Medicare Advantage High Level Training For contractors, vendors and other non-associates with access to Premera s information or information systems An Independent Licensee of the Blue Cross Blue Shield Association 030689 (02-2015)
Premera Medicare Advantage Compliance and Preventing Fraud, Waste, and Abuse Training Introduction In this training we cover the basics of fraud, waste, and abuse (FWA), how Premera s Compliance Program works to prevent FWA, and how to report potential noncompliance. Every year millions of dollars are improperly spent because of fraud, waste, and abuse. It affects everyone, including you. This training will help you detect, correct, and prevent fraud, waste, and abuse. Everyone connected with Premera has three responsibilities: First, you are required to comply with all applicable statutory, regulatory, and other Part C or Part D requirements, including Premera s effective compliance program. Premera s Medicare Advantage product includes Part C and Part D and this information is covered in the companion training. Second, you have a duty to the Medicare Advantage Program as well as Medicare Advantage Members to report any potential violations of laws or noncompliance concerns. Third, you have a duty to follow Premera s Code of Conduct that articulates both your and the organization s commitment to standards of conduct and ethical rules of behavior. For prevention, Premera, and all groups we do business with, must have policies and procedures in place to address fraud, waste, and abuse and to ensure compliance with our Code of Conduct. This should assist you in detecting, correcting, and preventing fraud, waste, and abuse as well as in knowing the components of our Compliance Program. So do make sure you have read and are familiar with it. Note: Links to Premera Policies and Procedures and applicable laws are not available with this training. Should you wish to see a document referenced here or within the Code, please contact Compliance & Ethics (contact information available in the Audit Aid). Fraud, Waste, and Abuse Here are the definitions for Fraud, Waste, and Abuse: Criminal FRAUD is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program; or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. WASTE is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. ABUSE includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Do not be overly concerned about whether it is fraud, waste, or abuse. Just report any potential compliance concerns to our Compliance & Ethics department. They will investigate and make the proper determination. 2 P a g e
Compliance Now let s look at compliance, which is everyone s responsibility, even those that don t work with Medicare Advantage! You are expected to know and follow our Code of Conduct. Every action you take potentially affects Medicare members in the Medicare program. The impact of noncompliance and fraud, waste, and abuse may include: Delayed services Denial of Benefits Difficulty in using providers of choice Hurdles to receiving care Higher Premiums Reduced revenue Higher Insurance Copayments Fewer benefits for individuals and employers Our Premera compliance culture: Prevents noncompliance Detects noncompliance Corrects noncompliance In an effort to prevent fraud, waste, and abuse, the Centers for Medicare and Medicaid Services (CMS) requires us to implement an effective compliance program. At Premera, our compliance program does the following: Provides guidance on how to handle compliance questions and concerns. Provides guidance on how to identify and report compliance violations. Articulates and demonstrates Premera s commitment to legal and ethical conduct. These are the core requirements that create an effective compliance program: 1. Written Policies, Procedures and Standards of Conduct 2. Compliance Officer, Compliance Committee and a Governing Body 3. Effective Training and Education 4. Effective Lines of Communication 5. Enforcement of Well-Publicized Disciplinary Standards 6. Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks 7. Procedures and System for Prompt Response to Compliance Issues 8. First Tier, Downstream and Related Entity (FDR) Oversight 3 P a g e
This is what you can do to comply: Act Fairly and Honestly Read the Code of Conduct It is important that you conduct yourself in an ethical and legal manner. It s about doing the right thing! Comply with the letter and spirit of the law Adhere to high ethical standards in all that you do Report suspected violations. Everyone is required to report violations of the Code of Conduct as well as any suspected noncompliance. Some people may feel afraid to report noncompliance and fraud, waste, and abuse. If that is you, the following information may help. Premera does not tolerate retaliation against you for reporting suspected noncompliance in good faith. Employees, and those who do business with Premera, are protected from retaliation for False Claims Act complaints, as well as any other applicable antiretaliation protections or retribution against any employee, or entity that works for us, who in good faith reports suspected fraud, waste, and abuse. Premera offers reporting methods that are confidential, anonymous, and nonretaliatory. You may report potential noncompliance, and fraud, waste, and abuse, by whichever method you are most comfortable. A list of reporting options is available in the Code of Conduct and this training s companion audit aid. After noncompliance has been detected, it will be investigated immediately, and then promptly corrected. Everyone is expected to assist in the resolution of reported compliance issues, if necessary. Correcting noncompliance avoids recurrence, promotes efficiency and effective internal controls, protects enrollees, and ensures ongoing compliance with CMS requirements. Premera has disciplinary standards in place for noncompliant behavior. Those who engage in, or have knowledge of, non-compliant behavior may be subject to disciplinary action. The level of discipline is at the discretion of the Company, and may include any of the following: (1) verbal warning (2) written warning (3) suspension (4) termination (5) restitution 4 P a g e
Practice Try out some scenarios applying this information to situations. Read each scenario, and then select the best response to apply this training. The correct answers are available on Page 7. Scenario 1 You have discovered an email inbox or fax machine in your office that is not being monitored but it receives beneficiary appeals requests. You suspect that no one is processing the appeals. What should you do? A. Contact Law Enforcement B. Contact your Compliance Officer C. Contact your supervisor D. Nothing E. Wait to confirm someone is processing the appeals before taking further action Scenario 2 Your job is to submit risk diagnoses to CMS for purposes of payment. As part of this job you are to verify that the data is accurate. Your supervisor tells you to ignore the process and to adjust risk diagnosis codes for certain individuals. What should you do? A. Contact law enforcement B. Discuss concerns with your supervisor C. Do what is asked by your supervisor D. Ignore your supervisor s comments and follow the process E. Report the incident to the Compliance Officer Medicare Advantage Compliance Audit Aid You must be prepared to answer some basic questions about fraud, waste, and abuse, and our compliance program if called to do so in a Medicare Advantage Compliance audit. A Medicare Advantage Compliance Audit Aid with helpful reminders of key components of our Compliance Program is available beginning on Page 6. Download a copy to your computer now. Keep the latest version handy at your desk to report possible noncompliance and fraud, waste, and abuse, and to get answers to your questions. Conclusion You should now be able to correctly report Medicare Advantage fraud, waste, and abuse, or noncompliance, as part of our compliance program and integrity value. 5 P a g e
Premera Medicare Advantage Compliance Audit Aid Keep the latest version handy for quick access Q: Who is the Premera Compliance Officer for our Medicare Advantage program? Quentin Powers Q: How do I contact the Compliance Officer? Quentin Powers 425-918-4339 Quentin.Powers@Premera.com Q: Does the company have a compliance program for Medicare Advantage? Yes, it is overseen by the Medicare Advantage Compliance team and fulfills all CMS requirements. The Program elements are: 1. Written Policies and Procedures and Standards of Conduct 2. Compliance Officer, Compliance Committee, and Governing Body 3. Effective Training and Education 4. Effective Lines of Communication 5. Enforcement of Well-Publicized Disciplinary Standards 6. Effective System for Routine Monitoring, Auditing, and Identification of Compliance Risks 7. Procedures and Systems for Promptly Responding to Compliance Issues 8. FDR Oversight (First Tier, Downstream or Related Entity) Q: Does the compliance program address specific requirements? Yes, requirements are addressed in the Medicare Advantage Compliance program document and the Code of Conduct. These provide guidance on how to handle compliance questions and concerns, and how to identify and report compliance violations. Q: What is the definition of Fraud, Waste, and Abuse? FRAUD is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program; or to obtain, by means of false or fraudulent pretenses, any of the money or property owned by, or under the custody or control of, any health care benefit program. WASTE is the overutilization of services that result in unnecessary costs to the program through misuse of resources. ABUSE results in unnecessary costs to the program for items or services when there is not legal entitlement and where the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Q: What must I do if I think something in Medicare Advantage is out of compliance, or suspect fraud, waste, or abuse? Any knowledge or suspicion of noncompliance must be reported to the Compliance Officer or contact Compliance & Ethics. - Email: Ethics@Premera.com - Compliance & Ethics FAX: 425-918-4163 Attn: Medicare Advantage Compliance - Anti-Fraud Hotline at 1-888-848-0244 or 425-918-5500 or Ext. 8-5500 Q: What must I do if I think a Medicare Advantage claim was paid incorrectly? Any knowledge or suspicion of noncompliance must be reported to the Compliance Officer or contact Compliance & Ethics. Q: What if I m afraid of retaliation for reporting noncompliance? The Premera Non-retaliation Policy prohibits retaliation against you for reporting in good faith. You may report anonymously. - Anonymous reporting: www.listenupreports.com or EthicsLine: 1-866-398-0010. - Provide enough information so that the report can be followed up on, including names of persons involved, dates, any documents, and description of violations with all information known. Please check the system often to see if additional information is needed. 6 P a g e
Q: Where should I direct questions about Medicare Advantage sales or service? We want all our customers to have the best experience and correct information. If customers contact you about sales, you should direct their questions to our internal Individual Medicare Advantage Sales team 1-888-868-7767. Q: Where can I go to learn more? More information is available in the Premera Learning Center (PLC) and externally at the Centers for Medicare and Medicaid Services (CMS) website. Please access the Compliance & Ethics website and read the Code of Conduct. Review policies on the Corporate Policy website. Contact anyone in the Compliance & Ethics department for additional information. Practice Answers Scenario One The correct answer is to contact your Compliance Officer. Suspected or actual noncompliance should be reported immediately upon discovery. It is best to report anything that is suspected rather than wait and let the situation play out. Our Compliance Officer has properly trained individuals who can investigate the situation and then, as needed, take steps to correct the situation according to our Code of Conduct and related policies and procedures. Scenario Two The correct answer is to report the incident to your Compliance Officer. The Compliance Department is responsible for investigating and taking appropriate action. Your supervisor may NOT intimidate or take retaliatory action against you for good faith reporting concerning a potential noncompliance, fraud, waste, or abuse issue. 7 P a g e
Medicare Essentials Course Summary Medicare is a federal health insurance program for individuals: Age 65 or older Under age 65 who have certain disabilities and Anyone of any age who is diagnosed with End Stage Renal Disease, also referred to as ESRD. Medicare coverage is divided into four parts: A, B, C and D. Part A is hospital insurance issued by the federal government. Part B is voluntary insurance issued by the federal government that covers physician services, outpatient care and other services. Part C consists of plans offered by private insurers that provide higher levels of hospital, physician and other services. Part D is composed of prescription drug plans offered by Private insurers. Today Medicare covers over 52 million Americans. The program helps with the cost of healthcare but does not cover all medical expenses or the cost of most long-term care. Medicare is a federal program, so our plan has to follow strict regulations regarding fraud, waste and abuse associated with Medicare. And, compliance with relevant regulations is every associate s responsibility. The Centers for Medicare and Medicaid Services, or CMS will conduct regular audits of Premera. Any associate may be contacted by an auditor, and there are specific things you ll be expected to know. Medicare Part A is a type of hospital insurance. Individuals are automatically enrolled if they meet eligibility requirements, while others can apply when they become eligible. Part A coverage includes inpatient care in hospitals and skilled nursing facilities, but does not include long-term care or custodial care. However, if a beneficiary meets certain requirements they may be eligible for hospice or home health services. Part A coverage is funded by payroll taxes. Enrollees without a sufficient work history may pay a premium. Medicare Part B is voluntary insurance that the beneficiary pays for, though it is partially subsidized by the federal government. Part B helps with the cost of physician services, outpatient care, some preventative services, and other services not covered by Part A, including ambulance, clinical labs, durable medical equipment and some supplies. 8 P a g e
Parts A and B together are informally called traditional or original Medicare. They are issued by the federal government, and beneficiaries who enroll in Part B pay their subsidized premiums to CMS. Medicare Part C is for beneficiaries who want more complete coverage that covers more services at a higher level. CMS allows private insurers to offer additional plans, such as our new Medicare Advantage plan. To offer a Part C Medicare Advantage Plan, or MA plan, Premera contracted with CMS. CMS then pays a set amount of money to Premera for Medicare Advantage member care. And, MA members will typically pay a premium to Premera in addition to the Part B premium they pay to CMS. Member generally gets all their Medicare-covered services (Part A and B) through the MA plan, which can include other benefits such as dental, hearing, vision and even discounted health club memberships. To qualify, a beneficiary needs to: Live in the plan s geographic service area Be entitled to Part A Be enrolled in Part B and Not have ESRD when they enroll in Medicare Advantage Medicare Part D prescription drug plans are run by private insurers that contract annually with CMS. Part D is offered As stand alone coverage to beneficiaries who only have Part A and B, and As part of a Part C Medicare Advantage plan like Premera s. Part D must meet a minimum standard of coverage approved by CMS. The benefits and cost also vary from year to year. Beneficiaries must decide on this coverage annually. Since our Part D is offered together with our Part C Medicare Advantage plan, beneficiaries typically enroll during a fall open enrollment window (except when they first enroll in Medicare). Open Enrollment occurs every year between October 15 and December 7, with coverage beginning January 1. 9 P a g e
Premera s Medicare Advantage plan will be available only in King, Pierce, Snohomish, Thurston and Spokane counties: 10 P a g e