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Medicare Compliance and Fraud, Waste and Abuse (FWA) Training. FRAUD, WASTE AND ABUSE (FWA) EXECPTION-NOTICE.
YOU are part of the solution.
In order to detect fraud, waste, and abuse you need to know the Law
18 United States Code §1347
Violations of the code of conduct, ethics or any fraud, waste or abuse must be reported. Not reporting fraud or suspected fraud can make you a party to a case by allowing the fraud to continue.
abuse which is clearly stated in the IEHP Code of Conduct
Refer to the following slide regarding IEHP compliance reporting options
IEHP Compliance Hotline 866-355-9038
Failure to Provide Medically Necessary Services
Inappropriate Enrollment / Disenrollment
Formulary or Coverage Decisions
The following are examples of fraud by Medicare beneficiaries (members):
Improper Coordination of Benefits
Kickbacks: Soliciting, offering, or receiving a kickback, bribe, or rebate
Inducements: Such as copay waivers or free services to retain patients
False Claims: Billing for services not rendered or supplies not provided
Date of Service: Misrepresenting the date services were rendered.
Identity: Misrepresenting the identity of the individual who received the services.
Rendering Provider: Misrepresenting who rendered the service.
False Coding or Services: Billing for a covered item or service when the actual item or service provided was a non-covered item or service.
Unnecessary Care: Providing unnecessary procedures or prescribing unnecessary drugs.
Altering Medical Records: Erroneous or false or late entries in the medical record.
Delay in Care: Delay in authorizing or providing access to medically necessary care.
Patient Dumping: Encouraging disenrollment for high cost patients to defer costs and care to original Medicare when in a capitated model.
Over Prescribing: Over-prescription or false prescription of narcotics
Selling Prescriptions: Participating in illegal remuneration schemes, such as selling prescriptions.
Inducements: Prescribing medications based on illegal inducements, rather than the clinical needs of the patient.
Not Medically Necessary: Writing prescriptions for drugs that are not medically necessary, often in mass quantities, and often for individuals that are not patients of a provider.
Theft – Identity Fraud: Theft of a prescriber’s Drug Enforcement Agency (DEA) number, prescription pad, or e-prescribing log-in information.
Falsifying Justification: Falsifying information in order to justify coverage, such as ruling out lower cost generics
Dilution or Illegal Importation: Diluted substances or substituted provider administered drugs that may be either less than effective or contraindicated or illegal importation of drugs used or sold as covered drugs.
Steering & Kickbacks:
Bait and switch pricing:
Forging and altering prescriptions:
Expired Drugs or Tainted Drugs:
Manipulating the True Out-of-Pocket cost:
Inappropriate documentation of pricing information:
Kickbacks, inducements, and other illegal remuneration:
Records Management: Lack of integrity of data to establish payment and/or determine reimbursement, such as missing or inappropriate documentation of pricing information.
Formulary and formulary support activities:
Inappropriate relationships with physicians:
Off Label Use: Illegal promotion of off-label drug usage.
Billing for Free Samples: Illegal usage of free samples to physicians knowing and expecting those physicians to bill the federal health care programs for the samples.
Identified fraud, waste, or abuse must be promptly corrected. Correcting the problem saves the government money and ensures you are in compliance with CMS requirements.
The following slides provide very high level information about specific laws. For details about the specific laws, such as safe harbor provisions, consult the applicable statute and regulations concerning the law.
42 United States Code §1395nn
Knowingly and willfully soliciting, receiving, offering or paying remuneration (including any kickback, bribe, or rebate) for referrals for services that are paid in whole or in part under a federal health care program (which includes the Medicare program).
42 United States Code §1320a-7b(b)
Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191)
Carefully handle all data that can identify the member:
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.
42 U.S.C. §1395(e)(1)
42 C.F.R. §1001.1901
The following are potential penalties. The actual consequence depends on the violation.
Repayment / Restitution is just the start
(Note: the Patient Protection and Affordable Care Act (PPACA) may provide for increased penalties and restitution amounts)
A person comes to your pharmacy to drop off a prescription for a beneficiary who is a “regular” customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step?
A. Fill the prescription for 160
B. Fill the prescription for 60
C. Call the prescriber to verify quantity
D. Call IEHP compliance department
E. Call law enforcement
Call the prescriber to verify that the quantity should be 60 and not 160.
Your next step should be to immediately call the IEHP Compliance Hotline. IEHP Compliance Department will provide the next course of action.
IEHP Compliance Hotline 866-355-9038
Your job is to submit risk diagnosis to CMS for purposes of payment. As part of this job you are to verify, through a certain process, that the data is accurate. Your immediate supervisor tells you to ignore the sponsor’s process and to adjust/add risk diagnosis codes for certain individuals.
What do you do?
A. Do what is asked of you by your immediate
B. Report the incident to the compliance
department (via compliance hotline or other
C. Discuss concerns with immediate supervisor
D. Contact law enforcement
Report the incident to the compliance department (via compliance hotline or other mechanism)
The compliance department is responsible for investigating and taking appropriate action. Your sponsor/supervisor may NOT intimidate or take retaliatory action against you for good faith reporting concerning a potential compliance, fraud, waste, or abuse issue.
You are in charge of payment of claims submitted from providers. You notice a certain diagnostic provider (“Doe Diagnostics”) has requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize that Doe Diagnostics’ claims far exceed any other provider that you reviewed.
What do you do?
A. Call Doe Diagnostics and request additional
information for the claims
B. Consult with your immediate supervisor for next
C. Contact the compliance department
D. Reject the claims
E. Pay the claims
Answers B or C
Consult with your immediate supervisor for next steps
Contact the compliance department
Either of these answers would be acceptable. You do not want to contact the provider. This may jeopardize an investigation. Nor do you want to pay or reject the claims until further discussions with your supervisor or the compliance department have occurred, including whether additional documentation is necessary.
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?
A. Call the local law enforcement
B. Perform another review
C. Contact your compliance department
D. Discuss your concerns with your supervisor
E. Follow your pharmacy’s procedures
Follow your pharmacy’s procedures
Since this is a minor discrepancy in the inventory you are not required to notify the DEA. You should follow your pharmacy’s procedures to determine the next steps.
Thank you for participating and expanding compliance program effectiveness by ensuring you and your organization incorporate the information into your individual compliance program and business practices.