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CMS Initiatives to Combat Medicare Advantage and Part D Fraud

CMS Initiatives to Combat Medicare Advantage and Part D Fraud

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CMS Initiatives to Combat Medicare Advantage and Part D Fraud

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  1. CMS Initiatives to Combat Medicare Advantage and Part D Fraud <Speaker Name><Date> Tanette Downs Director, Division of Plan Oversight and Accountability <Subhead to Specific Event>

  2. Medicare Fraud costs our country $60 Billion a year (Attorney General Eric Holder) If we do not step up our efforts, the Medicare Trust Funds could become insolvent by 2024 (Medicare Board of Trustees) And our entire healthcare system would be compromised… …for all Americans But we are fighting back, and it’s working…

  3. Amazing results from an amazing group of dedicated people… Including you and your organization The fight continues… We now have new tools to help us work together to win the war on fraud… And help ensure healthcare for this generation and future generations to come.

  4. “Today, we are releasing a report, which shows that our work to take on the criminals who steal from Medicare and Medicaid is paying off: we are regaining the upper hand in our fight against health care fraud. As this report shows, our anti-fraud efforts recovered $4.1 billion last year. That’s up 58 percent from 2009.” Kathleen Sebelius, Secretary US Department of Health and Human ServicesFebruary 14, 2012

  5. Our Agenda for Today’s Discussion Building on a Successful Anti-Fraud Effort Introduction to the Center for Program Integrity (CPI) and its Role in Combating Fraud Waste & Abuse Outreach & Education Initiatives Prevalent Fraud Schemes Resources & How to Report Fraud Questions & Answers

  6. Deterrence Expanded overpayment recovery efforts, e.g. Recovery Audit Contractors (RACs) Stronger civil and monetary penalties Tougher new sentences for criminals Building on a Successful Anti-Fraud Effort New Initiatives Detection • Pre-payment detection model vs. “pay & chase” • New technologies, e.g. predictive modeling and innovative data sources • Temporary “stop payments” for suspicious claims • More rigorous provider enrollment screening

  7. Center for Program Integrity (CPI) Division of Plan Oversight and Accountability (DPOA) Introduction to the Center for Program Integrity (CPI) and its Role in Combating Fraud Waste & Abuse

  8. Center for Program Integrity (CPI) In 2010, CMS established CPI and appointed Dr. Budetti as Deputy Administrator • Realigned all CMS fraud, waste and abuse (FWA) activities under one Center • Heightened level of attention to FWA • Enhanced data sharing across programs • Stronger industry partnerships for anti-fraud collaboration

  9. Division of Plan Oversight and Accountability (DPOA) Leading the Fight Against Medicare Part C & D Fraud • DPOA’s Vision: To be the organization at CMS that will safeguard the integrity of the Part C & Part D programs • DPOA’s Mission: To manage all the facets of program integrity functions as they relate to the provision of Part C & Part D benefits

  10. Outreach & Education MEDIC Medicare Parts C & D Anti-Fraud Team Working Together Against Fraud • National Benefit Integrity MEDIC • Complaints Intake • Proactive Data Analysis • Referrals from Sponsoring Organizations (SOs) • Investigations /Audits • Collaboration with Law Enforcement • Assistance to SOs • Outreach Activities • MEDIC Website • Education and Training • Quarterly Fraud Workgroups • Fraud Tools O&E MEDIC NBI MEDIC CPI DPOA Part D RAC Part D Recovery Audit Contractor • Audit of (PDE) Claims Paid to Excluded Providers • Improper Payment Determinations • Fraud Referrals to NBI MEDIC

  11. Medicare Parts C & D Anti-Fraud Team Working Together Against Fraud • National Benefit Integrity MEDIC • Complaints Intake • Proactive Data Analysis • Referrals from Sponsoring Organizations (SOs) • Investigations / Audits • Collaboration with Law Enforcement • Assistance to SOs NBI MEDICHealth Integrity O&E MEDIC CPI DPOA Part D RAC

  12. Medicare Parts C & D Anti-Fraud Team Working Together Against Fraud O&E MEDIC NBI MEDIC CPI DPOA Part D RACACLR Strategic Business Solutions Part D Recovery Audit Contractor • Audit of (PDE) Claims Paid to Excluded Providers • Improper Payment Determinations • Fraud Referrals to NBI MEDIC

  13. Outreach & Education MEDIC Medicare Parts C & D Anti-Fraud Team Working Together Against Fraud • Outreach Activities • MEDIC Website • Education and Training • Quarterly Fraud Workgroups • Fraud Tools O&E MEDICRainmakers NBI MEDIC CPI DPOA Part D RAC

  14. Outreach & Education Initiatives Fraud Work Groups: Working Together to Create Cutting Edge Tactics O&E MEDIC Website: Keeping Updated on the Latest Information Fraud Tools: Making it Easier to Detect & Report Fraud Education & Training: Shortening the Learning Curve for Faster Results 14

  15. 2012 Fraud Work Groups • VALUE PROPOSITION: Coming together to create cutting edge tactics for fighting fraud 15

  16. Keeping Updated on the Latest Information – Every Day http://medic-outreach.rainmakerssolutions.com 16

  17. Content includes: Fraud news updates Training Fraud tools Fraud Work Group meeting registration e-Resource Library containing basic references and contact listings FAQs O&E MEDIC Website Resources and Information to Aid Anti-Fraud Efforts Provides a HIPAA-compliant secure site for: • CMS • SOs • Law Enforcement • Other Professionals • Consumers VALUE PROPOSITION: Providing you with a complete online guide for combating fraud

  18. Fraud Tools Examples of 2012 Deliverables VALUE PROPOSITION: Making it easier for you to detect and report fraud

  19. Education and Training Shortening the Learning Curve for Faster Results VALUE PROPOSITION: Helping you get up to speed quickly

  20. Prevalent Fraud Schemes Services Not Rendered/Not Medically Necessary Top Prescribers/Top Providers Drug Diversion False Front Providers Upcoding

  21. SERVICES NOT RENDERED or NOT MEDICALLY NECESSARY Ways to Identify: • Pharmacy audits reveal shortages: invoices for medications do not support the claims processed by the plan, falsified invoices for drug manufacturers or distributors • Forged physician or patient signatures on documents • Physician prescribes outside his/her practice • Patient/member complaints of not receiving items received on EOB or items being delivered that were not requested • High claim volume of abused drugs such as controlled substance medications, pain medications, muscle relaxers, etc. • Diagnosis on file does not match the services or items being billed • Home Healthcare or other services billed while patient was in the hospital Description: Claims submitted for services that never were received/ delivered, or were not medically necessary for the patient. Recently Reported High Risk Areas: CA, FL, IL, NC, NJ, NY, MI, PR, TN, TX

  22. TOP PRESCRIBERS/TOP PROVIDERS Ways to Identify: • Proactive data analysis can reveal top prescribers and providers of highly abused drugs and/or services in paid claim files • Multiple plans have identified possible overprescribing physicians • Prepay review departments reveal no patient history for services billed Description: Top prescribers and providers are identified as prescribing or providing more services or items than others in the same professional peer group within their respective area or region. Recently Reported High Risk Areas: MI, MO, NC, NY, OK, PA, TX

  23. DRUG DIVERSION Ways to Identify: • Diversion of drugs for medical purposes to the illegal market occurs in several ways, including doctor shopping, drug theft, prescription forgery, and illicit prescribing by a physician, beneficiaries bribed to sell their drugs or family members stealing drugs • Drugs usually abused in this "pill mill" environment are: Abilify, Zyprexa, Cymbalta, Zetia, Lorazepam, Hydrocodone, Vicodin, Oxycodone, Oxycontin or allergy/cough syrups Description: Drug diversion is a criminal act involving the unlawful distribution of prescription drugs. Recently Reported High Risk Areas: AZ, CA, FL, IN, MI, NJ, NY, OH, PA, WA

  24. FALSE FRONT PROVIDERS Ways to Identify: • New provider with sudden increase in billing pattern • UPS or FedEx® address • High number of claims being submitted by a new provider Description: These are fictitious clinics, laboratories or other fake providers that bill for services or items not delivered. Many are identified as empty “shell” offices generating false claims. Recently Reported High Risk Areas: South FL, NY

  25. UPCODING Ways to Identify: • Data analysis can quantify: • spikes in specific codes such as durable medical equipment, prosthetics, and orthotics ( i.e., billing for customized orthotic, but delivering an off-the-shelf product) • spikes in brand name drugs versus generics • Beneficiary Complaints Description: Billing healthcare plans for more costly services or items versus what was delivered or received by the patient. This is done by billing a different level code to obtain a higher reimbursement. Recently Reported High Risk Areas: CA, FL, UT

  26. Resources and How To Report Fraud

  27. More Resources • NBI MEDIC http://www.healthintegrity.org/ • O&E MEDIC Website/Part C & Part D Fraud Work Grouphttp://medic-outreach.rainmakerssolutions.com/ • Compromised Number Contractorhttp://www.tpgsi.com/ • Senior Medicare Patrol (SMP)http://www.smpresource.org/ • Corrective Action Plans (CAPs) http://www.cms.gov/MCRAdvPartDEnrolData/CAP/list.asp • OIG Work Plans http://oig.hhs.gov/publications/workplan/2011

  28. How You Can Report Fraud Contact National Benefit Integrity MEDIC at: 1-877-7SAFERX (1-877-772-3379) orhttp://www.healthintegrity.org/html/contracts/medic/case_referral.html

  29. ? Questions 29