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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

At the end of this training session, you will:

become familiar with the CMS mandate for

FWA training requirements.

recognize examples of health care FWA within your field.
understand what HFHP is doing to identify and

prevent FWA

know the appropriate steps to report suspected health care FWA.

The CMS Mandate

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.

The CMS Mandate

HFHP’s contracted entities, including network providers, pharmacies, and vendors must receive training to detect, correct, and prevent Medicare fraud.
This training includes downstream individuals involved in the administration or delivery of the Medicare benefit as defined under 42 CFR 423.504(b)(vi)(H).

Combat Fraud

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.

By educating ourselves on how to detect and prevent fraudulent activities, we can:

saving unnecessary costs that could increase health care premiums
protecting Medicare funds that are relied upon by millions

Special Investigations Unit (SIU)

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.

FWA

SIU Regulatory Requirements

Our health plan is required by state and federal laws to maintain a Special Investigations Unit.

State

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

SIU Program

Our program is comprised of the following elements:

 Detection

 Prevention

 Correction

 Reporting

 and most importantly…

YOU!

Health First associates, participating providers, pharmacies,

and contracted entities all play a vital role in detecting

Fraud, Waste, and Abuse

associated with

Medical and Pharmaceutical services.

FWA Important Laws

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.

What is Fraud, Waste, and Abuse?

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.

Health Care Fraud is a Crime

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.

Who commits fraud?

Anyone of the following could potentially commit healthcare fraud:

Providers
Members
Pharmacies
Pharmaceutical manufacturers
Employees of healthcare entities

Provider Fraud Examples

Unbundling and/or upcoding; altering claim forms or medical documentation.
Billing for services not rendered and/or supplies not provided.
Prescribing drugs without reviewing a patient’s condition; unnecessary drugs could be resold.
Writing a prescription for a higher quantity than appropriate to assist member with minimizing their copayment.

Employee or Patient Fraud Examples

Stealing a prescription pad and writing their own prescriptions; resale of drugs.
Using someone else’s ID card to obtain covered healthcare benefits.
Modifying a prescription to add more refills, increase quantities, etc.

Pharmacy Fraud Examples

▪Billing for the full amount prescribed but

only filing a portion, and not crediting the

difference back to the health plan.

Intentionally billing for brand but

dispensing generic, or the wrong NDC

code.

Manipulating calculations to keep

beneficiaries in the coverage gap or to

push beneficiaries into catastrophic

coverage.

Prescription forging or altering.

Pharmaceutical Manufacturer Fraud Examples

Offering inducements if the purchased products are reimbursable by any of the federal healthcare programs.
Promoting off-label drug usage illegally through marketing, financial incentives, or other promotion campaigns.
Using free samples illegally by knowingly providing them to physicians who will bill the federal healthcare programs for the samples.

Health Insurance Fraud Examples

Violating the healthcare marketing guidelines, such as offering beneficiaries a cash payment as an inducement to enroll.
Bait and switch pricing: lure customers by advertising a product/service at an unprofitably low price, then later reveal the product is not available but a substitute is.
Payment for prescriptions written by known deceased or sanctioned physician.
Misrepresenting or falsifying information furnished to CMS.

Difference Between Fraud and Abuse

There is a fine line between fraud and abuse, based on whether there is intent to deceive the healthcare industry.

Fraud involves conscious deception or misrepresentation intended to result in an unauthorized medical or pharmacy benefit.
Abuse may be similar to fraud except that it may not be probable that the abusive acts were done with an intent to deceive the insurer.

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.

Red Flags Rule

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.

Identity Theft: Red Flag Examples

Address discrepancy
Name discrepancy on identification and insurance information
Personal information inconsistent with information already on file
Medical documentation is inconsistent with medical history as reported by the patient
Patient denies receiving services that were billed to their insurance carrier

What is HFHP doing to help?

 Special Investigations Unit (SIU)

Housed internally within HFHP to investigate possible FWA activity.

 Exclusions List

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.

 Routine Auditing

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.

What Can You Do?

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!

Why Should I Report?

 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.

What If I’m Unsure?

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.

What Happens After I Report?

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.