Fraud, Waste & Abuse

TRAINING COURSEAs of March 2015

Provided by Health Care Service Corporation & its subsidiaries

Click here to enter the course.

The Bottom Line

WHY?FRAUD WASTE & ABUSE

is this training so important

Who Am I In the Big Picture

WHO?

FRAUD WASTE & ABUSE

The Action Steps

FRAUD WASTE & ABUSE

WHAT?can I d

o to stop fraud, waste & abuse

Know the Law

FRAUD WASTE & ABUSELAW?

What do I need to know about the

FRAUD WASTE & ABUSE

The Bottom Line

Who Am I In the Big

Picture?The Action

StepsKnow the

Law

Start here

Return to this page by

clicking the Home icon

Know the Law

The Action Steps

Who Am I In the Big Picture?

The Bottom Line

THE BOTTOM LINE

Why is this training so important?

WHY?Home

Back / Forward

THE BOTTOM LINE

CMS requires training

New & Existing Employees

for

Work on a government contract

who

THE BOTTOM LINE

7 CMS Core Requirements

1. Written Policies, Procedures and Standards of Conduct

2. Compliance Officer, Compliance Committee and High Level Oversight

3. Effective Training and Education

4. Effective Lines of Communication

5. Well Publicized Disciplinary Standards

6. Effective System for Routine Monitoring and Identification of

Compliance Risks

7. Procedures and System for Prompt Response to Compliance Issues

THE BOTTOM LINE

7 CMS Core Requirements

1. Written Policies, Procedures and Standards of Conduct

2. Compliance Officer, Compliance Committee and High Level Oversight

3. Effective Training and Education

4. Effective Lines of Communication

5. Well Publicized Disciplinary Standards

6. Effective System for Routine Monitoring and Identification of

Compliance Risks

7. Procedures and System for Prompt Response to Compliance IssuesClick here to view Chapter 9Click here to view the Federal Sentencing GuidelinesClick here to view HCSC’s Compliance Program

Ms. B. Skloss

Click on the magnifying glass

Ms. B. Skloss

Every patient has the same diagnosis

Ms. B. Skloss

Billing for more than 24 hours/day

Every patient has the same diagnosis

Ms. B. Skloss

Billing for Individual, Group & Family Therapy

for most clients

Billing for more than 24 hours/day

Every patient has the same diagnosis

Ms. B. Skloss

Every patient has the same diagnosis

Billing for Individual, Group & Family Therapy

for most clients

Billing for more than 24 hours/day

Billing for in-person visits when speaking

with them on the phone

Ms. B. Skloss

Billing for Individual, Group & Family Therapy

for most clients

Billing for more than 24 hours/day

Every patient has the same diagnosis

Billing for 7 days/week even on holidays

Billing for in-person visits when speaking

with them on the phone

Ms. B. Skloss

HCSC

Ms. B. Skloss

Explanation of Benefits

FRAUD

WHO AM I IN THE BIG PICTURE?

RESPONSIBILITIES

Know and abide by terms of government contract1

2 Stay true to your company’s codeClick here to view HCSC’s Code of Conduct. Save this page to your favorites.

Cooperate fully and truthfully with government agencies3

I have been hired within

the past 90 days.

This is my annual training.

I work directly or indirectly on

a government program, such

as Medicare or Medicaid.

DIRECTLY ON GOVERNMENT

PROGRAM

INDIRECTLY

Report improper payment to government officials4

5 Comply with the laws that impact government programs

Violations regarding gifts to government employees can result in serious consequences

RESPONSIBILITIES

Avoid conflicts of interest6

GOOD FOR ME

GOOD FOR MY

COMPANY

RESPONSIBILITIES

Recognize and report fraud, waste & abuse7

How do I report fraud,

waste and abuse?

RESPONSIBILITIES

WHO AM I?

Corporate Integrity Compliance Program

HCSC/HISC/GHS

WHO AM I?

TOM LUBBENHCSC’s ChiefCompliance & Privacy Officer

Corporate Integrity Compliance Program

HCSC/HISC/GHS

WHO AM I?

TOM LUBBENHCSC’s ChiefCompliance & Privacy Officer

Corporate Integrity Compliance Program

HCSC/HISC/GHS

Government Programs

Compliance

WHO AM I?

KIM GREEN

HCSC’s Government Programs Compliance Officer

Government Programs

Compliance

Specific policies

Oversees compliance

Government contracts

WHO AM I?

HCSC/HISC/GHSPlan Sponsor

Independent Practice

Associations

Providers

Call Centers

Health Services/ Hospital Groups

Radiology Hospitals

Providers

Mental Health

Providers

Fulfillment Vendors

Field Marketing

Organization

Agents

Credentialing PBM

PharmacyQuality

Assurance Firm

Claims Processing

Firm

First Tier

Down-stream

Downstream

Monitor & Audit

Implement policies & procedures Comply with the law Set high ethical standards Report suspected FWA to the Plan Sponsor

FDR RESPONSIBILITIES Monitor and audit themselves & downstream

WHO AM I?

HCSC/HISCPlan Sponsor

Independent Practice

Associations

Providers

Call Centers

Health Services/ Hospital Groups

Radiology Hospitals

Providers

Mental Health

Providers

Fulfillment Vendors

Field Marketing

Organization

Agents

Credentialing PBM

PharmacyQuality

Assurance Firm

Claims Processing

Firm

First Tier

Down-stream

Downstream

HCSC

Detect

Report

Correct

Prevent

THE ACTION STEPS

ACTION STEPS

Detect

Fraud Waste AbuseFraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice—

(1) To defraud any health care benefit program or

(2) 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

US Code Title 18, Section 1347

ACTION STEPS

Detect

FraudFraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice—

(1) To defraud any health care benefit program or

(2) 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

US Code Title 18, Section 1347

False information is intentionally submitted to the government to get money or a benefit

ACTION STEPS

Detect

Fraud

HCSC$43,904FRAUD

FRAUD

Law Litmus Test● Click the box next to

the correct answer.Which of the following laws prohibits knowingly submitting or causing someone else to submit a claim for payment with government funds using false information or making false statements in order to get a claim paid or approved by the government?

Stark Statute

False Claims Act

HIPAANO, but we’ll talk about this later.

NO, but we’ll talk about this later.

Anti-Kickback Statute

NO, but we’ll talk about this later.

That’s right!

There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud.

There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud. Ms. Skloss was found guilty of Theft related to the false claims filed with both the Texas Medicaid Program and BCBSTX.

Damages may be triple the amount of the claim and the government may impose a civil penalty

of $5,500 - $11,000 for each false claim.

It may also carry heavy criminal penalties. If convicted, depending upon the circumstances, the individual may be fined and/or imprisoned for a number of years up to and including life. There may be additional penalties required due to state governments based on the state False Claims Acts.

PENALTIES

It’s important to note that the False Claims

Act applies if the person knew or even

should have known that the claim was false.

ACTION STEPS

Detect

Fraud Waste Abuse

Intentional Not intentional

UNNECESSARY COSTS

ACTION STEPS

Detect

Waste Abuse

• Overutilization of services

• Generally not considered to

be criminally negligent

• Misuse of resources

• Request for payment

• No legal entitlement

• Not knowingly

misrepresented facts

ACTION STEPS

Detect

Which prescription is suspicious?

NO, not this one.

ACTION STEPS

Detect

CORRECT!

It appears that the date on this prescription has been altered.

ACTION STEPS

Detect

FRAUD CLUES

• Many identical prescriptions in a short time

• Prescription does not match the beneficiary’s medical history

• Generics are being provided when prescription requires a brand

• Drugs are expired.

PRESCRIPTIONS & MEDICINE

ACTION STEPS

Detect

Which scenario is suspicious?

This is a simple case of tonsillitis. You’ll be out of the

hospital today.

All of that for

tonsillitis?

I’m going

to run a series of 12 tests:

an MRI, blood work, CAT

Scan…

NO, not this one.

ACTION STEPS

Detect

CORRECT!

All of that for

tonsillitis?

I’m going

to run a series of 12 tests:

an MRI, blood work, CAT

Scan…

Does the treatment match the diagnosis?

ACTION STEPS

Detect

FRAUD CLUES

• Bills for services not

provided

• Prescriptions for a higher

quantity than medically

necessary for the condition

PHYSICIAN

ACTION STEPS

DetectRead the sales scenarios below.

Which one is suspicious?

If you sign up

for Medicare

today and

make Dr.

Popper your

primary

physician,

you’ll get a

$100 gift card.

These are the

services you

can expect if

you sign up for

Medicare. I’ve

also provided

a list of doctors

in your area

who accept

Medicare.

NO, not this one.

ACTION STEPS

DetectCORRECT!

If you sign up

for Medicare

today and

make Dr.

Popper your

primary

physician,

you’ll get a

$100 gift card.

Offering monetary rewards to sign up for a government health plan

Law Litmus Test● Click the box next to

the correct answer.Which of the following prohibits willfully receiving or offering a bribe or rebate for referrals for services that are paid under a federal health care program?

HIPAA

Anti-Kickback Statute

ExclusionNO, but we’ll talk about this later.

NO, but we’ll talk about this later.

Stark Statute

NO, but we’ll talk about this later.

PENALTIES

THAT’S RIGHT!

These 9 cardiologists paid the government over $3.2 million to settle their case for entering into the kickback scheme with the hospital. Two of them also plead guilty to criminal embezzlement charges involving the same conduct.

Fines up to $25,000, imprisonment up to 5 years or both.

If the sales rep offering a $100 gift card for beneficiaries to join the plan with Dr. Popper is receiving money from the doctor in return for referring patients to him, he is violating the Anti-Kickback Statute. Sales agents must always be honest and truthful in presenting products as outlined in the benefit guides, without adding anything to it. This law applies to more than sales people. The real live case below involves providers.

Nine cardiologists and a local hospital entered into a kickback agreement, under which the cardiologists received payment from the hospital (even though they did not perform services for the hospital) in exchange for referring their patients to the hospital for surgery.

$100

Detect

Report

ACTION STEPS

Report

Explanation of Benefits

ACTION STEPS

Report What’s suspicious about these claims?

Multiple almost identical

One provider / Same day

Exceed normal costs

Hm…these claims are

all the same! All submitted

by XYZ Diagnostics on March

31.

ACTION STEPS

Report

HCSC CODE

“Our Company is committed to the policy

that all employees have an obligation to

report problems or concerns involving

ethical or compliance violations…without

fear of retaliation.”

Click here to view HCSC’s Code of Conduct.

ACTION STEPS

Report

Plan Sponsor

Reporting is everyone’s responsibility.

Reporting ResourcesHCSC Fraud Hotlines (24/7, anonymous)

(877) 272-9741 SID* Fraud Hotline (Producers, Vendors, Providers)(800) 543-0867 SID* Fraud Hotline (Members)(877) 211-2290 Government Programs Hotline

On-line form (anonymous)https://www.incidentform.com/BCBSFraudHotline.jsp

Report

*SID = Special Investigations Department

ACTION STEPS

Report• Talk to a Manager or Supervisor• Report through the Website or Hotline• Call the Medicare Compliance Officer

Employees of Plan SponsorHCSC/HISC

• Talk to a Manager or Supervisor• Call Your Ethics/Compliance Help Line• Report through the Sponsor

FDR Employees

• Call the Sponsor’s compliance hotline• Make a report through Sponsor’s website• Call 1-800-Medicare

Beneficiaries

LAW LITMUS TEST

Stark Statute

Click the box next to the correct answerWhich of the following is also known as

the Physician Self-Referral Law?

Exclusion

HIPAA

NO, but we’ll cover this shortly.

NO, but we’ll cover this shortly.

That’s right!

A physician is prohibited from making a referral for health services to an entity in which the physician or a relative may have an ownership or compensation interest

Up to $15,000 for each service provided. $100,000 fine for entering into an arrangement or scheme.

Medicare claims tainted by an arrangement that does not comply with

Stark are not payable.

The Stark Statute is also known as the Physician Self-Referral Law.

PENALTIES

In a recent case, a physician routinely referred his

Medicare patients to an oxygen supply company.

No problem, right? Actually, he owned the oxygen

supply company and violated the Stark Statute.

He paid the government $203,000 to settle the

allegations.

Report

Correct

ACTION STEPS

Correct

Immediate Reporting Quick Correction

KIM GREEN

HCSC’s Government Programs Compliance Officer

ACTION STEPS

CorrectWhich is the correct response?

This sounds suspicious. It

might be fraud.

This guy probably doesn’t

remember what drugs

he’s taken.

I found a drug listed

on my Explanation

of Benefits

that I was never given.

No. The member’s concern should be reported, not ignored. This is possible fraud.

ACTION STEPS

Correct CORRECT!What should she do now?

This sounds suspicious. It

might be fraud.

Call her company’s fraud hotline

Notify her supervisor

Call the member’s provider

Call the pharmacy that filled the member’s prescription

Contact her compliance officer

No, the CSR should not contact the member’s provider.

No, the CSR should not contact the member’s pharmacy.

ACTION STEPS

Correct CORRECT!

Call her company’s fraud hotline

Notify her supervisor

Contact her compliance officer

HCSC Fraud Hotlines (24/7, anonymous)(877) 272-9741 SID Fraud Hotline (Producers, Vendors, Providers)(800) 543-0867 SID Fraud Hotline (Members)(877) 211-2290 Government Programs HotlineOn-line form (anonymous)https://www.incidentform.com/BCBSFraudHotline.jsp

ACTION STEPS

CorrectWhat happens after the suspected fraud is reported?

One of our members called

to report an error on his EOB…

Correct clerical error

Assigned to an investigator

ACTION STEPS

Correct

REAL LIFE

$200,000.00

Law Litmus Test● Click the box next to

the correct answer.No federal health care program payment may be made for any item or service furnished, ordered or prescribed by an individual or entity excluded by the Office of Inspector General (OIG). These exclusions are intended to protect beneficiaries from the risk of harm by untrustworthy individuals by barring them from participation in federal health care programs.

Exclusions may apply to:

Individuals

Both

OrganizationsAlmost, but not quite

Almost, but not quite

That’s right! You can check if an individual or company is on the OIG Exclusion list or the System of Award Management (SAM) website search feature.

Remember Mr. Hammerman, the pharmacist? Blue

Cross Blue Shield of Illinois worked with the government

to help prosecute Mr. Hammerman. He’s in jail now, but

the pharmacy also paid the price and was excluded from

participating in any government program.

PENALTIES

Exclusions may apply to individuals and to

organizations. Exclusion periods vary

depending on the reason.

The Office of Inspector General’s (OIG) special Advisory Bulletin entitled, “The Effect of Exclusion From Participation in Federal Health Care Programs” is a great resource that lays out some of the details concerning exclusions. Click here to access it.

Correct

Prevent

ACTION STEPS

Prevent

Detect

Report

Correct

Monitor Audit

Prevent

ACTION STEPS

High Risk Areas

Appeals & Grievances

Sales & Marketing

Enrollment & Disenrollment

Claims Processing

Formulary Administration

Agent / Broker

Prevent

ACTION STEPS

WHAT YOU CAN DO

Verify information is true

Put policies in practice

Know the law

Check billing information

Prevent

Law Litmus Test● Click the box next to

the correct answer.The Health Insurance Portability and Accountability Act (HIPAA):

Required organization to notify individuals if there is a breach of their PHI

All of the above

Provided individuals with the right to limit access to their PHIYES, but it did more than that

YES, but it did more than that

Mandated that organizations implement safeguards to prevent unauthorized access to protected health information (PHI)

YES, but it did more than that

PHI = Protected Health

Information

THAT’S RIGHT!

Note to self:

I am part of the solution

There is no acceptable excuse for inappropriate use of, disclosure of or access to PHI.

HIPAA does all of these. While it is a crime to

knowingly obtain or disclose protected health

information (PHI) for fraudulent purposes, it is a

HIPAA violation to disclose PHI to an unintended

recipient even when there is no criminal intent

ACTION STEPS

PROTECT PHI

Prevent Know and comply with any contractual

obligations that apply

Protect all health, financial and/or employment information

Limit access, use and sharing of information to the minimum amount necessary to achieve the task

Avoid using Social Security numbers when sending information out externally unless there is a compelling business need

ACTION STEPS

REPORT

Prevent

Correspondence or a claim goes to the wrong address

A company report gets into the wrong hands

A data file is sent to the wrong email address

Examples of unauthorized disclosures

Organizations are required by the HITECH Act to notify individuals within 60 days if there is a breach of their PHI

FRAUD WASTE & ABUSE

CONSEQUENCES

• Civil Money Penalties

• Criminal Conviction / Fines

• Civil Prosecution

• Imprisonment

• Loss of Provider License

• Exclusion from Federal Health Care Programs

Reporting ResourcesHCSC Fraud Hotlines (24/7, anonymous)

(877) 272-9741 SID Fraud Hotline (Producers, Vendors, Providers)(800) 543-0867 SID Fraud Hotline (Members)(877) 211-2290 Government Programs HotlineOn-line form (anonymous)https://www.incidentform.com/BCBSFraudHotline.jsp

Visit our web site at http://hisccompliance.com/ and stay current on government programs issues. Check out Kim Green’s quarterly newsletter.

Comments or suggestions concerning training?HISCCompliance@bcbsil.com

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