Effective Collaboration Between Compliance Officers and State and Federal Law Enforcement OBJECTIVES
|
|
- Lewis Greene
- 5 years ago
- Views:
Transcription
1 Effective Collaboration Between Compliance Officers and State and Federal Law Enforcement Elizabeth Lepic, Chief Counsel Illinois State Police Medicaid Fraud Control Unit Ryan Lipinski, CountyCare Compliance Officer Cook County Health & Hospitals System Kathleen McGinty, Chief Counsel & Deputy Inspector General Illinois Department of Healthcare & Family Services, Office of the Inspector General 1 OBJECTIVES 1. Learn effective strategies and best practices for collaboration between your Managed Care Compliance team, State Medicaid Inspector General s Office and State and federal law enforcement partners 2. Identify key metrics for your investigations Unit to ensure effective investigations, audits, recoupments and referrals to law enforcement 3. Discuss potential Impact of CMS Medicaid Managed Care rulemaking for Program Integrity in Managed Care 2 1
2 Collaboration Key to Successful Oversight Federal Government Federal Agencies State Law Enforcement State Agencies & MCOs Federal Law Enforcement 3 Fraud and Abuse Control Program Integrity Partners MFCU Federal HHS OIG Department of Justice FBI CMS Guidance Regulations State & Federal Law Enforcement Partners Managed Text Care Organizations Compliance and Special Investigation Units State Medicaid Department Program Integrity Units OIG 4 2
3 Constitution Legislative Executive Judicial Congress Office of the President Departments Federal Court System Department of Justice Department of Health and Human Services 13 other Departments Criminal Division Civil Division 94 US Attorneys Offices Office of Inspector General Centers for Medicare and Medicaid Services 24 other Departments 5 Federal Enforcement State Centers of Medicare and Medicaid Services United State s Attorney General s Department of Justice (DOJ) HHS Office of the Inspector General (HHS OIG) HHS OIG Investigators The Federal Bureau of Investigators (FBI) Internal Revenue Service State Attorney General State Medicaid Agency Inspector General Medicaid Fraud Control Units Local Law Enforcement Other: Federal / State Task Forces Private Insurance Investigators Managed Care Compliance Teams MCO Special Investigation Units 6 3
4 Accountability for Medicaid Expenditures State level Medicaid Criminal Fraud Prosecution Unit The MFCU conducts a Statewide program for investigating and prosecuting fraud in the administration of the Medicaid program, the provision of medical assistance, or activities of Medicaid providers. 42 U.S.C. 1396b(q); 42 C.F.R Federal & State Criminal & Civil Law Enforcement State & federal Law Enforcement Agencies US Attorneys / Attorneys General Offices represent governmental interests at the State and federal level Local Law enforcement local District Attorneys or State s Attorneys State OIG /PI MFCU MCO State Medicaid Agency State level OIG / Program Integrity Units Provider Screening & Monitoring Administrative Sanctions Liaison for Law Enforcement Coordination of investigations & referrals, payment suspensions Statewide audits & investigations Data Mining for FWA Statewide Preliminary analysis to determine the sufficiency of the complaint Peer reviews, referral for selfdisclosure, etc. State level Medicaid MCO Compliance Teams Compliance Plan Policies and Procedures that guard 42 U.S.C. against 455 fraud and abuse Compliance Officer and Compliance Committee accountable to senior management Effective Training and Education for compliance officer and employees Effective lines of communication Well publicized disciplinary guidelines Internal program integrity monitoring and auditing Prompt response to detected program integrity concerns/caps 42 CFR Effective Collaboration in Managed Care Oversight Ensure Collaboration between Law Enforcement Partners Ensure Quality FWA Reporting and Referrals Ensure Quality Investigations and Audits 8 4
5 Effective Collaboration Regular communication Regular Meetings between MCOs and Law Enforcement Monthly Ad hoc SemiAnnual Meetings Task Force Meetings 9 Monthly & Quarterly Meetings Review of MCO Program Integrity Activities & FWA work plan Review MCO investigations, data analysis, & adverse actions by MCO Opportunity for ongoing guidance Identification of high risk areas Ensure quality investigations & referrals 10 5
6 Ensure Quality & Uniform Reporting Ensure Consistent Reporting Requirements New Program Integrity Activities Adverse Actions Tips Preliminary Investigations Full Investigations/ Referrals Audits Initiated & Completed Overpayments Identified/ Recovered Outliers Lock In Program 11 Quality Referrals from MCO Identifying Information for Provider, including name, NPI and any other known ID # Contract(s) with MCO Credentialing Information Disclosure(s) Provider Education; including that specific to activity under review Fee Schedule Audits/Communication Medical records and all supporting documentation Information on Pre pay; including Reason(s), Status and History MCO Policy violation Relevant regulations and laws Provider participation history & status Records reviewed MCO Coders Report Other pertinent Information 12 6
7 Effective Program Integrity Data Analytics Data Mining Data Detection Systematic review Member Fraud: Prevention & Criminal Investigations Benefit Reviews and Analysis Qualified Staff Auditors Investigators Data Analysist Medical Coders & Healthcare Professionals Prevention: Provider Screening and Monitoring Pre-Payment Edits Pre-payment Audits Provider Fraud Investigations & recoupments Medical Reviews Medical coding 13 Effective Use of Data Double Billing Claims Processing Edits Overpayments Policy Outliers CPT Codes 7
8 Audits Purpose Criteria Scope Method 15 Fraud Analysis Unclear regulations or communication Poor communications with provider Documentation issues Services rendered lacking detail or format Regulatory requirement not essential to payment or quality of health service Authorization from Agency Broad impact Clear program violation False documentation Altered medical records Pattern of bad conduct Services not rendered Substitution of cheaper alternatives Differential billing for Medicaid Crime/ Loss Forgery Theft Drug Diversion Embezzlement Anti kickback Identity Theft False Claims 16 8
9 PROPOSED PROGRAM INTEGRITY RULES FOR MEDICAID MANAGED CARE 17 Proposed Medicaid Rules Rules Impacted: 42 CFR 431, 433, 438, 440, 457, 495 Proposed rule published June 1, 2015 Public comments due July 27, 2015 Document Citation: 80 FR Link: Comments can be found: D=CMS
10 Subjects covered by Proposed Rules: Actuarial Soundness of rates to Medicaid managed care plans Risk Sharing agreements Medical Loss Ratio Quality Improvement Strategy Network adequacy standards Accreditation Plan Payments to Providers Program Integrity 19 Provider Screening and Enrollment All providers contracted with Managed Care companies must be enrolled in Medicaid and periodically evaluated by the State State assumes responsibility for screening activities Managed care plans may still conduct their own additional level of provider screening or incorporate other screening requirements into their contracts Proposed 42 CFR (b) and (b) 20 10
11 Disclosures of Affiliations and Ownership/Interest Managed care plans and its subcontractors must disclose affiliation with debarred, suspended, or otherwise excluded individuals States must review ownership and control interest statements submitted by managed care plan and its subcontractors States must check monthly for exclusion sanctions Proposed 42 CFR (c) and (c)(1) and (2) 21 Data Submission and Verification Managed care plans to submit data to State: Encounters The basis for state certification of actuarial soundness in capitation rates Compliance with the MLR Adequate provision against risk of insolvency Compliance with availability and access of services and provider network adequacy Ownership and control Annual report of overpayment recoveries CEO or CFO must certify the accuracy and completeness and truthfulness Most rules of the information based on a reasonably diligent review Proposed 42 CFR and
12 Provider Payment Suspension Managed care plans are to suspend payments to providers for which the state determines there is a credible allegation of fraud or pending investigation (42 CFR ) Proposed 42 CFR (a)(8) 23 Recovery Overpayments If MCO recovers $ from Provider because the Provider was subsequently excluded from Medicaid or as a result of its FWA activities, the MCO may keep what it recovered. However: States are expected to take such recoveries into account in the development of future capitation rates. Requires Plans to require Providers to report overpayments and refund to Plans within 60 days of overpayments. Proposed 42 CFR (d)(1) and.608(d)2) 24 12
13 Seven elements of effective Compliance Plans Expands current requirements to make more robust: P&Ps Role of Compliance Office Requirements of the Regulatory Compliance Committee Internal Monitoring and Auditing Program SIU: coordination with State Program Integrity Unit Information exchange with State Proposed 42 CFR (a)(8) 25 Mandatory Reporting by Managed Care Plans All improper payments identified or recovered, specifying the improper payments due to potential fraud, to the State or law enforcement. Information about changes in an enrollee's circumstances that may affect the enrollee's eligibility including all of the following: Changes in the enrollee's residence or notification of an enrollee's mail that is returned as undeliverable. Changes in the enrollee's income. The death of an enrollee. Provider changes including termination of provider agreement. Direct referrals of fraud to Medicaid Fraud Control Unit Proposed 42 CFR (a)(2) 26 13
14 Medical Loss Ratio Standard Plans may include costs associated with program integrity activities (described in (a)(1) through (5), (7), (8) and (b)) in the numerator of the Medical Loss Ratio, limited to 0.5% of premium revenue. Proposed 42 CFR (a)(2) 27 Questions? 28 14
Program Integrity in Tennessee: TennCare Oversight Activities - Coordination
Program Integrity in Tennessee: TennCare Oversight Activities - Coordination D E N N I S J. G A RV E Y, J D D I R E C T O R, O F F I C E O F P RO G R A M I N T E G R I T Y B U R E AU O F T E N N C A R
More informationCMS New Mega-Regs & Program Integrity: Key Must-Know Provisions Spring Conference, Session 19 April 25, 2017
CMS New Mega-Regs & Program Integrity: Key Must-Know Provisions Spring Conference, Session 19 April 25, 2017 Selenna Moss, Chief Compliance/QM Officer Andrew Walsh, Chief Legal Officer Explore key provisions
More informationMedicare Part D: Retiree Drug Subsidy
A D V I S O R Y S E R V I C E S Medicare Part D: Retiree Drug Subsidy Programs to Control Fraud, Waste, and Abuse September, 2006 K P M G L L P Overview Summary Medicare Part D Prescription Drug Program
More informationRidgecrest Regional Hospital Compliance Manual
Printed copies are for reference only. Please refer to the electronic copy for the latest version. REVIEWED DATE: 06/02/2014 REVISED DATE: 07/02/2013 EFFECTIVE DATE: 10/17/2007 DOCUMENT OWNER: APPROVER(S):
More informationThis course is designed to provide Part B providers with an overview of the Medicare Fraud and Abuse program including:
This course is designed to provide Part B providers with an overview of the Medicare Fraud and Abuse program including: Medicare Trust Fund Defining Fraud & Abuse Examples of Fraud & Abuse Fraud & Abuse
More informationMAXIMUS Webinar Series. CMS Rule for Medicaid and CHIP Managed Care. Version
MAXIMUS Webinar Series CMS Rule for Medicaid and CHIP Managed Care What It Means for States 1 Introductions Bruce Caswell President MAXIMUS Kathleen Nolan Managing Principal HMA Cathy Kaufmann Managing
More informationRequired CMS Contract Clauses Revised 8/28/14 CMS MCM Guidance Chapter 21
Required CMS Contract Clauses Revised 8/28/14 CMS MCM Guidance Chapter 21 The following provisions are required to be incorporated into all contracts with first tier, downstream, or related entities as
More informationOffice of Inspector General. Regional Enforcement Efforts and Priorities in Florida. South Atlantic Regional Conference January 28, 2011
Office of Inspector General Regional Enforcement Efforts and Priorities in Florida Health Care Compliance Association South Atlantic Regional Conference January 28, 2011 Felicia Heimer, Esq. Office of
More informationCompliance Program. Investigation Policy. Purpose. Applicability. Policy. Unity House of Troy, Inc.
Investigations Policy Purpose To thoroughly respond to and investigate all potential compliance violations of federal, state, and local laws and regulations as well as policies and procedures as they apply
More informationALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-4 PROGRAM INTEGRITY DIVISION TABLE OF CONTENTS
ALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-4 PROGRAM INTEGRITY DIVISION TABLE OF CONTENTS 560-X-4-.01 560-X-4-.02 560-X-4-.03 560-X-4-.04 560-X-4-.05 560-X-4-.06 General Purpose Method Fraud,
More informationAMENDED ANTI-FRAUD PLAN FOR AVMED, INC. Amended November 2014
AMENDED ANTI-FRAUD PLAN FOR AVMED, INC. Amended November 2014 AvMed, Inc. hereby amends the Anti-Fraud Plan of its Special Investigations Unit ("SIU") which was created to identify, investigate, and rectify
More informationAnti-Kickback Statute and False Claims Act Enforcement
Anti-Kickback Statute and False Claims Act Enforcement Nicholas Gachassin, III, Esq. Gachassin Law Firm, LLC Nick3@gachassin.com Press Conference on Health Care Fraud and the Affordable Care Act May 13,
More informationThe Indiana Family and Social Services Administration Office of Medicaid Policy & Planning. Indiana Health Coverage Programs Program Integrity (PI)
The Indiana Family and Social Services Administration Office of Medicaid Policy & Planning Indiana Health Coverage Programs Program Integrity (PI) 2018 IHCP Provider Workshops Agenda Program Integrity
More informationContents of Presentation:
Office of the Attorney General Medicaid Fraud and Abuse Control Division Michael E. Brooks, Executive Director Medicaid Fraud and Abuse Control Division Office of the Attorney General mike.brooks@ag.ky.gov
More informationProgram Integrity: Fraud Prevention, Detection & Correction
Program Integrity: Fraud Prevention, Detection & Correction Kelly Tobin, Director, Special Investigations Amy Petschauer, Director, Compliance February 15, 2019 Who We Are 1 Disclaimer The information
More informationMMP (CalMediconnect) Community Health Group. and. First Tier, Downstream & Related Entity
MMP (CalMediconnect) Community Health Group and First Tier, Downstream & Related Entity MMP (CalMediconnect)MMP (CalMediconnect) and Part D Compliance Plan 2015 i TABLE OF CONTENTS Policy Statement 1 Purpose
More information1/29/2011. Mark G. Bodner Bureau Chief Complex Civil Enforcement Bureau Medicaid Control Unit Office of the Attorney General
Mark G. Bodner Bureau Chief Complex Civil Enforcement Bureau Medicaid Control Unit Office of the Attorney General The enactment of the Medicare and Medicaid Anti-Fraud and Abuse Amendments of 1977 authorized
More informationMedical Monitoring Program: PPACA and CMS Final Recommended Guidelines vs. Rules: New License Monthly Screening Requirements
PPACA and CMS Final Recommended Guidelines vs. Rules: New License Monthly Screening Requirements The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation
More informationMENTAL HEALTH MENTAL RETARDATION OF TARRANT COUNTY. Board Policy. Number A.3 July 31, 2001 COMPLIANCE PLAN
MENTAL HEALTH MENTAL RETARDATION OF TARRANT COUNTY Board Policy Board Policy Adopted: Number A.3 July 31, 2001 OVERVIEW COMPLIANCE PLAN As adopted by the Board of Trustees on July 31, 2001 The Board of
More informationMedicare Program Integrity: Overview and Issues
Medicare Program Integrity: Overview and Issues Marjorie Kanof, M.D. Managing Director, Health Care U.S. Government Accountability Office February 22, 2007 1 Overview Introduction to Medicare What is Program
More informationMedicaid: Auditing in the Managed Care Era. May 23, Darnell Dent
Medicaid: Auditing in the Managed Care Era May 23, 2016 Darnell Dent About FirstCare Health Plans At FirstCare, we believe that all Texans and our communities should be healthy and that health care should
More informationCMS Opens its Doors by Creating the Stark Voluntary Self-Referral Disclosure Protocol But Enter at Your Own Risk
A BNA s HEALTH LAW REPORTER! Reproduced with permission from BNA s Health Law Reporter, hlr, 10/07/2010. Copyright 2010 by The Bureau of National Affairs, Inc. (800-372-1033) http:// www.bna.com CMS Opens
More informationCOMPLIANCE AND MANDATORY DISCLOSURE OBLIGATIONS FOR GOVERNMENT CONTRACTORS
COMPLIANCE AND MANDATORY DISCLOSURE OBLIGATIONS FOR GOVERNMENT CONTRACTORS Bob Wagman Jeff Vaden May 17, 2017 WHAT WE ARE GOING TO COVER Federal Sentencing Guidelines for Organizations Background Recent
More informationCommunity Care Plan (CCP) Anti-Fraud Plan MMA
Community Care Plan (CCP) Anti-Fraud Plan MMA 2017-2018 1 Table of Contents Table of Contents 2 Introduction 3 Elements of the Anti-Fraud Plan 3 Fraud, Waste, and Abuse Definitions 3 CCP Administration
More informationPREVENTION, DETECTION, AND CORRECTION OF FRAUD, WASTE AND ABUSE
1 of 9 PREVENTION, DETECTION, AND CORRECTION OF FRAUD, WASTE AND ABUSE 1. Purpose The purpose of this policy is to articulate commitment by Kaiser Permanente Hawaii Region to control fraud, waste and abuse
More informationDepartment of Health and Human Services. Centers for Medicare & Medicaid Services. Medicaid Integrity Program
Department of Health and Human Services Centers for Medicare & Medicaid Services Medicaid Integrity Program Florida Comprehensive Program Integrity Review Final Report Reviewers: Lauren Reinertsen, Review
More informationCompliance and Fraud, Waste, and Abuse Awareness Training. First Tier, Downstream, and Related Entities
Compliance and Fraud, Waste, and Abuse Awareness Training First Tier, Downstream, and Related Entities 1 Course Outline Overview Purpose of training Effective Compliance program Definition of Fraud, Waste,
More informationHELAINE GREGORY, ESQ.
HCCA Puerto Rico Regional Annual Conference May 3, 2013 MODERATOR HELAINE GREGORY, ESQ. HCCA CONFERENCE CO-CHAIR PANEL DOROTHY DEANGELIS FTI CONSULTING MAITE MORALES MARTINEZ, ESQ., LL.M. MEDICAL CARD
More informationStark Self-Disclosure. Thomas S. Crane 1/ Mintz Levin Cohn Ferris Glovsky and Popeo, PC
Stark Self-Disclosure Thomas S. Crane 1/ Mintz Levin Cohn Ferris Glovsky and Popeo, PC A. Background 1. Stark Law The Physician Self-Referral Statute (or the Stark Law ) prohibits a physician from referring
More informationCCP Anti-Fraud Plan MMA
CCP Anti-Fraud Plan MMA 2016-2017 1 Table of Contents Table of Contents 2 Introduction 3 Elements of the Anti-Fraud Plan 3 Fraud, Waste, and Abuse Definitions 3 CCP Administration and Management 4 Role
More informationFraud, Waste and Abuse: Compliance Program. Section 4: National Provider Network Handbook
Fraud, Waste and Abuse: Compliance Program Section 4: National Provider Network Handbook December 2015 2 Our Philosophy Magellan takes provider fraud, waste and abuse We engage in considerable efforts
More informationThe Indiana Family and Social Services Administration Office of Medicaid Policy & Planning
The Indiana Family and Social Services Administration Office of Medicaid Policy & Planning Indiana Health Coverage Programs Program Integrity (PI) 2017 Annual IHCP Provider Workshops James Waddick, Jr.,
More informationWhat is the HHS OIG?
An Update on Government Enforcement Actions from the OIG HCCA - Southwest Regional Annual Conference February 21, 2014 Karen Glassman, Senior Counsel Office of Counsel to the Inspector General What is
More informationDepartment of Health and Human Services. Centers for Medicare & Medicaid Services. Medicaid Integrity Program
Department of Health and Human Services Centers for Medicare & Medicaid Services Medicaid Integrity Program West Virginia Comprehensive Program Integrity Review Final Report January 2013 Reviewers: Tonya
More informationBAY-ARENAC BEHAVIORAL HEALTH AUTHORITY POLICIES AND PROCEDURES MANUAL
Page: 1 of 10 Policy It is the policy of Bay-Arenac Behavioral Health Authority (BABHA) to conduct corporate compliance investigations when a complaint is received and/or there is reasonable cause to suspect
More informationRegulatory Compliance Policy No. COMP-RCC 4.21 Title:
I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.21 Page: 1 of 6 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)
More informationFraud, Waste and Abuse
Fraud, Waste and Abuse A Presentation for Network Providers Presented by: Pennsylvania and Northeast Presentation Topics TOPICS SLIDES Our Pledge 1 The Law 4-8 Definitions 9-12 Waste and Recovery 14-18
More informationIt s Here: The Final 60 Day Overpayment Rule
It s Here: The Final 60 Day Overpayment Rule (What it means for you and your clients) Hillary M. Stemple, Esq. Associate Arent Fox LLP Washington, DC 20006 hillary.stemple@arentfox.com December 5, 2017
More informationImproving Integrity in Nursing Centers
Improving Integrity in Nursing Centers Susan Edwards Reed Smith LLP AHCA/NCAL s General Counsel Goals of this webinar Introduce you to AHCA/NCAL s Fraud and Abuse Toolkit Provide you with a basic understanding
More informationIHCP Rendering Provider Agreement and Attestation Form
Version 6.4E, July 2017 Page 1 of 5 This agreement must be completed, signed, and returned to the IHCP for processing. By execution of this Agreement, the undersigned entity ( Provider ) requests enrollment
More informationMission Statement. Compliance & Fraud, Waste and Abuse Training for Network Providers 1/31/2019
Compliance & Fraud, Waste and Abuse Training for Network Providers Mission Statement To promote the quality of life of our communities by empowering others and working together to creatively solve unique
More informationDepartment of Health and Human Services. Centers for Medicare & Medicaid Services. Medicaid Integrity Program
Department of Health and Human Services Centers for Medicare & Medicaid Services Medicaid Integrity Program Alabama Comprehensive Program Integrity Review Final Report Reviewers: Margi Charleston, Review
More informationCorporate Legal Policy
Corporate Legal Title Number Current Effective Date Original Effective Date Replaces Cross Reference Fraud, Waste and Abuse General Information & Reporting CP.LE.SI.001.v1.5 04/20/18 03/19/04 External
More informationCurrent Payor Audit Mechanics and How to Defend Against Them. Role of Office of Inspector General in Federal Audits
Current Payor Audit Mechanics and How to Defend Against Them Stephen Bittinger Healthcare Reimbursement Attorney NEXSEN PRUET, LLC Role of Office of Inspector General in Federal Audits Most Recent OIG
More informationNATIONAL FRAUD CONTROL
2009 KAISER PERMANENTE NATIONAL FRAUD CONTROL UPDATE Over $2.2 trillion is spent on health care in the United States each year. The United States spends more than a $1,000 per capita per year 1 or close
More informationRepay Overpayments (18 USC 1347; 42 CFR et seq.)
Repay Overpayments (18 USC 1347; 42 CFR 401.301 et seq.) Repaying Overpayments If provider has received an overpayment, provider must: Return the overpayment to federal agency, state, intermediary, or
More informationANTI-FRAUD PLAN INTRODUCTION
ANTI-FRAUD PLAN INTRODUCTION We recognize the importance of preventing, detecting and investigating fraud, abuse and waste, and are committed to protecting and preserving the integrity and availability
More informationFraud, Waste and Abuse A Presentation for Network Providers
Fraud, Waste and Abuse A Presentation for Network Providers Presentation Topics TOPICS SLIDES Our Pledge 1 The Law 4-8 Definitions 9-12 Waste and Recovery 14-18 Recipient Fraud 19-25 Provider Fraud 26-28
More informationDepartment of Health and Human Services. Centers for Medicare & Medicaid Services. Medicaid Integrity Program
Department of Health and Human Services Centers for Medicare & Medicaid Services Medicaid Integrity Program Rhode Island Comprehensive Program Integrity Review Final Report Reviewers: Margi Charleston,
More informationSTRIDE sm (HMO) MEDICARE ADVANTAGE Fraud, Waste and Abuse
Fraud, Waste and Abuse Detecting and preventing fraud, waste and abuse Harvard Pilgrim is committed to detecting, mitigating and preventing fraud, waste and abuse. Providers are also responsible for exercising
More informationMedicare Parts C & D General Compliance Training
Medicare Parts C & D General Compliance Training Developed by the Centers for Medicare & Medicaid Services Issued: February, 2013 Part 2: Medicare Parts C & D Compliance Training Developed by the Centers
More informationPrescription Drug Benefit Manual
Prescription Drug Benefit Manual Chapter 9 Part D Program to Control Fraud, Waste and Abuse Last Updated Rev.1, 02-08-06 Table of Contents 10 Part D Program to Control Fraud, Waste and Abuse 10.1 Definition
More informationWhat s On Tap? Who Are the Players? 4/3/2017. Healthcare Enforcement Trends What To Do When the Government Comes Knocking?
Healthcare Enforcement Trends What To Do When the Government Comes Knocking? Holly Logan Craig Sieverding 1 What s On Tap? Enforcement landscape, generally Fraud and Abuse Update o Brief primer on major
More informationIntroduction to Provider Compliance. Dr. Melissa Berdell December 2017
Introduction to Provider Compliance Dr. Melissa Berdell December 2017 Key Terms 2 Medicare Annual FWA Training The Centers of Medicare & Medicaid Services (CMS) requires Medicare providers to complete
More informationSTATE OF NEW YORK OFFICE OF THE MEDICAID INSPECTOR GENERAL 800 North Pearl Street Albany, New York Self-Disclosure Guidance
STATE OF NEW YORK OFFICE OF THE MEDICAID INSPECTOR GENERAL 800 North Pearl Street Albany, New York 12204 Self-Disclosure Guidance March 12, 2009 Table of Contents Introduction...1 Advantages of Self-Disclosure...2
More informationA DISCUSSION WITH THE OIG
1 A DISCUSSION WITH THE OIG MICHAEL J ARMSTRONG REGIONAL INSPECTOR GENERAL FOR AUDIT SERVICES STEPHEN J CONWAY DIRECTOR, ADVANCED AUDIT TECHNIQUES ROBERT K DECONTI CHIEF, ADMINISTRATIVE & CIVIL REMEDIES
More informationFRAUD, WASTE, & ABUSE (FWA) for Brokers. revised 10/17
FRAUD, WASTE, & ABUSE (FWA) for Brokers revised 10/17 OBJECTIVES After reviewing this information, you will be able to: Understand Fraud, Waste, and Abuse (FWA) training requirements; Be familiar with
More informationRendering Provider Agreement
Rendering Provider Agreement IHCP Rendering Provider Enrollment and Profile Maintenance Packet indianamedicaid.com To enroll multiple rendering providers, complete a separate IHCP Rendering Provider Enrollment
More information3/17/2015. HCCA Compliance Institute April 19, Legal Obligations to Disclose and Refund. Background on Government Approach to Overpayments
HCCA Compliance Institute April 19, 2015 Exploring CMS s Proposed Rule on Reporting and Refunding Overpayments Gary W. Eiland, Partner King & Spalding LLP Houston, Texas Background on Government Approach
More informationHOSPITAL COMPLIANCE POTENTIAL IMPLICATION OF FRAUD AND ABUSE LAWS AND REGULATIONS FOR HOSPITALS
HOSPITAL COMPLIANCE H C C A R E G I O N A L C O N F E R E N C E A P R I L 2 8, 2 0 1 6 S A N J U A N, P U E R T O R I C O S A N C H E Z B E T A N C E S, S I F R E & M U Ñ O Z N O Y A, C S P J A I M E S
More informationCardinal McCloskey Community Services. Corporate Compliance. False Claims Act and Whistleblower Provisions
Cardinal McCloskey Community Services Corporate Compliance False Claims Act and Whistleblower Provisions Purpose: Cardinal McCloskey Community Services is committed to prompt, complete and accurate billing
More informationTop 10 Issues in APM Contract Negotiations
Legal Issues in New Contracting and Risk Sharing Models - What To Know Before You Sign Alexis Finkelberg Bortniker Foley & Lardner LLP 617-226-3177 Abortniker@foley.com June 2, 2017 Top 10 Issues in APM
More informationSANCTION SCREENING: OIG HIGH RISK PRIORITY
SANCTION SCREENING: OIG HIGH RISK PRIORITY Overview Healthcare organizations and entities have as a Condition of Participation the affirmative duty to screen all those with whom they have a business relationship
More informationNEW JERSEY DID NOT ADEQUATELY OVERSEE ITS MEDICAID NONEMERGENCY MEDICAL TRANSPORTATION BROKERAGE PROGRAM
Department of Health and Human Services OFFICE OF INSPECTOR GENERAL NEW JERSEY DID NOT ADEQUATELY OVERSEE ITS MEDICAID NONEMERGENCY MEDICAL TRANSPORTATION BROKERAGE PROGRAM Inquiries about this report
More informationLIMITED POWER OF ATTORNEY
State of Utah ) County of _Salt Lake ) LIMITED POWER OF ATTORNEY I, (print provider name), being of sound mind, willfully and voluntarily appoint the University of Utah, a body politic and corporate of
More informationU.S. v. Sulzbach: Government Theories, Potential Defenses, and Lessons Learned
U.S. v. Sulzbach: Government Theories, Potential Defenses, and Lessons Learned Presented By: David O Brien Christine Rinn Michael Paddock HOOPS 2007 - Washington, DC October 15-16 Background June 1994:
More informationAnswers to Frequently Asked Questions
Answers to Frequently Asked Questions What are the Centers for Medicare & Medicaid Services (CMS) requirements for Medicare Advantage Organizations and Part D Plan Sponsors in regard to compliance programs?
More informationMedicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training. Developed by the Centers for Medicare & Medicaid Services
Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training Developed by the Centers for Medicare & Medicaid Services Important Notice This training module consists of two parts:
More informationFAQ: Federal Regulations and Coding Compliance
Question 1: Why is coding compliance important? Answer 1: Coding compliance is part of the overall effort of medical practices to comply with regulations in the coding area. Compliant claims are an indication
More informationIssue brief: Medicaid managed care final rule
Issue brief: Medicaid managed care final rule Overview In the past decade, the Medicaid managed care landscape has changed considerably in terms of the number of beneficiaries enrolled in managed care
More informationEffective Date: 12/23/2005 Reissue Date: 6/18/2018. I. Summary of Policy
Issuing Department: Internal Audit, Compliance, and Enterprise Risk Management Prohibition Against Employing or Contracting with Ineligible Persons and Exclusion Screening Effective Date: 12/23/2005 Reissue
More informationGOALS OF THIS PRESENTATION HOW WE GOT HERE WHERE WE ARE MANDATORY COMPLIANCE REQUIREMENTS LESSONS FROM MANDATORY COMPLIANCE IN NEW YORK MY PREDICTIONS
MANDATORY COMPLIANCE: WHAT THE FUTURE LOOKS LIKE HCCA SOUTH ATLANTIC REGIONAL MEETING 1/28/11 JAMES G. SHEEHAN NEW YORK MEDICAID INSPECTOR GENERAL James.Sheehan@Omig.NY.gov GOALS OF THIS PRESENTATION HOW
More informationDepartment of Health and Human Services OFFICE OF INSPECTOR GENERAL
Department of Health and Human Services OFFICE OF INSPECTOR GENERAL RHODE ISLAND DID NOT ENSURE ITS MANAGED-CARE ORGANIZATIONS COMPLIED WITH REQUIREMENTS PROHIBITING MEDICAID PAYMENTS FOR SERVICES RELATED
More informationCompliance Program Integrity and Fraud, Waste & Abuse. Agenda
Compliance Program Integrity and Fraud, Waste & Abuse Caron Cullen, MJ, CHC, CFE compliance strategies Katherine Leff, RN, CLU, ALHC, CFE, AHFI, CHC CareSource Kelly Tobin, CFE, AHFI United Healthcare
More informationFalse Claims Act Enforcement in the Managed Care Space: Recent Trends and Proactive Compliance Tips
False Claims Act Enforcement in the Managed Care Space: Recent Trends and Proactive Compliance Tips Thomas Clarkson* U.S. Attorney s Office Southern District of Georgia Scott R. Grubman Chilivis Cochran
More informationThere is nothing wrong with change, if it is in the right direction Winston Churchil
Changes Changes 2012 2012 There is nothing wrong with change, if it is in the right direction Winston Churchill New tools provided by the Affordable Care Act are strengthening the Obama administration
More informationREPORT OF THE OFFICE OF THE INSPECTOR GENERAL
OFFICE OF THE INSPECTOR GENERAL CHICAGO HOUSING AUTHORITY REPORT OF THE OFFICE OF THE INSPECTOR GENERAL 2016 FOURTH QUARTER REPORT OCTOBER 1, 2016 THROUGH DECEMBER 31, 2016 ELISSA RHEE-LEE INSPECTOR GENERAL
More informationMedicaid Program Integrity Section is Not Cost-Effectively Identifying and Preventing Fraud, Waste, and Abuse
Medicaid Program Integrity Section is Not Cost-Effectively Identifying and Preventing Fraud, Waste, and Abuse A presentation to the Joint Legislative Program Evaluation Oversight Committee November 15,
More informationJennifer Putt, CFE Manager of Program Integrity August 12, VBH-PA Provider Self-Audit Protocol
VBH-PA Provider Self-Audit Protocol Jennifer Putt, CFE Manager of Program Integrity August 12, 2016 1 Topics for Today s Presentation Background and Requirements for Provider Self- Audits Examples of Inappropriate
More informationOVERSIGHT OF SURVEILLANCE AND UTILIZATION REVIEW SUBSYSTEM (SURS) MEDICAID PROGRAM INTEGRITY ACTIVITIES LOUISIANA DEPARTMENT OF HEALTH
OVERSIGHT OF SURVEILLANCE AND UTILIZATION REVIEW SUBSYSTEM (SURS) MEDICAID PROGRAM INTEGRITY ACTIVITIES LOUISIANA DEPARTMENT OF HEALTH PERFORMANCE AUDIT SERVICES ISSUED DECEMBER 5, 2018 LOUISIANA LEGISLATIVE
More informationRegion 10 PIHP FY Corporate Compliance Program Plan
Region 10 PIHP FY 2018 Corporate Compliance Program Plan 1 Mission The purpose of the Region 10 Corporate Compliance Program Plan is to provide quality care for all the individuals it serves by acting
More informationChapter 13 Section 2. Controls, Education, and Conflicts of Interest
Program Integrity Chapter 13 Section 2 Revision: 1.0 CONTROLS 1.1 Controls for the Prevention And Detection Of Fraudulent Or Abusive Practices The contractor shall establish procedures and utilize controls
More informationSelf-Disclosure: Why, When, Where and How
American Bar Association Washington Health Law Summit Self-Disclosure: Why, When, Where and How December 8, 2015 Margaret Hutchinson U.S. Attorney s Office for the Eastern District of Pennsylvania Kaitlyn
More informationMedicare Parts C & D Fraud, Waste, and Abuse Training
Medicare Parts C & D Fraud, Waste, and Abuse Training IMPORTANT NOTE All persons who provide health or administrative services to Medicare enrollees must satisfy FWA training requirements. This module
More informationFDR. Compliance Guide
FDR Compliance Guide Table of Contents Section I: Introduction to the FDR Compliance Guide iii Section II: SelectHealth Medicare Compliance Program 1 Section III: FDR Compliance Requirements & How to Meet
More informationFraud and Abuse Compliance for the Health IT Industry
Fraud and Abuse Compliance for the Health IT Industry Session 89, March 6, 2018 James A. Cannatti III, Senior Counselor for Health Information Technology, U.S. Department of Health and Human Services (HHS),
More informationFraud and Abuse in the Medicare Program
Fraud and Abuse in the Medicare Program 1 / March 2009 Learning Objectives Define what fraud is and identify examples of fraud. Identify proactive measures to mitigate risk to your business or organization.
More informationMedical Loss Ratio. Institute for Health Plan Counsel May 8, Presenters:
Medical Loss Ratio Institute for Health Plan Counsel May 8, 2013 Presenters: Melissa J. Hulke, CPA, ABV, CFF Navigant, Phoenix, AZ melissa.hulke@navigant.com Scott O. Jones, FSA, MAAA Milliman, Seattle,
More informationSharmin Rahman, BS Consultant, Compliance. Senior Manager, Compliance. Objectives. We the People - Government Authority
Exclusion Checks: Who? What? When? Where? How? Sharmin Rahman, BS Consultant, Compliance Karen Voiles,MBA,CHC, CHPC, CHRC Senior Manager, Compliance Objectives We the People - Government Authority Legislative
More informationCOMPLIANCE; It s Not an Option
COMPLIANCE; It s Not an Option AAPC April 17, 2013 Rose B. Moore, CPC, CPC-I, CPC-H, CPMA, CEMC, CMCO, CCP, CEC, PCS, CMC, CMOM, CMIS, CERT, CMA-ophth President/CEO Medical Consultant Concepts, LLC Copyright
More informationCompliance: Fraud and Abuse
United Behavioral Health Compliance: Fraud and Abuse Policy Identifier/Number: AD-01 Annual Review Completed Date: November 2017 Policy Category: Government - Pierce Regional Support Network Approved by:
More informationScope: Hometown Health Compliance Policies & Procedures apply to the following individuals and entities:
Category: Author: HOMETOWN HEALTH POLICY Compliance Manager of Compliance Current Version Effective Date: Page 1 of 5 05/01/18 Next Review 05/01/19 Date: Revision History: 02/28/13 04/17/15 08/19/16 04/28/17
More informationC. Enrollees: A Medicaid beneficiary who is currently enrolled in the MCCMH PIHP.
professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program. 42 CFR 455.2 B. CMS: Centers for Medicare & Medicaid
More informationMedicare Program Integrity: Activities to Protect Medicare from Payment Errors, Fraud, and Abuse
Order Code RL34217 Medicare Program Integrity: Activities to Protect Medicare from Payment Errors, Fraud, and Abuse October 24, 2007 Holly Stockdale Analyst in Medicare Domestic Social Policy Division
More informationThe Anatomy of an Investigation. AAPC Regional Conference Lisa L. Campbell, CPC, CPC-H Friday, October 8, 2010
The Anatomy of an Investigation AAPC Regional Conference Lisa L. Campbell, CPC, CPC-H Friday, October 8, 2010 1 2 Your honor, my client would like to explain the difference between a financial incentive
More informationFederal Fraud and Abuse Enforcement in the ASC Space
Federal Fraud and Abuse Enforcement in the ASC Space SCOTT R. GRUBMAN, ESQ. PARTNER CHILIVIS COCHRAN LARKINS & BEVER, LLP (ATLANTA GA) Fraud & Abuse Enforcement Landscape FBI CMS OCR MFCU DCIS DOJ HHS-OIG
More informationREIMBURSEMENT AGREEMENT FOR HOSPITAL SERVICES between OKLAHOMA HEALTH CARE AUTHORITY and
REIMBURSEMENT AGREEMENT FOR HOSPITAL SERVICES between OKLAHOMA HEALTH CARE AUTHORITY and U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OKLAHOMA CITY AREA INDIAN HEALTH SERVICE ARTICLE I. PURPOSE The purpose
More informationCMS Oversight Strategy for Part D
CMS Oversight Strategy for Part D Kimberly Brandt Director CMS Program Integrity Group Health Care Compliance Association December 8, 2008 CMS & Program Integrity Group Overview and Part D Strategy I.
More informationCompliance Program. Health First Health Plans Medicare Parts C & D Training
Compliance Program Health First Health Plans Medicare Parts C & D Training Compliance Training Objectives Meeting regulatory requirements Defining an effective compliance program Communicating the obligation
More informationStaying Compliant: A Roadmap to Self-Disclosure
12/18/2015 Staying Compliant: A Roadmap to Self-Disclosure By Linda A. Baumann and Hillary Stemple, Arent Fox LLP The new requirements for overpayment return, along with increasing enforcement, are making
More information