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© 2008 WellCare Health Plans Inc. All rights reserved.

WellCare iCare Compliance Training

on Fraud, Waste and Abuse and

HIPAA

3/8/2016

Module 2

Call us anytime with questions. Need to raise a compliance concern? Call 1-866-364-1350.

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Training Requirements

• As a Managed Care organization and covered entity, WellCare is required to

train its employees on FWA and HIPAA.

• WellCare is also required to train persons working for or on behalf of

WellCare, or validate that such persons have completed equivalent training

on FWA and HIPAA.

• This includes vendors, contractors and subcontractors.


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Objectives

• Introduce the WellCare iCare Compliance Program

• Provide an overview of key compliance topics

• Identify important Compliance phone numbers

• Identify how to raise a compliance related concern


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The WellCare Compliance Program

WellCare Health Plans, including it’s affiliates and subsidiaries (collectively

“WellCare” or the “Company”) is committed to the highest standards of

excellence and professionalism in all it’s endeavors.

WellCare provides managed care services exclusively for government-sponsored

health care programs, focusing on Medicaid and Medicare.

Because of this exclusive focus, we are highly regulated by multiple federal and

state governmental agencies as well as being subject to applicable federal and

state laws and regulations.

WellCare is committed to compliance through:

• The WellCare Code of Conduct and Business Ethics (“the Code of Conduct” or

“the Code”), which outlines our ethical principles.

• WellCare policies and procedures, which clarify the Code and ensure proper

operations of our company.

• The iCare Compliance Program (the “Compliance Program”), designed to

prevent and address violations.


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The WellCare Compliance Program (cont’d)

All associates, including temporary and contracted associates (“workforce

members”), are expected to know and comply with WellCare’s compliance

program, the Code of Conduct, WellCare policies and procedures (either

referenced in this training or those that apply to your role), as well as the spirit

and letter of all laws and regulations.

Any workforce member who violates these expectations is subject to

disciplinary action, up to and including termination of employment or

contract, and referral for criminal prosecution.

Please take a moment and review the WellCare Code of Conduct. A copy is

available by clicking “attachment” in the top right of this screen. The Code

of Conduct can also be found on WellCare Link and on WellCare.com.

http://wellcareportal.wellcare.com/Pages/default.aspx

https://www.wellcare.com/


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Key Compliance Topics

Workplace Environment

• WellCare is committed to providing a healthy, productive and safe place to

work. Workforce members are expected to adhere to security requirements

when entering a WellCare facility or on company premises (e.g. security

badges, keypad or door locks etc.).

• WellCare is committed to providing a workplace free from harassment or

discrimination. Workforce members are expected to treat all workforce

members, vendors, business partners, etc. with respect and dignity as defined

in the Code of Conduct.

• Hiring and promotion decisions are based on merit, skills, experience,

leadership, and other job-related factors. Not on ethnicity, religion, gender or

sexual preference.

• Workforce members have an affirmative responsibility to report any incidences

of harassment or discrimination.


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Key Compliance Topics (cont’d)

WellCare Assets

• WellCare’s computer systems are for business purposes.

– Work conducted on these systems, including email and internet usage, are

the property of WellCare.

– WellCare can review, monitor and record this information without prior

notice.

• Other WellCare assets include member lists, financial transactions and

documents.

– All workforce members are required to protect WellCare assets.


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Improper Payments (“Kickbacks”)

• The knowing and willful offer, payment, solicitation or receipt of any

“remuneration” to induce referrals or order or recommend items or services,

which may be paid for under a federal health care program is prohibited.

Business Courtesies, Gifts and Entertainment

• Workforce members must abide by the Code of Conduct as it relates to

Business Courtesies, Gifts or Entertainment offered to or accepted from

current or prospective members, agents, vendors or suppliers. Ineligible Persons

• WellCare is prohibited from hiring or entering into contracts with individuals or

entities who are ineligible to participate in federal and/or state healthcare

programs.


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Health Insurance Portability and Accountability Act (HIPAA)

• A federal law that protects the privacy of individually identifiable member

information, provides for the electronic and physical security of member

medical information, and simplifies billing and other electronic transactions

through the use of standard transactions and code sets (billing codes).

• All Health Care Providers have an obligation to protect the privacy and

security of Protected Health Information (PHI).

Fraud Waste and Abuse (FWA)

• All Health Care Providers must have a plan to detect, correct and prevent

fraud, waste and abuse.

• All WellCare workforce members have a duty to prevent healthcare fraud and

report suspected fraud, waste or abuse.


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Protected Health Information (PHI) and Personally Identifiable

Information (PII)

What is PHI?

PHI is Protected Health Information. It is any information about health

status, provision of health care or payment for health care that can be

linked to an individual.

– Examples include name, address, Social Security number, member ID

number, e-mail address, etc.

– This includes any part of a member’s medical record or payment

history.

– Communication of PHI comes in the following forms; written,

electronic, and verbal.

What is PII?

PII is Personally Identifiable Information. It is any information that permits

the identity of an individual to be directly or indirectly inferred, including

any information that is linked or linkable to that individual.


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Protected Health Information (PHI) and Personally

Identifiable Information (PII) cont. What is Sensitive PII?

• Sensitive PII, if lost, compromised, or disclosed without authorization, could result in substantial

harm, embarrassment, inconvenience, or unfairness to an individual.

• Sensitive PII requires stricter handling guidelines because of the increased risk to an individual if

the data is compromised. Some categories of PII are sensitive as stand alone data elements.

Social Security

Number

Drivers License

Number

Passport Number Financial Account

Number

Biometric

Identifiers

State Identification

Number

Alien Registration

Number

Sensitive PII if Stand Alone

Sensitive PII if Included with Another Identifier

Citizenship or

Immigration Status

Medical Information Ethnic or Religious

Affiliation

Mother’s Maiden

Name

Account

Passwords

Last 4 digits of Social

Security Number

Date of Birth Sexual Orientation


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Safeguarding & Securing PHI & PII

Safeguarding and Securing PHI and PII

– Shred with the appropriate means when PHI & PII is no longer needed.

– PHI & PII should be secured at all times.

– Take extra precautions to safeguard and secure PHI & PII when transporting.

– Do not leave PHI & PII in an unattended vehicle.

– Unsecured & unauthorized access of PHI & PII can lead to a potential breach.

– A breach is the impermissible use or disclosure of PHI & PII that compromises

the privacy and security of PHI and PII.

The Minimum Necessary Rule

– The Minimum Necessary Rule within the Privacy Rule requires that any

request or distribution of PHI occurs with only the minimum amount of PHI

required to complete the intended task. This includes email or physical

distribution.


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Reporting a Compliance Concern

We all have a duty to report a HIPAA violation or breach. You can do so

by:

– Calling anonymously to the WellCare Compliance Hot Line at (866)

364-1350

OR

– Contacting the Information Security and Privacy Office with questions

or concerns at [email protected]


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How Common is Health Care Fraud?

• The United States Department of Health and Human Services-Office of

Inspector General (HHS-OIG) conservatively estimates that $100 Billion is

lost to healthcare fraud each year.

– That is $273 Million a day… and with healthcare costs escalating this

number is expected to rise.

• Fraud can be committed by any person or entity in the healthcare delivery

chain.


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How Do I Prevent Fraud, Waste, and Abuse?

• Make sure you are up to date with laws and regulations applicable to your role

• Make sure you are familiar with WellCare’s Policies and Procedures

• Ensure data/billing is both accurate and timely

• Verify information provided to you

• Be on the lookout for suspicious activity

• Understand the difference between Fraud, Waste and Abuse


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How Do I Know What is Fraud, Waste, and Abuse?

• “Fraud” is an intentional deception or misrepresentation made by someone

with knowledge that the deception will result in benefit or financial gain.

• There can be several different types of Fraud including:

‒ Provider Fraud

‒ Member and Agent Fraud

‒ Health Plan Fraud

‒ Associate Fraud

• “Abuse” is a practice that is inconsistent with accepted business or medical

practices or standards and that results in unnecessary cost.

• “Waste” includes any practice that results in an unnecessary use or

consumption of financial or medical resource.

The next few slides provide examples of the different types of Fraud, Waste and

Abuse that could be encountered to help you understand what to look for.


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Provider Fraud Examples

Billing for services not rendered

• Billing for individual therapy, where only group therapy was performed.

• Billing for Durable Medical Equipment (DME) supplies never delivered.

• “Phantom” provider obtains Medicaid ID number, and bills for supplies or

services never rendered.

• Billing for appointments the patient failed to keep.

• Billing for a “gang visit” whereby a physician visits a nursing home and

bills for seeing 20 patients without providing any specific service to any of

them, merely signing the chart.

Kickbacks

• Pay for the referral of patients in exchange for the ordering of diagnostic

tests or other services or medical equipment.


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More Provider Fraud Examples

Rendering and billing for non-medically necessary services

• Performing Magnetic Resonance Imaging with contrast although the

contrast was not indicated or necessary.

• Ordering higher-reimbursed, complete blood lab tests for every patient

although specific or targeted tests are indicated.

Upcoding - Billing a higher level service than provided

• Reporting CPT code 99245 (High Level Office Consultation) where

services provided only warranted use of CPT code 99243 (Mid level

Office Consultation).

• Reporting CPT code 99233 (High Level Subsequent Hospital Care)

where services provided only warranted use of CPT code 99231 (Lower

Level Subsequent Hospital Care.


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More Provider Fraud Examples (cont’d)

Unbundling - The separate pricing of goods and services to increase revenue

• Billing separately for a post-operative visit when it is included in a global billing code.

• Billing a series of tests individually instead of billing a global or “panel” code.

Provider Prescription Drug Fraud

• Overprescribing opioids and high cost drugs which are in turn sold on the street with the provider getting a cut (also known as “pill mills”) or result in harm to a patient.

• Dilution or illegal importation of drugs from other countries; example high cost cancer treatment drugs.

• Falsifying information in order to justify coverage, such as ruling out lower cost generics.


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Pharmacy Fraud

• Pharmacy increases the number of refills on a prescription without the prescriber’s permission.

• Pharmacy shorting - providing less medication than ordered and billed.

• Pharmacy dispenses expired drugs or adulterated drugs.

• Processing for services that are not covered under the WellCare Over-the-Counter (OTC) benefit.

• Splitting prescriptions, such as splitting a 30-day prescription into four 7-day prescriptions to get additional copays and dispensing fees.

• Billing for prescriptions that are never picked up.

• Re-dispensing unused medications that have been returned or not picked up.


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Overbilling or Duplicate Billing

• Billing a patient more than the co-pay amount for services that

were prepaid or paid in full by the benefit plan under the terms of a

managed care contract.

• Waiving patient co-pays or deductibles and overbilling the

insurance carrier or benefit plan.

• Billing Medicare or Medicaid and the patient or private insurance

for the same service.

• Provider bills in error and receives payment, then they decide to

continue to submit their claims the same way because it paid them

an additional amount they had not been receiving previously.


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Billing for Non-Covered Services

• Billing for non-covered services as covered services (e.g., billing a rhinoplasty as deviated-septum repair).

Fraudulently Justifying Payment

• Misrepresenting a diagnosis in order to justify payment.

• Falsifying documents such as certificates of medical necessity,

plans of treatment and medical records to justify payment.


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Member and Agent Fraud Examples

Member Fraud

Misrepresenting personal information by:

• Sharing a beneficiary ID card.

• Falsifying identity, eligibility, or medical condition in order to illegally

receive a drug benefit.

• Member steals prescription pads from her doctor and forges the

provider’s signature.

• Member falsely reports the loss or theft of drugs to obtain prescriptions

for narcotics.

• Member obtains and stores large quantities of drugs to avoid paying out

of pocket costs and ensure access to the drugs during periods of non-

coverage (i.e., purchasing large amounts of drugs and then disenrolling

from the plan).


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More Member and Agent Fraud Examples

Doctor Shopping

• A beneficiary consults a number of doctors for the purpose of obtaining

multiple prescriptions for narcotics or other prescription drugs. Doctor

shopping might be indicative of an underlying scheme, such as stockpiling

or resale on the black market/street.

Theft of ID/Services

• An unauthorized individual uses a member’s Medicare/Medicaid card to

receive medical care, supplies, pharmacy scripts, or equipment; often a

family member or acquaintance.


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More Member and Agent Fraud Examples (cont’d)

Agent Fraud

Falsification of Documentation/Forgery

• An agent forging a person’s signature on an application.

Misrepresentation of Benefits

• An agent misrepresenting benefits to persuade an individual to join a

health plan.


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Health Plan and Provider Fraud Examples

Encounter Data Falsification

• Health plans knowingly submitting falsified claims encounter data to gain a higher Healthcare Effectiveness Data and Information Set (HEDIS) score.

Underutilization

• Providers or health plans deliberately and systematically deterring members from receiving medically necessary services in order to maximize service funds or capitation revenue.

Quality Access

• Falsification of network adequacy reporting in order obtain government contracts.


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Health Plan and Provider Fraud Examples (cont’d)

Inappropriate Enrollment/Disenrollment

• Health plan improperly reporting enrollment and disenrollment data to CMS to inflate prospective payments.

• Online enrollment requests received in the last days of a month, followed by submission of high-cost claims such as infusion therapy claims, in the initial days of the following month.

• Outbound enrollment verification calls identifying that the beneficiary’s telephone number is an automated voicemail box that has not been set up.

• Enrollment requests for beneficiaries deceased prior to enrollment date.


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Associate Fraud Examples

• Creating a fictitious provider in the system, and submitting claims that result in

checks going back to the associate’s business or designated address, (i.e., to

a “dummy” corporation).

• Selling or exchanging member information to sales agents with other plans.

• Receiving a kickback or commission from an outside individual or entity in

return for approving claims that should have been denied.

• Falsifying enrollee signatures on any type of document.

• Providing WellCare computer system log-in credentials to other employees or

non-employees for purposes of allowing others to access member information.

• Falsely inflating production-related statistics in order to meet personal or

corporate goals.

• Intentionally providing or concealing inaccurate data in a report to a

government agency.


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More Associate Fraud Examples

• Receiving a kickback or commission from an outside individual or entity in

return for approving claims that should have been denied.

• Deliberately and falsely altering the information on a provider ‘s credentialing

application (e.g., altering the date of a provider credentialing application) to

ensure they are credentialed by the Company.


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Examples of Abuse

“Abuse” can include a range of improper behaviors or billing practices. For

example:

• Billing for a non-covered service.

• Misusing codes on the claim.

(i.e., the way the service is coded on the claim does not comply with national

or local guidelines or is not billed as rendered)

• Inappropriately allocating costs on a cost report.


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Difference Between Fraud and Abuse

Both fraud and abuse are prohibited. The key difference between fraud and abuse is that there is a higher standard for fraud than for abuse: you needintent (knowledge or willfulness) to commit fraud.

Examples of Fraud and Abuse include:

Fraud: The provider knew that service was non-covered, but changed the ICD-9 diagnosis to obtain coverage.

Abuse: Provider suspected that service might not be covered, but figured that she would “test” and submit a claim anyway.

Fraud: Provider sat down with billing policies and deliberately figured out “loop-holes.

Abuse: Provider assumed that must be billing correctly as long as claims paid.

Fraud: Hospital personnel deliberately misclassified expense items.

Abuse: Hospital construed regulatory ambiguities guided solely by financial benefit to hospital.


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Abuse Example

Due to poor training, a doctor’s office staff bills all office visits under a single

Current Procedural Terminology (CPT) code (e.g., 99214) for every service,

regardless of complexity or duration. The office staff did not intend to commit

fraud and overcharge and undercharge for the services the doctor provided, but

the doctor ultimately received more reimbursement than she should have

received.


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Waste Example

In a hospital setting, a patient needs 375 ml of medication. The pharmaceutical

company does not make a 375 ml bottle but only 500 ml or 1000 ml bottles.

Once the bottle is opened, the unused portion must be disposed of, i.e., “wasted.”

Even greater waste would occur if the hospital consistently orders and uses the

1000 ml bottle when the 500 ml bottle is available.

(Fraud may be occurring if the hospital’s choice to purchase 1000 ml bottles is

influenced, for example, by favorable manufacturer rebates tied to 1000 ml

bottles.)


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FWA Red Flags

• Medical claims that duplicate or unbundle procedures to maximize payment.

• Dates of service not recorded in medical records or that do not match bill

dates.

• Different names or addresses of dependents and primary covered person.

• Duplicate requests for authorization of a service that has been denied.

• Changing documentation during the appeals and grievance process to

overturn a denied authorization.

• Multiple claims submitted on different dates for the same member, each

showing same dates of services or overlapping dates of service.

• Members continually switching Primary Care Providers in order to obtain drug

prescriptions from each.

• Significant “spike” in provider’s claims activity or reimbursement in comparison

to provider’s historical activity.


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Individual Responsibilities

WellCare’s policies and procedures provide you with a road map of appropriate

health plan conduct.

Familiarize yourself with these policies and procedures and follow them.

If, in the course of your work, you come across situations that do not make sense

and you feel might involve fraud, waste or abuse, you can do any and all of the

following:

• Discuss the situation with your supervisor;

• Report the situation to WellCare’s iCare Hotline at 1-866-364-1350 if the

situation involves conduct by WellCare or its associates;

• Report the situation directly to WellCare’s Compliance or Legal

Department personnel.

If you suspect that a provider may be committing fraud, report your suspicion to

WellCare’s Fraud Hotline at 1-866-678-8355.


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WellCare’s Responsibility

Through its Corporate Compliance Program, WellCare investigates suspected

fraud, waste or abuse, and, as appropriate, reports and cooperates with both

federal and state agencies, including law enforcement, CMS and Medicare Drug

Integrity Contractors.

WellCare’s Special Investigations Unit (SIU) investigates and resolves cases

involving potential fraud where WellCare is the potential victim.

The SIU comprises claims specialists, investigators, clinical personnel,

regulatory experts and data analysts who focus on detecting, investigating

and resolving cases of FWA.

To ensure compliance and to deter and detect fraud, waste and abuse, WellCare

conducts regular and periodic compliance audits performed by both internal and

external auditors and staff who have expertise in federal and state health care

laws and regulations.


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What’s the Difference Between the iCare Hotline

and the Fraud Hotline?

iCare Hotline (phone or web, located on WellCare link): if you suspect inappropriate conduct within WellCare, you should report it to the iCare Hotline (1-866-364-1350). You may choose to remain anonymous. The iCare Hotline portal is maintained by a third party and is designed to allow a reporter to maintain his or her anonymity throughout the course of an investigation. Calls to the iCare Hotline are handled internally by a small number of designated compliance staff.

Fraud Hotline: if you suspect that a provider or member may be committing fraud against WellCare, you should report it to the Special Investigation Unit’s Fraud Hotline (1-866-678-8355) or refer to one of the referral mailboxes RXFRAUD, SIU and/or iCare.

WellCare supports a strong Non-Retaliation Policy and

does not tolerate retaliation against anyone who, in

good faith, reports possible or actual misconduct.

http://wellcareportal.wellcare.com/Pages/default.aspx


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Real Life Examples

• In New Jersey, a podiatrist was sentenced to 24 months in prison and ordered

to pay $350,000 in restitution for his guilty plea to health care fraud. An

investigation revealed that the podiatrist performed routine foot care on

residents in community rooms of low-income buildings, then billed the Medicare

program as if he performed more complex procedures. In fact, residents were

only getting their nails clipped.

• In Georgia, a respiratory therapist was sentenced to 5 years in prison and

ordered to pay $2.7 million in restitution for conspiracy to commit health care

fraud. The respiratory therapist, who worked in a hospital, provided false blood

test results for patients so a Durable Medical Equipment provider could in turn

bill Medicare and Medicaid for unnecessary oxygen treatments.


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Potential False Claims Violations

• Misrepresentation of information presented in reports to Medicare or Medicaid

– Pharmaceutical industry paid substantial sums to settle False Claims Act

(FCA) cases based on prices reported to the Red Book and First Data Bank

which did not reflect discounts the companies routinely gave customers.

• Misrepresentation of claims or eligibility data reported to Medicare or Medicaid

– Humana paid $14.5 million to settle allegations that it incorrectly claimed

members as dually eligible for both Medicare and Medicaid, and entered

into a broad five-year corporate integrity agreement with the OIG.


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Potential False Claims Violations (cont’d)

Calculation/reporting to Medicare/Medicaid of utilization or costs not supported by

applicable law or regulations.

Interpretations which produce greater revenue to plan at greater cost to

government programs likely to be suspect.

Providing full disclosure, and in some instances obtaining prior approval, is

important to defending such interpretations.

– Columbia/HCA pled guilty to an FCA violation and paid a substantial sum to

settle allegations involving aggressive positions taken on its hospital cost

reports.

Failing promptly to return known or identified overpayments made by the

government or government intermediaries can trigger FCA liability.


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Background Checks

As part of our hiring or placement process, WellCare performs background

checks and screens against certain government exclusion lists on all new

associates upon hire and then on a monthly basis.

As part of the temporary employment placement process, similar background

checks and screening against these same exclusion lists are coordinated.

These checks are important for many reasons, including that the Company may

be sanctioned for employing or contracting with individuals who have certain

types of criminal convictions or who have been excluded from participating in

Federal or State health care programs.

If an individual is found on any of these lists, he or she will be subject to

immediate termination from employment.


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Fair Enforcement

WellCare is committed to complying with federal and

state laws.

In cases where laws, regulations, or WellCare’s Code of

Conduct is violated, corrective or disciplinary action will

be based upon a consideration of the facts and

circumstances and other factors, applied to all, without

regard to title or level of responsibility within the

organization.


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Reporting a Suspected Incident

All WellCare workforce members, in good faith, are required to report suspected violations or conduct that appears to be fraudulent or in conflict with the principles of the Compliance Program.

• Reports may be verbal or in writing to:

‒ Supervisor

‒ iCare Hotline (1-866-364-1350) or iCare Web Portal

‒ Regional Compliance or Regulatory Affairs Staff

‒ Chief Auditor

‒ Compliance Liaisons

‒ Corporate Compliance Department

‒ Chief Compliance Officer

• All reports will remain confidential as outlined in the Compliance

Program.

• No adverse or retaliatory actions may lawfully be taken against anyone who reports an issue in good faith.


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Duty to Raise Compliance Concerns

Workforce members are WellCare’s first line of defense in detecting and

preventing violations and all workforce members are obligated to report actual or

suspected violations.

• Failure to report misconduct may disqualify workforce members from eligibility

for raises or bonuses or other disciplinary action, up to and including

termination.

• Always seek advice when you are not sure about the right ethical or legal thing

to do at WellCare. Do not guess whether a particular action is permitted.

• WellCare absolutely prohibits retaliation against any workforce member

who raises a compliance concern in good faith.

‒ Retaliation towards a workforce member who raises a compliance concern

in good faith is subject to disciplinary action, up to and including

termination.

‒ If you believe someone has retaliated against you for raising a compliance

concern, call the Compliance Hotline immediately.


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Prohibition on Bribes, Kickbacks and Illegal Inducements

• The Federal Anti-Kickback statute (AKS) is designed to protect patients and

Federal health care programs (such as Medicare and Medicaid) from fraud

and abuse.

• It is a felony to knowingly and willfully solicit, receive, offer or pay anything of

value (also called “remuneration”) in return for:

- Patient referrals, or

- Recommendations or orders for any item or service reimbursed by a

Federal health care program.

• Compliance with this law is of the utmost importance because you no longer

need intent or knowledge to commit a violation of the statute.


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(cont’d)

• Actions that may violate this law include the receipt or offering of gifts or

entertainment, forgiveness of debts, sales of items at less than fair market

value, and payment for services that exceeds fair market value.

- REMINDER – providing gifts or cash incentives to WellCare

members or physicians in exchange for enrollment or accepting

payments from drug or device manufacturers for coverage of their

products is prohibited.

• There are some exceptions to the federal AKS, but given that several states

have enacted anti-kickback laws that may be more restrictive than the federal

AKS, please contact the Compliance or Legal Departments if you are asked to

give or receive certain items referred to above.


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Penalties:

Medicare Advantage Organization (MAO) – Prescription Drug Benefit (PDP)

enrollment freeze and sanctions under CMS authority up to $25,000 per

beneficiary impacted by an anti-kickback violation.

Providers: up to five years in prison and fine up to $25,000.

• If a patient suffers bodily injury as a result of any kickback schemes, such as

unnecessary procedures, the prison sentence may be 20 plus years.

The Beneficiary Inducement Statute prohibits certain inducements to Medicare

beneficiaries. i.e. waives the coinsurance and deductible amounts after

determining in good faith that the individual is in financial need; or fails to collect

coinsurance or deductible amounts after making reasonable collection efforts.


(cont’d)


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Physician Self-Referral – “Stark Law”

The Stark Law is related to, but not the same as, the Federal Anti-Kickback

Statute.

The Stark Law:

• Prohibits a physician from making referrals for certain designated health

services payable by Medicare and Medicaid to an entity with which he or she

(or an immediate family member) has a financial relationship (ownership,

investment, or compensation), unless an exception applies.

• Prohibits the entity from presenting or causing to be presented claims to

Medicare and/or Medicaid (or billing another individual, entity, or third party

payer) for those referred services.

• Establishes a number of specific exceptions and grants the Secretary the

authority to create regulatory exceptions for financial relationships that do not

pose a risk of program or patient abuse.


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Physician Self-Referral – “Stark Law” (cont’d)

Penalties:

• Civil monetary penalties of potentially $15,000 for each service.

• Civil assessment up to treble the amount claimed.

• Overpayment refund obligation.

• False claims liability.

• Program exclusion for knowing violations.


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Government Reimbursement and the False Claims Act

The Federal False Claims Act (FCA) is a general fraud statute that aids the

federal government in recovering losses it suffers due to fraud in Federal health

care programs.

• The FCA enables private “whistleblowers” to bring suits on behalf of the

government for a portion of the fraud recovery.

• The law has been expanded in recent years to:

- Encompass so-called “reverse false claims” (i.e., failures to return

overpayments).

- Require any overpayments to be reported and returned within 60 days

from identification.

• Associates involved with submitting claims or making payments to Federal

health care programs will receive additional training on the False Claims Act.


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(cont’d)

In general, part of the statute refers to any entity knowingly presenting, or causing

to be presented, a false claim for payment or approval or causing to be made or

used, a false record or statement material to a false or fraudulent claim.

The Office of Inspector General (OIG), in consultation with the Attorney General

determines whether states have false claims acts that qualify for an incentive

under Section 1909 of the Social Security Act. Those states deemed to have

qualifying laws, receive a ten (10) percentage-point increase in their share of any

amounts recovered under such laws. The OIG guidelines for evaluating states’

FCAs were updated and became effective March 15, 2013.


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“Knowingly” can be:

• Actual knowledge.

• “Deliberate ignorance”.

• “Reckless disregard”.

• But not “mere negligence”.


(cont’d)


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In recent years, the FCA was expanded explicitly to reach reverse false claims in cases of failure to repay overpayments.

• A reverse false claim is when you receive money that you should not, and say nothing or conceal that an amount is owed.

• The Patient Protection and Affordable Care Act (PPACA), signed into law on

March 23, 2010, requires that any overpayments be reported and returned

within 60 days from identification to avoid FCA liability and administrative

penalties.

Risk of investigation and liability and repayment obligations have increased following enactment of these new laws.


(cont’d)


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Penalties may include:

• Treble damages: up to three times the amount of damages sustained by the

government as a result of the fraudulent claim(s).

• Fines: A civil monetary penalty of between $5,500 - $11,000 per false claim.

• Exclusion: FCA liability can give rise to exclusion* from Federal health care

programs, such as Medicare and Medicaid.

• Suspensions/loss of provider license/ Medicare Provider number.

Many states, such as Florida, Hawaii, Georgia, Illinois and New York, have their

own false claims acts that apply to state Medicaid programs and can lead to

additional liability.

*Exclusion: 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 the Inspector General (OIG).

Individuals must be checked at the time of hire and monthly thereafter against the OIG List of Excluded

Individuals and Entities and the U.S. Government’s System for Award Management (SAM) list.


(cont’d)


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Under the civil FCA, each instance of an item or a service billed to Medicare or

Medicaid counts as a claim, so fines can add up quickly.

The fact that a claim results from a kickback or is made in violation of the Stark

law also may render it false or fraudulent, creating liability under the civil FCA as

well as the Anti-Kickback Statute or Stark law.

There also is a criminal FCA. Criminal penalties for submitting false claims

include imprisonment and criminal fines.


(cont’d)


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Examples of False Claims

• Preparing a bid submission package to CMS or a State Medicaid program that contains false data and other information.

• Overstating the amount of payment due from a state or federal health care program.

• Certifying to the accuracy of a report or data used in a submission to the government knowing that the data is inaccurate or without checking its accuracy; the submission of false enrollment or claims data to CMS constitutes a false claim.

• Understating a refund obligation in a report to Medicare or a state Medicaid program.

• Concealing an identified overpayment made by Medicare or a state Medicaid program without reporting and returning the overpayment to the appropriate payor.


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Relevant Laws

The False Claims Act, or FCA was enacted in 1863 to fight procurement fraud

in the Civil War.

• The FCA has historically prohibited knowingly presenting or causing to be

presented to the federal government a false or fraudulent claim for payment or

approval.

• The FCA was recently amended through the American Recovery and

Reinvestment Act of 2009 (ARRA) to expand the scope of liability and give the

government enhanced investigative powers.

• FCA liability now extends to subcontractors working on government funded

projects as well as those who submit claims for reimbursement to government

agents and state agencies. This may indicate FCA liability for claims submitted

to MAO and Medicaid HMOs.


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Relevant Laws (cont’d)

Whistleblower and Whistleblower Protections:

The False Claims Act and some state false claims laws permit private citizens

with knowledge of fraud against the U.S. Government or state government to file

suit on behalf of the government against the person or business that committed

the fraud.

Individuals who file such suits are known as ‘whistleblowers’. The Federal False

Claims Act and some state false claims acts prohibit retaliation against

individuals for investigating, filing, or participating in a whistleblower action.

WellCare expressly prohibits retaliation against employees – including

employees of first tier, downstream, and related entities – who, in good

faith, report or participate in the investigation of compliance concerns.


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Excluded Entities and Individuals

The CFR provides the OIG the authority to exclude individuals or entities from

participating in federal or state healthcare programs.

• First tier, downstream and related entities may not employ or contract with

entities or individuals who are excluded from doing business with the federal

government.

• The OIG maintains a database of excluded individuals and entities and all

providers have an obligation to screen individuals and entities prior to hiring

and on a periodic basis.


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Penalties for Non-Compliance – Federal Criminal Statutes

Knowing and intentional compliance violations, depending on their severity, may

cause WellCare (and any associates, officers, contractors, or agents) to violate

criminal fraud statutes, including statutes that punish:

• Submission of False Claims and Making False Statements: Imposes

criminal fines or up to 5 years in prison if WellCare knowingly and

intentionally submits or causes the submission of false claims to the

government. Such false “claims” may include:

- Requests for reimbursement through Kick payment claims or billing to

State Pharmaceutical Assistance Programs (SPAPs).

- Reports of costs.

- Encounter data.

- Any other reports that contain information and data and affect the

reimbursement WellCare receives from CMS or state Medicaid programs.


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• Mail Fraud: Imposes criminal fines and/or 20 years in prison for anyone

who commits fraud through the mail.

• Health Care Fraud: Imposes criminal fines and up to 10 years in prison for

anyone who defrauds Medicare or Medicaid.

• Wire Fraud: Imposes criminal fines and up to 20 years in prison for

committing fraud through wire, radio or television communications.

• Obstruction of Justice: Imposes criminal fines and up to 20 years in prison

for anyone who covers up or conceals records in order to interfere with a

government investigation.

Penalties for Non-Compliance – Federal Criminal Statutes

(cont’d)


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Summary

As members of the WellCare workforce, we are expected to:

• Follow the WellCare Code of Conduct and Business Ethics.

• Abide by all Company Policies and Procedures.

• Adhere to State and Federal Regulations.

• Report Any Suspected Compliance Violations.

• Complete General Compliance training on at least an annual basis.


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Thank you!

You have successfully completed:

WellCare General Compliance

Training and

Fraud Waste and Abuse Prevention Awareness Training

Module 2

wellcare compliance program training for new associates · call us anytime with questions. need to...

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