par vs. Non- Par Par'cipa'ng or non- par'cipa'ng providers may not ask Medicare pa'ents to pay a second 'me for services which Medicare has already paid (It is legal to charge pa'ents for services that are not covered by Medicare, however charging an access fee or administra've fee that allows them to obtain services cons'tutes double billing) Par'cipa'ng Providers: May not overcharge Medicare beneficiaries Non- par'cipa'ng Providers: Bill directly to pa'ents Pa'ents reimbursed by Medicare Illegal to charge more than 15% above the Medicare rate

83 Case Examples A psychiatrist was fined $400,000 and permanently excluded from par'cipa'ng in the Federal health care programs for misrepresen'ng that he provided therapy sessions requiring 30 or 60 minutes of face- to- face 'me with the pa'ent, when he had provided only medica'on checks for 15 minutes or less. The psychiatrist also misrepresented that he provided therapy sessions when in fact a non- licensed individual conducted the sessions.

84 Case Examples A cardiologist paid the Government $435,000 and entered into a 5- year Integrity Agreement with OIG to se\le allega'ons that he knowingly submi\ed claims for consulta'on services that were not supported by pa'ent medical records and did not meet the criteria for a consulta'on. The physician also allegedly knowingly submi\ed false claims for E&M services when he had already received payment for such services in connec'on with previous claims for nuclear stress tes'ng.

85 Case Examples An endocrinologist billed rou'ne blood draws as cri'cal care blood draws. He paid $447,000 to se\le allega'ons of up- coding and other billing viola'ons. A dermatologist was sentenced to two years of proba'on and 6 months of home confinement and ordered to pay 2.9 million auer he pled guilty to one count of obstruc'on of a criminal health care fraud inves'ga'on. The dermatologist admi\ed to falsifying lab tests and backda'ng le\ers to referring physicians to substan'ate false diagnoses to make the documenta'on appear that his pa'ents had Medicare- covered condi'ons when they did not.

86 Case Examples Nine cardiologists paid the Government over $3.2 million for allegedly engaging in a kickback scheme. The cardiologists received salaries under clinical faculty services agreements with a hospital under which, the Government alleged, they did not provide some or any of the services. In exchange, the cardiologists referred their pa'ents to the hospital for cardiology services. Two of the physicians also pled guilty to criminal embezzlement charges involving the same conduct. A physician paid the Government $203,000 to se\le allega'ons that he violated the physician self- referral prohibi'on in the Stark law for rou'nely referring Medicare pa'ents to an oxygen supply company he owned.

87 ACA Compliance Plans The Affordable Care Act includes Mandatory Compliance Plans that will be coming soon CMS has not finalized these requirements and will publish proposals in the future Begin with a PROACTIVE compliance plan now

88 Compliance Program Basics 1. Have wri\en policies and procedures 2. Iden'fy compliance professionals/ resources 3. Use effec've training 4. Use effec've communica'on 5. Use internal monitoring 6. Enforce standards 7. Respond Promptly

89 OIG Recommenda=ons 1. Make compliance plans a priority now 2. Know your fraud and abuse risk areas 3. Manage your financial rela'onships 4. Just because your compe'tor is doing something doesn t mean that you can or should 5. When in doubt, ask for help

90 OIG Recommenda=ons Develop compliance plan and measure its effec'veness through benchmarks Make training a part of the job with a Compliance Officer Proac've audit: Coding, Contracts, and Care Delivered Act promptly when issues arise; take and document correc've ac'on

91 Resolu=ons OIG = Civil Monetary Penal'es law se\lement DOJ = False Claims Act se\lement No Corporate Integrity Agreement (CIA) if coopera've

92 Web Resources OIG Website OIG ListServ h\p://oig.hhs.gov/mailinglist.html CMS Website MLN Website h\p:// CMS Mailing Lists h\p:// An'- Kickback Statute h\p://oig.hhs.gov/fraud.html Physician Self- Referral Prohibi'on Statute OIG Advisory Opinions h\p://oig.hhs.gov/fraud/advisoryopinions.html CMS Advisory Opinion h\p://

93 Web Resources Con=nued Excluded Par'es List System (EPLS) h\p://epls.arnet.gov FI and Carrier Contact Informa'on h\p:// CallCenterTollNumDirectory.zip CMS Prescrip'on Drug Benefit Manual h\p:// Code of the Federal Regula'on (see CFR and CFR ) h\p:// Medicare Learning Network (MLN) Fraud & Abuse Job Aid h\p:// _Medicare_Fraud_and_Abuse_brochure.pdf

94 Summary of Fraud, Waste and Abuse You show now be able to iden'fy the following: How to iden'fy various types of health care abuse and fraud Who is responsible for comba'ng FWA How to report suspected case of heath care FWA Some of the basics on the relevant laws for FWA GET YOUR ROADMAP FROM THE OIG/HHS HERE: h\p://oig.hhs.gov/compliance/physician- educa'on/ roadmap_web_version.pdf

95 Ques=ons/Feedback

96 1. In terms of FWA (Fraud, Waste, and Abuse): a) Fraud is a larger problem than abuse b) Waste is a larger problem than fraud c) Abuse is a larger problem than waste d) All three of these carry equal concern Applying Concepts Quiz

97 Applying Concepts Quiz 1. Answer: d) All three of these carry equal concern Ra'onale: FWA as a group are highlighted as a concern for everyone in healthcare.

98 Applying Concepts Quiz 2. Examples of FWA for providers includes: a) Unbundling b) Billing for services not provided (or not documented) c) Signing up pa'ents for coverage with gius d) Answers A & B above e) All of the above

99 2. Answer: d) Answers A & B above Applying Concepts Quiz Ra'onale: In this ques'on, the op'on of signing up pa'ents with giws is a FWA example commi4ed by brokers, not providers.

100 Applying Concepts Quiz 3. A whistleblower is: a) A term for someone who ignores FWA, whistling away b) Someone who tells his or her supervisor what they know c) Someone who reports FWA to the insurance company d) Someone who reports FWA to the OIG or CMS

101 Applying Concepts Quiz 3. Answer: d) Someone who reports FWA to the OIG or CMS Ra'onale: A whistleblower is someone who reports to the federal government about poten'al FWA occurring. There is a non- retalia'on policy in most organiza'ons because it is against federal law to retaliate against someone ac'ng in the interest of the government.

102 Applying Concepts Quiz 4. Medicare beneficiaries can be found guilty of FWA. a) True b) False

103 Applying Concepts Quiz 4. Answer: a) True Ra'onale: Beneficiaries can also be guilty of FWA through avenues such as: falsely represen'ng his or her status; selling prescrip'ons; using one another s ID cards; doctor shopping; forging or altering prescrip'ons; and more.

104 Applying Concepts Quiz 5. Who may report FWA? a) Only healthcare administrators b) Only licensed healthcare providers c) Only persons in the insurance industry d) Anyone

105 Applying Concepts Quiz 5. Answer: d) Anyone Ra'onale: One of the main purposes of FWA training is to remind everyone working in the healthcare industry that anyone can and should report FWA whenever it is suspected.

106 Applying Concepts Quiz 6. The False Claims Act, passed in 1863, is s'll in use today, par'cularly as it pertains to: a) Billing the government for services not rendered b) Repor'ng providers who have billed insurances fraudulently c) Billing insurance companies for services d) Repor'ng pa'ents who have made a false claim

107 Applying Concepts Quiz 6. Answer: a) Billing the government for services not rendered Ra'onale: The False Claims Act is also known as the Lincoln Law because it was passed under the administra'on of President Lincoln in It prohibits: (1) Knowingly presen'ng, or causing to be presented a false claim for payment or approval; etc..

108 Applying Concepts Quiz 7. Under the False Claims Act, penal'es include: a) 3 'mes the amount suffered by the government b) An amount equal to the improperly billed amount c) 5,500 to 11,000 per claim d) Answers A & C above

109 Applying Concepts Quiz 7. Answer: d) Answers A & C above Ra'onale: Penal'es of the False Claims Act include 5,500 to 11,000 per claim PLUS 3 'mes the amount suffered by the federal government.

110 Applying Concepts Quiz 8. Relevant or related laws to FWA include: a) The False Claims Act b) The Stark Law c) Civil Monetary Penal'es Law d) An'- Kickback Statute e) All of the above

111 Applying Concepts Quiz 8. Answer: e) All of the above Ra'onale: There are several laws involved in FWA. The importance of recognizing there are so many laws relevant to FWA is important to understanding FWA as it is governed and applied.

112 Applying Concepts Quiz 9. An Advisory Opinion is: a) An opinion from a licensed provider on the appropriate treatment op'ons b) An opinion from the OIG on appropriate billing that pertains to everyone in the same circumstance(s) c) An opinion from the OIG on appropriate billing that pertains only to the organiza'on posing the ques'on d) An opinion from the director of CMS on appropriate billing

113 Applying Concepts Quiz 9. Answer: c) An opinion from the OIG on appropriate billing that pertains only to the organiza'on posing the ques'on Ra'onale: An Advisory Opinion may be requested from the OIG when there may be extenua'ng circumstances related to billing, payment and referral prac'ces. When the OIG makes an advisory opinion, it is only valid for the reques'ng or inquiring en'ty and cannot be applied to others.

114 Applying Concepts Quiz 10. The OIG exclusion list is: a) A list of pa'ents excluded from a service b) A list of insurance companies excluded from certain rules c) A list of providers and other healthcare members who are excluded from billing services to the government d) A list of hospitals who are excluded from performing some services

115 Applying Concepts Quiz 10. Answer: c) A list of providers and other healthcare members who are excluded from billing services to the government Ra'onale: The OIG exclusion list is a list of those who have billed fraudulently or been found guilty of unethical prac'ces and are unable to bill for services to the federal government. Placement on this list is the death of a healthcare career.

116 Disclaimer For Illustra=ve, Educa=onal and Discussion Purposes Only This program may contain references or links to statutes, regula'ons, or other policy materials. The informa'on provided is intended only to be a general summary. It is not intended to take the place of either the wri\en law or regula'ons. We encourage readers to review the specific statutes, regula'ons and other interpre've materials for a full and accurate statement of their contents.

117 Further Informa=on Material and informa=on used in this presenta=on was compiled from the Medicare Learning Network and the CMS website. For further informa=on, please contact:

118 Thank You Don t forget to complete the Ajesta=on Form (when provided)

119 Contact Brian Boyce, BSHS, CPC, CPC- I CEO, Proprietor and Managing Consultant PO Box Richmond, VA Brian@ionHealthcareLLC.com Medical Record Audit and Review - Physician Prac'ce Op'miza'on - Leadership Mentoring Healthcare Educa'on and Networking for Pa'ents and Professionals - Risk Adjustment