ceu fraud, waste & abuse training · 2019. 7. 8. · course objectives 1. the regulatory...
TRANSCRIPT
![Page 1: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/1.jpg)
Fraud, Waste & Abuse Training
![Page 2: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/2.jpg)
Course Objectives1. Theregulatoryrequirement
2. Thescopeoffraud,waste&abuse
3. Theobligationalresponsibilitiesofallthoseinvolved
4. Howtogoaboutreportingfraud,waste&abuse
5. Thelawssurroundingfraud,waste&abuse
6. Theconsequencesofcommittingfraud,waste&abuse
![Page 3: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/3.jpg)
Why do I have to take this course?
PertheCenterforMedicareandMedicaidServices(CMS),allpartiesinvolvedwithreceivingordeliveringCMSsanctionedservicesarerequiredtogothroughatrainingonstatute,regulationsand
policiesthatgovernallCMSprograms.
Everyyearmillionsofdollarsareimproperlyspentduetofraud,waste,andabuse.Itaffectseveryone…includingYOU.Thistrainingwillhelpyoutodetect,correct,andpreventfraud,waste,
andabuse.
Youarepartofthesolution.
![Page 4: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/4.jpg)
Where does everyone fit in?Programparticipants:
Company:Provider
Clients:Enrollee
FieldStaff:Employee
You
AsapersonwhoprovideshealthoradministrativeservicestoaPartCorPartDenrolleeyouareeithera:
•PartCorDSponsorEmployee•FirstTierEntity
Examples:PBM,aClaimsProcessingCompany,contractedSalesAgent
•DownstreamEntityExample:Pharmacy
•RelatedEntityExample:EntitythathasacommonownershiporcontrolofaPartC/DSponsor
![Page 5: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/5.jpg)
What do I have to do?v Followallappropriatestatutory,regulatory,andotherPartCorPartDrequirements,includingadoptingandimplementingyouremployer’scomplianceprogram.
v Reportanyviolationsoflawsthatyoumaybeawareof.
v FollowHHHC’sCodeofConductthatexplainsyourcommitmenttostandardsofconductandethicalrulesofbehavior.
![Page 6: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/6.jpg)
Prevention
![Page 7: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/7.jpg)
How do I prevent Fraud, Waste & Abuse?v UnderstandwhatFraud,Waste&Abuseare
v UnderstandindicatorsofFraud,Waste&Abuse
vMakesureyouareuptodatewithlaws,regulationsandpolicies
v Ensuretimecardsareaccurateandproperlydocumented
v Verifyinformationprovidedtoyou
v Beonthelookoutforsuspiciousactivity
![Page 8: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/8.jpg)
What is Criminal Fraud?Knowinglyandwillfullyexecuting,orattemptingtoexecute,aschemeorartificetodefraudany
healthcarebenefitprogram;ortoobtain,bymeansoffalseorfraudulentpretenses,representations,orpromises,anyofthemoneyorpropertyownedby,orunderthecustodyor
controlof,anyhealthcarebenefitprogram.
18UnitedStatesCode§1347
![Page 9: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/9.jpg)
What does that mean?Intentionallysubmittingfalseinformationtothegovernmentoragovernmentcontractorin
ordertogetmoneyorabenefit.
Example: Youdon’tdeliverservicestoaclient,butyouchartontoyourtimecardthatservicesweredeliveredbyyoutotheclient.
![Page 10: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/10.jpg)
What is Waste?Touse,consumeandspendunnecessarilythroughthoughtlessnessorcarelessness.
Example: Takingcompanysuppliedequipment(likegloves),whenyoustillhaveagoodsupplyonhandorusingthesuppliedequipmentcarelessly.
![Page 11: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/11.jpg)
What is Abuse?Givinginformationordocumentationregardingservicesinawaythatimproperlyusesprogramresourcesforpersonalgainorbenefit.Abusecanhappenwithnointentionaldeceptionorintentionalmisrepresentation.
Example: Notutilizingservicetimecorrectlyandreportingthatmoretimeisneededorthattimeisnotenoughtocareforaclient,whenclientisreceivingsufficienttimeneededforrequiredcares.
![Page 12: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/12.jpg)
Detection
![Page 13: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/13.jpg)
Indicators for Fraud, Waste & Abuse?ForProviders:Youshouldlookforthefollowing:v Employeeperformingunnecessarytasks
v Theemployeechartingincorrectly
v Clientand/oremployeesignaturesdonotmatchsignaturesonhand
v Employeechartingtimeswhenclientisnotavailable
v Employeechartingfortimeswhenemployeeisnotavailable
![Page 14: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/14.jpg)
Indicators for Fraud, Waste & AbuseForClients:Youshouldlookforthefollowing:v Homehealthvisitsthatyourdoctorordered,butthatyoudidn’tget.v Visitsbyhomehealthstaffthatyoudidn’trequestandthatyoudon’tneed.v Billsforservicesandequipmentyounevergot.v Fakesignatures(yoursoryourdoctor’s)onmedicalformsorequipmentorders.v Pressuretoacceptitemsandservicesthatyoudon’tneedorthatMedicaredoesn’tcover.v ItemslistedonyourMedicareSummaryNoticethatyoudon’tthinkyougotorused.v Homehealthservicesyourdoctordidn’torder.Thedoctorwhoapproveshomehealthservicesforyoushouldknowwhoyouare,andshouldbeinvolvedinyourcare.Ifyourplanofcarechanges,makesurethatyourdoctorwasinvolvedinmakingthosechanges.
v AhomehealthagencythatoffersyoufreegoodsorservicesinexchangeforyourMedicarenumber.TreatyourMedicarecardlikeacreditcardorcash.NevergiveyourMedicareorMedicaidnumbertopeoplewhotellyouaserviceisfree,andtheyneedyournumberfortheirrecords.
![Page 15: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/15.jpg)
Indicators for Fraud, Waste & Abuse
ForEmployees:Youshouldlookforthefollowing:v Clientabusingservicesprovidedtothem
v Clientmakinganyarrangementswherepaymentissharedinexchangefornodeliveryofservices.
v Clientorcompanyrequestingthatyouworkatlocationsoutsideofcareplan
v Clientorcompanyrequestingforservicesthatareoutsideofcareplan
![Page 16: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/16.jpg)
Reporting
![Page 17: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/17.jpg)
Reporting Fraud, Waste & Abuse
Donotbeconcernedaboutwhetheranactisoffraud,waste,orabuse.Itisyourresponsibilitytoreportanyconcernstoyourcomplianceofficer.Thecomplianceofficerwillinvestigateandmaketheproperdetermination.
Everyoneisrequiredtoreportsuspectedinstancesoffraud,waste,andabuse.Youremployer’sCodeofConductandEthicsshouldclearlystatethisobligation.Employersmaynotretaliateagainstyouformakingagoodfaitheffortinreporting.
![Page 18: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/18.jpg)
What do I do?Thinkcarefullyabouttheallegationandtheinformationyouhaveavailablethatcanhelpusdeterminewhethermismanagementorcriminalconducthasbeencommitted.Toprocessyourallegations,wewillneedyoutoprovideasmuchinformationaspossibleregardingthesuspectandvictim.Yourinformationshouldinclude:vWhocommittedthewrongdoing(person,companyororganization)?vWhatexactlydidtheindividualorentitydo?vWheredidtheactivitytakeplace?vWhendidithappen?vHowwastheactivitycommitted?vDoyouknowwhythepersoncommittedthewrongdoing?vWhoelsehasknowledgeofthepotentialwrongdoing?
![Page 19: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/19.jpg)
Reporting Fraud, Waste & AbuseWithoutsufficientinformationwemaybeunabletoactonyourallegation.Themoreinformationyoucanprovide,thebetterchancewehaveofdeterminingwhetherany
wrongdoinghasbeencommitted.Weareveryinterestedintheinformationyouhavetoprovideregardingwaste,fraud,abuse,mismanagementormisconduct.
Ifyouhaveanyquestionsorneedadditionalinformation,pleasecallourcomplianceofficer.
ComplianceOfficer:Shoua MouaContactNumber:651-262-5510
![Page 20: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/20.jpg)
Reporting Fraud, Waste & AbuseYoucanalsoreportanyconcernsto:
vMinnesotaDepartmentofHumanServicev ProviderFraud:651-431-2650(TollFree)800-657-3750v RecipientFraud:800-627-9977
v CentersforMedicare&MedicaidServicesv RegionalOffice:312-886-6432
v OfficeoftheAttorneyGeneralv Local:651-296-3353(TollFree)800-657-3787v 1-800-HHS-TIPS(1-800-447-8477)
![Page 21: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/21.jpg)
Laws & Regulation
![Page 22: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/22.jpg)
Civil Fraud/Civil False Claims ActProhibits:v Presentingafalseclaimforpaymentorapproval;
vMakingorusingafalserecordorstatementinsupportofafalseclaim;
v ConspiringtoviolatetheFalseClaimsAct;
v Falselycertifyingthetype/amountofpropertytobeusedbytheGovernment;
v Certifyingreceiptofpropertywithoutknowingifit’strue;
v BuyingpropertyfromanunauthorizedGovernmentofficer;and
v KnowinglyconcealingorknowinglyandimproperlyavoidingordecreasinganobligationtopaytheGovernment.
![Page 23: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/23.jpg)
Civil False Claims Act Damages and Penalties
v Thedamagesmaybetripled.CivilMoneyPenaltybetween$5,000and$10,000foreachclaim.
v Ifconvicted,theindividualshallbefined,imprisoned,orboth.Iftheviolationsresultedindeath,theindividualmaybeimprisonedforanytermofyearsorforlife,orboth.
18UnitedStatesCode§1347
![Page 24: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/24.jpg)
Anti-Kickback StatuteProhibits:v Knowinglyandwillfullysoliciting,receiving,offeringorpayingremuneration(includinganykickback,bribe,orrebate)forreferralsforservicesthatarepaidinwholeorinpartunderafederalhealthcareprogram(whichincludestheMedicareprogram).
42UnitedStatesCode§1320a-7b(b)
![Page 25: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/25.jpg)
Anti-Kickback Statute Penalties
vFineofupto$25,000,imprisonmentuptofive(5)years,orbothfineandimprisonment.
![Page 26: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/26.jpg)
Stark Statute(Physician Self-Referral Law)Prohibits:v Aphysicianfrommakingareferralforcertaindesignatedhealthservicestoanentityinwhichthephysician(oramemberofhisorherfamily)hasanownership/investmentinterestorwithwhichheorshehasacompensationarrangement(exceptionsapply).
42UnitedStatesCode§1395nn
![Page 27: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/27.jpg)
Stark Statute Damages and PenaltiesMedicareclaimstaintedbyanarrangementthatdoesnotcomplywithStarkarenotpayable.Uptoa$15,000fineforeachserviceprovided.Uptoa$100,000fineforenteringintoanarrangementorscheme.
![Page 28: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/28.jpg)
ExclusionvNoFederalhealthcareprogrampaymentmaybemadeforanyitemorservicefurnished,ordered,orprescribedbyanindividualorentityexcludedbytheOfficeofInspectorGeneral.
42U.S.C.§1395(e)(1)
42C.F.R.§1001.1901
![Page 29: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/29.jpg)
HIPAAvHealthInsurancePortabilityandAccountabilityActof1996(P.L.104-191)
vCreatedgreateraccesstohealthcareinsurance,protectionofprivacyofhealthcaredata,andpromotedstandardizationandefficiencyinthehealthcareindustry.
vSafeguardstopreventunauthorizedaccesstoprotectedhealthcareinformation.
vAsanindividualwhohasaccesstoprotectedhealthcareinformation,youareresponsibleforadheringtoHIPAA.
![Page 30: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/30.jpg)
Consequences
![Page 31: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/31.jpg)
Consequences of Committing Fraud, Waste, or Abuse
vHealthInsurancePortabilityandAccountabilityActof1996(P.L.104-191)
vCreatedgreateraccesstohealthcareinsurance,protectionofprivacyofhealthcaredata,andpromotedstandardizationandefficiencyinthehealthcareindustry.
vSafeguardstopreventunauthorizedaccesstoprotectedhealthcareinformation.
vAsanindividualwhohasaccesstoprotectedhealthcareinformation,youareresponsibleforadheringtoHIPAA.
![Page 32: CEU Fraud, Waste & Abuse Training · 2019. 7. 8. · Course Objectives 1. The regulatory requirement 2. The scope of fraud, waste & abuse 3. The obligational responsibilities of all](https://reader036.vdocuments.site/reader036/viewer/2022071416/6112d8cc5c85077125732a73/html5/thumbnails/32.jpg)
Government Resourcesv NationalBenefitIntegrityMEDIC:http://www.healthintegrity.org/html/contracts/medic/index.html
v StopMedicareFraud:http://www.stopmedicarefraud.gov
v ThePatientProtectionandAffordableCareAct:http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
v ComplianceGuidanceforMedicare+ChoiceOrganizations:http://oig.hhs.gov/fraud/docs/complianceguidance/111599.pdf
v OfficeoftheInspectorGeneral,ComplianceProgramGuidancefortheHealthcareIndustry:http://oig.hhs.gov/compliance/compliance-guidance/index.asp
v FederalSentencingGuidelines:http://www.ussc.gov/Guidelines
v FraudAlerts,BulletinsandOtherGuidancefromtheOIG:http://oig.hhs.gov/compliance/alerts/index.asp
v FalseClaimsAct:http://www.justice.gov/jmd/ls/legislative_histories/pl99-562/pl99-562.html
v HealthInsurancePortabilityandAccountabilityAct(HIPAA):http://aspe.hhs.gov/admnsimp/pl104191.htm
v Anti-KickbackStatute(seesection1128B(b)):http://www.ssa.gov/OP_Home/ssact/title11/1128B.htm#f
v StarkLaw(PhysicianSelf-Referral):https://www.cms.gov/PhysicianSelfReferral/