Fraud & Abuse. Training for First Tier, Downstream and Related Entities. Purpose of this Training.
Training for First Tier, Downstream and Related Entities
The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage and Prescription Drug Plans to provide Fraud, Waste and Abuse (FWA) training to its employees, First Tier, Downstream and Related Entities on an annual basis beginning in calendar year 2009.
First Tier, Downstream and Related Entities can provide their own training or use training materials from one of their Medicare Advantage or Prescription Drug plans.
For fiscal year 2008, the US Department of
Health and Human Services Office of
Inspector-General (OIG) reported:
Can be at member, pharmacy, prescriber,
PBM, wholesaler or manufacturer level:
October 9, 2009, Department of Justice
3 Miami-Dade County, Fla., residents indicted in connection with an alleged $2.3 million Medicare fraud scheme operated out of a Detroit-area clinic that purported to specialize in providing injection and infusion therapies.
August 7, 2009, U.S. Attorney, Southern District of Florida
Federal Judge Sentences Defendants Who Perpetrated $10.9 Million Medicare Fraud HIV Infusion Scheme
August 17, 2009, U.S. Attorney, Southern District of Florida
Durable Medical Equipment Company Owner Convicted In Medicare Fraud Scheme for fraudulent DME billing. DME prescriptions were not signed by doctors; DME was not provided as claimed; some DME claims were for dead people.
October 9, 2008, U.S. Attorney, Southern District of Florida
Chiropractor and 2 Others Charged in Medicare Fraud Scheme (defendants solicited accident victims and persons to "stage" accidents to file fraudulent insurance claims on non-existent and exaggerated personal injuries).
September 29, 2008, Department of Justice
Walgreens Pays $9.9 million to Settle Medicaid Prescription Drug Allegations
January 4, 2008, OIG website
Shands Hospital paid fine of $119,838 for employing an individual that the OIG alleges Shands knew or should have known had been excluded from participation in Federal health care programs
Known as the “Lincoln Law”, covers fraud involving any federally funded contract/program. Imposes civil liability on any person who:
Key word is “knowingly”!
Amended in 1986 to increase the penalties and qui tam
A False Claims Act case can be brought by:
From 1986 to 2006:
(Source: US DOJ statistics)
It is a felony to knowingly and willfully to offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services paid in whole or in part by a federal health care program. “Remuneration” includes transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind.
The “Stark Law” prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or a member of his/her family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies.
HIPAA established health care fraud as
a federal criminal offense and increased
PUP’s FWA Program (cont’d)
3. The following are potential elements of civil prosecutions and penalties:
5. Fraud is:
6. The ________________ prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or a member of his/her family) has an ownership/ investment interest or with which he or she has a compensation arrangement, unless an exception applies.
7. The _____________ has the authority to exclude (sanction) providers or suppliers who have been convicted of health care-related offenses.
8. The ____________ pays an incentive award to individuals who provide information on Medicare fraud and abuse or other sanctionable activities.
Inappropriate bundling and unbundling
Services rendered to a person of the wrong gender
Inappropriate place of service for a procedure
All of the above