Health First Health Plans Fraud, Waste, and Abuse Compliance Training Welcome… to our Compliance & Fraud, Waste, and Abuse (FWA) training course for all of our Network Providers, Pharmacies, Contracted Vendors and their employees. Learning Objectives
to our Compliance & Fraud, Waste, and Abuse (FWA) training course for all of our Network Providers, Pharmacies, Contracted Vendors and their employees.
At the end of this training session, you will:
FWA training requirements.
The Center for Medicare & Medicaid Services (CMS) final rule entitled, “Revisions to the Medicare Advantage and Part D Prescription Drug Contract Determinations, Appeals, and Intermediate Sanctions Processes,” published in December of 2007, requires Medicare Advantage (MA) organizations to incorporate FWA training guidelines into their existing compliance plans beginning in plan year 2009.
This presentation was designed to help you become an active participant in the fight against fraud in the health care industry by identifying suspicious activities related to medical benefits and prescription drug coverage.
HFHP has implemented an internal FWA program also known as the Special Investigations Unit (SIU) which is housed within the Government Programs Department.
To ensure HFHP continuously delivers quality health care, it is important that we safeguard the federal funds entrusted to us by working to prevent health care fraud.
Our health plan is required by state and federal laws to maintain a Special Investigations Unit.
Florida Statute: FS 626.9891 Insurer anti-fraud investigative units; reporting requirements; penalties for noncompliance
Federal (Part C)
42 CFR §422.504, Contract provisions
Federal (Part D)
42 CFR §423.505, Contract provisions
Our program is comprised of the following elements:
and most importantly…
Health First associates, participating providers, pharmacies,
and contracted entities all play a vital role in detecting
Fraud, Waste, and Abuse
Medical and Pharmaceutical services.
The False Claims Act (FCA)
Prohibits knowingly presenting (or causing to be presented) to the federal government a false or fraudulent claim for payment or approval.
The Anti-Kickback Statute
Section 1128B(b) of the Social Security Act (42 USC 13207b(b)) provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward business payable (or reimbursement) under the Medicare or other federal health care programs.
The Health Insurance Portability and Accountability Act (HIPAA)
All member information must be done in compliance with HIPAA regulations and internal policies to manage and maintain adequate controls in use and handling of member data.
Fraud— When a consumer or health care provider intentionally submits, or causes someone else to submit false or misleading information to obtain medical treatment or payment for services.
Waste— Actions by an individual which causes the health plan to consistently pay for or authorize unnecessary services. Health care spending that can be eliminated without reducing the quality of care. The act itself is not meant to defraud the health.
Abuse— Consistent errors or improper behaviors that results in excessive, unreasonable and unnecessary cost to the health plan. The act is not meant to defraud the health plan.
Fraud is a crime when an individual intentionally submits, or causes someone else to submit, false or misleading information to obtain treatment or payment for services they are NOT entitled to.
Anyone of the following could potentially commit healthcare fraud:
only filing a portion, and not crediting the
difference back to the health plan.
dispensing generic, or the wrong NDC
beneficiaries in the coverage gap or to
push beneficiaries into catastrophic
There is a fine line between fraud and abuse, based on whether there is intent to deceive the healthcare industry.
Can you prove that the person knew they were committing a crime? If so, it could be fraud. If not, it’s most likely abuse. In either case, you should report it.
Under the new Red Flags Rule, certain organizations including physician offices, hospitals and other health care organizations, are required to be familiar with warnings signs that could indicate identity theft.
These warning indicators assist in minimizing the damages of identity theft within the healthcare field.
Special Investigations Unit (SIU)
Housed internally within HFHP to investigate possible FWA activity.
Reviewed quarterly to ensure the Health Plan is not conducting business with a
provider or entity that has been excluded from participating in a federally- funded healthcare program.
Pro-active steps to ensure the Health Plan is conducting business in
accordance with state and federal guidelines.
Medicare Compliance Plan
Establishes internal controls and monitors the Health Plan’s conduct to reduce
the risk of unlawful or improper activities.
If you recognize activities that may constitute healthcare fraud, waste, or abuse committed by a provider, pharmacy, member, subcontractor, or employee, report these incidents as quickly as possible.
You can help prevent potential fraudulent activities related to the healthcare industry by reporting any suspicious acts to our SIU department.
It’s the right thing to do!
Combating fraud helps to lowers healthcare costs and taxes.
CMS requires us to report all suspicious activities.
Reporting could essentially prevent someone from
being victimized by fraudulent behavior and protects
the integrity of the healthcare industry.
If you suspect something is not right or unethical, it’s critical that you reportit!
For concerns that impact Health First Health Plans, please contact our SIU or Customer Service departments.
If you feel you could be wrong about your suspicions, don’t be! Also know that you may report anonymously.
The SIU department will investigate to determine if the issue is related to fraudulent health care activities.
When necessary, HFHP will report fraudulent findings to the proper State and/or Federal agencies for further investigation and possible law enforcement actions.
Health First Health Plans
Special Investigations Unit (SIU)
Report Healthcare Fraud, Waste, and Abuse Concerns.
We can’t do it without you.
Take a proactive stance.
All calls will be handled confidentially and may be made anonymously.
Beth Fleming, CCO/Director of Government Programs, HFHP
Laura Breisch, Privacy Officer & Compliance Manager, HFHP(321) 434-5660
Cheryl Rasbach, Compliance Analyst/SIU, HFHP
Office of Inspector General (OIG)
Florida Department of Financial Services