medicare advantage and medicare part d required fraud, waste and abuse training 2009

Download Medicare Advantage and Medicare Part D Required Fraud, Waste and Abuse Training 2009

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Medicare Advantage and Medicare Part D Required Fraud, Waste and Abuse Training 2009 Slide 2 2 Introduction The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAO) to have policies and procedures to identify and address Fraud, Waste and Abuse (FWA) in the delivery of health care services through the Medicare Advantage benefit. CMS also requires the MAO to have a procedure in place to facilitate FWA training and education for vendors and providers. SOURCE: Prescription Drug Benefit Manual, Chapter 9 - Part D Program to Control Fraud, Waste and Abuse as well as part 42 of the Code of Federal Regulations sections 422.503 and 423.504. Slide 3 3 Our Commitment Empire Blue Cross Blue Shield (Empire) and subsidiaries, must ensure that all delegated and external entities implement fraud, waste and abuse training for all personnel who deal directly with our Medicare members or who view Protected Health Information (PHI) in any capacity. We must establish training requirements and communication to our first tier, downstream and related entities of which we have a contractual relationship. SOURCE: Federal Register Part V Department of Health and Human Services, 42 CFR 422 and 423. Slide 4 4 How Does this Effect You? As an entity that contracts with Empire, on behalf of our Medicare Advantage members, your office must meet the new education and training requirements outlined in the contract addendums sent earlier this year. Slide 5 5 Requirements In order to ensure we are in compliance with the CMS regulations, we are providing three avenues for you to fulfill the training requirements. 1. Provide your own internal FWA and compliance training, and complete the attestation form via our online attestation with United Mail. You will need to enter User ID: EmpireBCBS and Password: fwatrain 2.Take the training through LearnSomething, Inc. 3. Continue through this presentation as your FWA training, and complete the attestation form at the end of this presentation. Click Here Slide 6 6 Providing Your Own Internal FWA Training Providing your own internal FWA and compliance training will require that the training is acceptable per the regulations found in 42 CFR 422.504(b)(4)(vi)(c) and 423.504(b)(4)(vi)(c), as well as the learning objectives listed on the next page. Slide 7 7 Providing Your Own Internal FWA Training FWA Training Learning Objectives Laws and regulations including the False Claims Act, Anti- Kickback Statute and HIPAA Identify processes for reporting fraud, waste and abuse to the Medicare Advantage and Part D plan sponsors Information on protections for employees who report suspected fraud, waste and abuse Identifying fraud, waste and abuse Click Here for the Attestation Slide 8 8 LearnSomething, Inc. If your practice does not have a training program and using the Empire training is not an option for you, the National Health Care Antifraud Association (NHCAA), in conjunction with the Blue Cross and Blue Shield Association (BCBSA), has launched an online Fraud, Waste and Abuse General Compliance Training Course. Slide 9 9 LearnSomething, Inc. This course was developed in collaboration with LearnSomething, Inc., a leading producer of customized, multimedia training and learning management solutions. This online training program was specifically developed to help Medicare Advantage first tier and downstream contractors meet CMS compliance requirements. You can access the online training via the course portal at www.wellpoint.learnsomething.com. This course is reasonably priced, with volume discounts available and can be purchased through this link. www.wellpoint.learnsomething.com Slide 10 Fraud, Waste and Abuse Training Slide 11 11 Empire Blue Cross Blue Shield Fraud, Waste & Abuse Training The following slides provide learning objectives, regulations, definitions, relevant laws and examples of potential FWA and prevention plans. At the conclusion of this presentation, an authorized representative from your organization will need to complete the attestation statement. Slide 12 12 FWA Training Outline Identify Who Needs to Take the Training Identify Fraud, Waste and Abuse Who Can Commit Fraud? Laws and Prohibitions Compliance Programs Reporting Suspected Fraud & Abuse Attestation Statement Additional Sources and Finding More Information Acronyms and Glossary Slide 13 Who Needs to Take the Training? Slide 14 14 Who Needs to Take the Training? The Prescription Drug Benefit Manual, Chapter 9 states that these requirements are related to all first tier, downstream, and related entities. Slide 15 15 First Tier Entity The First Tier Entity is any party that enters into a written arrangement acceptable to CMS with a sponsor or applicant to provide administrative services or health care services for a Medicare eligible individual under Part D. First Tier Entity Examples Pharmacy Benefits Manager (PBM) Contracted hospital Clinics Physicians and non-physician practitioners SOURCE: Prescription Drug Benefit (PDB) Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse; 42 CFR 422.503 and 423.504 Slide 16 16 Downstream Entity The Downstream Entity is any party that enters into a written arrangement, acceptable to CMS, below the level of the arrangement between a sponsor and a first tier entity. These written arrangements continue down to the level of ultimate provider of both health and administrative services. Downstream Entity Examples Pharmacies Marketing firms Quality assurance companies Claims processing firms Billing agencies SOURCE: Prescription Drug Benefit (PDB) Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse; 42 CFR 422.503 and 423.504 Slide 17 17 Related Entity A Related Entity is any entity that is related to the sponsor by common ownership or control and performs some of the Sponsors management functions under contract or delegation, or furnishes services to Medicare enrollees under an oral or written agreement; or leases real property, or sells materials to the Sponsor at a cost of more than $2,500 during a contract period. SOURCE: Medicare Managed Care Manual (MCM) Chapter 11- Medicare Advantage Application Procedures and Contract Requirements Slide 18 Identifying Fraud, Waste & Abuse Slide 19 19 What is Fraud? Fraud is the intentional misrepresentation of data for financial gain. Fraud happens when an individual knows or should know that something is false and makes a knowing deception that could result in some unauthorized benefit to themselves or another person. SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN) Slide 20 20 What is Waste? Waste is the extravagant, careless or needless expenditure of healthcare benefits or services that results from deficient practices or decisions. SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN) Slide 21 21 What is Abuse? Abuse involves payment for items or services where there was no intent to deceive or misrepresent but the outcome of poor insufficient methods results in unnecessary costs to the Medicare program. Abuse may include: Billing for a non-covered service. Misusing codes on the claim. Inappropriately allocating costs on a cost report. SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN) Slide 22 Who Can Commit Fraud? Slide 23 23 Who Commits Fraud and Abuse? Many individuals and organizations can potentially commit fraud including: Beneficiaries Physicians, nurses and other healthcare providers Pharmacies Laboratories Pharmaceutical manufacturers Durable Medical Equipment (DME) Providers Hospitals Pharmacy Benefit Managers (PBMs) Employees of health plans Home Health Agencies SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN) Slide 24 24 Beneficiary Fraud Examples of fraud committed by beneficiaries of a federal program may include: Identify theft Resale of drugs on black market Falsely reporting loss or theft of drugs to receive replacements Doctor shopping SOURCE: PDM Manual Chapter 9, Part 70.1.7 Slide 25 25 Provider Fraud Fraud can be found in some day-to-day operations within any medical practice. Some forms of fraud may include: Billing for items or services not rendered or not provided as claims. Submitting claims for equipment or supplies and services that are not reasonable and necessary. Double billing resulting in duplicate payments. Unbundling. Failure to properly code using coding modifiers or up-coding the level of service provided, inappropriate use of place of service codes. Altering medical records. SOURCE: CMS Glossary; CMS Medicare Learning Network (MLN); Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals, Tenth Edition. Slide 26 26 Pharmacy Benefit Manager (PBM) Fraud Fraud committed by a PBM may include: Unlawful remuneration in order to steer a beneficiary toward a certain plan or drug, or for formulary placement. Includes unlawful remuneration from vendors beyond switching fees. Not offering a beneficiary the negotiated price of a Part D drug. SOURCE: Prescription Drug Benefit Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse Slide 27 27 Fraud Committed by Plan Sponsors and Medicare Advantage Organizations Plan Sponsors and MAOs may commit fraud by: Making payments for excluded drugs. Conducting marketing schemes. Offering beneficiaries a cash payment as an inducement to enroll. Unsolicited door-to-door marketing. Enrollment of beneficiaries without their consent. Stating that a marketing agent/broker works for or is contracted with the Social Security Administration or CMS. Misrepresenting the product being marketed as an approved Part D Plan when it actually is a Medigap policy or non-Medicare drug plan. Requiring beneficiaries to pay up front premiums. SOURCE: Prescription Drug Benefit Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse Slide 28 Laws, Statutes and Prohibitio

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