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Fraud, Waste & Abuse. TRAINING COURSE As of May 2014. Click here to enter the course. Provided by Health Care Service C orporation & its subsidiaries. FRAUD WASTE & ABUSE. WHY?. i s this training so important. The Bottom Line. FRAUD WASTE & ABUSE. Who Am I In the Big Picture. WHO?.

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slide1

Fraud, Waste & Abuse

TRAINING COURSE

As of May 2014

Click here to enter the course.

Provided by Health Care Service Corporation & its subsidiaries

slide2

FRAUD WASTE & ABUSE

WHY?

is this training so important

The Bottom Line

slide3

FRAUD WASTE & ABUSE

Who Am I In the Big Picture

WHO?

slide4

FRAUD WASTE & ABUSE

WHAT?

can I do to stop fraud, waste & abuse

The Action Steps

slide5

FRAUD WASTE & ABUSE

What do I need to know about the

LAW?

Know the Law

slide6

FRAUD WASTE & ABUSE

Start here

Return to this page by clicking the Home icon

Who Am I In the Big Picture?

The Bottom Line

The Action Steps

Know the Law

slide7

THE BOTTOM LINE

The Bottom Line

Who Am I In the Big Picture?

The Action Steps

Know the Law

Why is this training so important?

WHY?

Back / Forward

Home

slide8

CMS requires training

for

New & Existing Employees

who

Work on a government contract

slide9

Written Policies, Procedures and Standards of Conduct

Compliance Officer, Compliance Committee and High Level Oversight

Effective Training and Education

Effective Lines of Communication

Well Publicized Disciplinary Standards

Effective System for Routine Monitoring and Identification of Compliance Risks

Procedures and System for Prompt Response to Compliance Issues

7 CMS Core Requirements

slide10

Written Policies, Procedures and Standards of Conduct

Compliance Officer, Compliance Committee and High Level Oversight

Effective Training and Education

Effective Lines of Communication

Well Publicized Disciplinary Standards

Effective System for Routine Monitoring and Identification of Compliance Risks

Procedures and System for Prompt Response to Compliance Issues

Click here to view Chapter 9

Clickhereto view the Federal Sentencing Guidelines

Clickhereto view HCSC’s Compliance Program

7 CMS Core Requirements

ms b skloss
Ms. B. Skloss

Click on the magnifying glass

ms b skloss1
Ms. B. Skloss

Every patient has the same diagnosis

ms b skloss2
Ms. B. Skloss

Every patient has the same diagnosis

Billing for more than 24 hours/day

ms b skloss3
Ms. B. Skloss

Every patient has the same diagnosis

Billing for more than 24 hours/day

Billing for Individual, Group & Family Therapy for most clients

ms b skloss4
Ms. B. Skloss

Every patient has the same diagnosis

Billing for more than 24 hours/day

Billing for Individual, Group & Family Therapy for most clients

Billing for in-person visits when speaking with them on the phone

slide16

Ms. B. Skloss

Every patient has the same diagnosis

Billing for more than 24 hours/day

Billing for 7 days/week even on holidays

Billing for Individual, Group & Family Therapy for most clients

Billing for in-person visits when speaking with them on the phone

ms b skloss6
Ms. B. Skloss

Explanation of Benefits

FRAUD

slide20

Know and abide by terms of government contract

1

Stay true to your company’s code

2

Click here to view HCSC’s Code of Conduct. Save this page to your favorites.

3

Cooperate fully and truthfully with government agencies

RESPONSIBILITIES

slide21

I have been hired within the past 90 days.

This is my annual training.

I work directly or indirectly on a government program, such as Medicare or Medicaid.

INDIRECTLY

DIRECTLY ON GOVERNMENT PROGRAM

slide22

Report improper payment to government officials

4

Violations regarding gifts to government employees can result in serious consequences

Comply with the laws that impact government programs

5

RESPONSIBILITIES

slide23

6

Avoid conflicts of interest

GOOD FOR MY COMPANY

GOOD FOR ME

RESPONSIBILITIES

slide24

How do I report fraud, waste and abuse?

Recognize and report fraud, waste & abuse

7

RESPONSIBILITIES

slide26

TOM LUBBEN

HCSC’s Chief Compliance & Privacy Officer

Corporate Integrity Compliance Program

HCSC/HISC/GHS

slide27

TOM LUBBEN

HCSC’s Chief Compliance & Privacy Officer

Corporate Integrity Compliance Program

HCSC/HISC/GHS

Government Programs Compliance

slide28

KIM GREEN

HCSC’s Government Programs Compliance Officer, Medicare Compliance Officer

Government Programs Compliance

Specific policies

Oversees compliance

Government contracts

slide29

Monitor & Audit

FDR RESPONSIBILITIES

First Tier

Down-stream

  • Monitor and audit themselves & downstream
  • Implement policies & procedures
  • Comply with the law
  • Set high ethical standards
  • Report suspected FWA to the Plan Sponsor

Downstream

slide30

First Tier

Down-stream

Downstream

slide32

THE ACTION STEPS

Detect

Report

Correct

Prevent

slide33

Abuse

Waste

Fraud

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice—

(1) To defraud any health care benefit program or

(2) To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program

US Code Title 18, Section 1347

Detect

slide34

Fraud

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice—

(1) To defraud any health care benefit program or

(2) To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program

US Code Title 18, Section 1347

False information is intentionally submitted to the government to get money or a benefit

Detect

slide35

Fraud

$43,904

FRAUD

FRAUD

HCSC

Detect

slide36
Law Litmus Test

Click the box next to the correct answer.

Which of the following laws prohibits knowingly submitting or causing someone else to submit a claim for payment with government funds using false information or making false statements in order to get a claim paid or approved by the government?

Anti-Kickback Statute

NO, but we’ll talk about this later.

Stark Statute

NO, but we’ll talk about this later.

False Claims Act

HIPAA

NO, but we’ll talk about this later.

penalties
PENALTIES

That’s right!

There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud.

There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud. Ms. Skloss was found guilty of Theft related to the false claims filed with both the Texas Medicaid Program and BCBSTX.

Damages may be triple the amount of the claim and the government may impose a civil penalty of $5,500 - $11,000 for each false claim.

It may also carry heavy criminal penalties. If convicted, depending upon the circumstances, the individual may be fined and/or imprisoned for a number of years up to and including life. There may be additional penalties required due to state governments based on the state False Claims Acts.

It’s important to note that the False Claims Act applies if the person knew or even should have known that the claim was false.

slide38

Abuse

Waste

Fraud

IntentionalNot intentional

UNNECESSARY COSTS

Detect

slide39

Abuse

Waste

  • Overutilization of services
  • Generally not considered to be criminally negligent
  • Misuse of resources
  • Request for payment
  • No legal entitlement
  • Not knowingly misrepresented facts

Detect

slide40

Which prescription is suspicious?

NO, not this one.

Detect

slide41

CORRECT!

It appears that the date on this prescription has been altered.

Detect

slide42

PRESCRIPTIONS & MEDICINE

FRAUD CLUES

  • Many identical prescriptions in a short time
  • Prescription does not match the beneficiary’s medical history
  • Generics are being provided when prescription requires a brand
  • Drugs are expired.

Detect

slide43

Which scenario is suspicious?

This is a simple case of tonsillitis. You’ll be out of the hospital today.

All of that for tonsillitis?

I’m going to run a series of 12 tests: an MRI, blood work, CAT Scan…

Detect

NO, not this one.

slide44

CORRECT!

All of that for tonsillitis?

I’m going to run a series of 12 tests: an MRI, blood work, CAT Scan…

Does the treatment match the diagnosis?

Detect

slide45

PHYSICIAN

FRAUD CLUES

  • Bills for services not provided
  • Prescriptions for a higher quantity than medically necessary for the condition

Detect

slide46

Read the sales scenarios below.

Which one is suspicious?

These are the services you can expect if you sign up for Medicare. I’ve also provided a list of doctors in your area who accept Medicare.

If you sign up for Medicare today and make Dr. Popper your primary physician, you’ll get a $100 gift card.

Detect

NO, not this one.

slide47

CORRECT!

If you sign up for Medicare today and make Dr. Popper your primary physician, you’ll get a $100 gift card.

Offering monetary rewards to sign up for a government health plan

Detect

slide48
Law Litmus Test

Click the box next to the correct answer.

Which of the following prohibits willfully receiving or offering a bribe or rebate for referrals for services that are paid under a federal health care program?

Stark Statute

NO, but we’ll talk about this later.

HIPAA

NO, but we’ll talk about this later.

Exclusion

NO, but we’ll talk about this later.

Anti-Kickback Statute

penalties1
PENALTIES

THAT’S RIGHT!

These 9 cardiologists paid the government over $3.2 million to settle their case for entering into the kickback scheme with the hospital. Two of them also plead guilty to criminal embezzlement charges involving the same conduct.

Fines up to $25,000, imprisonment up to 5 years or both.

If the sales rep offering a $100 gift card for beneficiaries to join the plan with Dr. Popper is receiving money from the doctor in return for referring patients to him, he is violating the Anti-Kickback Statute. Sales agents must always be honest and truthful in presenting products as outlined in the benefit guides, without adding anything to it. This law applies to more than sales people. The real live case below involves providers.

$100

Nine cardiologists and a local hospital entered into a kickback agreement, under which the cardiologists received payment from the hospital (even though they did not perform services for the hospital) in exchange for referring their patients to the hospital for surgery.

slide53

What’s suspicious about these claims?

Multiple almost identical

Hm…these claims are all the same! All submitted by XYZ Diagnostics on March 31.

One provider / Same day

Exceed normal costs

Report

slide54

“Our Company is committed to the policy that all employees have an obligation to report problems or concerns involving ethical or compliance violations…without fear of retaliation.”

Click here to view HCSC’s Code of Conduct.

HCSC CODE

Report

slide56

Reporting Resources

HCSC Fraud Hotlines (24/7, anonymous)

(877) 272-9741 SID* Fraud Hotline (Producers, Vendors, Providers)

(800) 543-0867 SID* Fraud Hotline (Members)

(877) 211-2290 Medicare Compliance Hotline

On-line form (anonymous)

https://www.incidentform.com/BCBSFraudHotline.jsp

Report

*SID = Special Investigations Department

slide58
LAW LITMUS TEST

Stark Statute

Click the box next to the correct answer

Which of the following is also known as the Physician Self-Referral Law?

Exclusion

NO, but we’ll cover this shortly.

HIPAA

NO, but we’ll cover this shortly.

penalties2
PENALTIES

That’s right!

A physician is prohibited from making a referral for health services to an entity in which the physician or a relative may have an ownership or compensation interest

Up to $15,000 for each service provided.

$100,000 fine for entering into an arrangement or scheme.

Medicare claims tainted by an arrangement that does not comply with Stark are not payable.

The Stark Statute is also known as the Physician Self-Referral Law.

In a recent case, a physician routinely referred his Medicare patients to an oxygen supply company. No problem, right? Actually, he owned the oxygen supply company and violated the Stark Statute. He paid the government $203,000 to settle the allegations.

slide62

Immediate Reporting

Quick Correction

KIM GREEN

HCSC’s Government Programs Compliance Officer, Medicare Compliance Officer

Correct

slide63

Which is the correct response?

I found a drug listed on my Explanation of Benefits that I was never given.

This sounds suspicious. It might be fraud.

This guy probably doesn’t remember what drugs he’s taken.

Correct

No. The member’s concern should be reported, not ignored. This is possible fraud.

slide64

CORRECT!

What should she do now?

Contact her compliance officer

Call her company’s fraud hotline

This sounds suspicious. It might be fraud.

Notify her supervisor

Call the pharmacy that filled the member’s prescription

Call the member’s provider

No, the CSR should not contact the member’s pharmacy.

Correct

No, the CSR should not contact the member’s provider.

slide65

HCSC Fraud Hotlines (24/7, anonymous)

(877) 272-9741 SID Fraud Hotline (Producers, Vendors, Providers)

(800) 543-0867 SID Fraud Hotline (Members)

(877) 211-2290 Medicare Compliance Hotline

On-line form (anonymous)

https://www.incidentform.com/BCBSFraudHotline.jsp

CORRECT!

Contact her compliance officer

Call her company’s fraud hotline

Notify her supervisor

Correct

slide66

What happens after the suspected fraud is reported?

One of our members called to report an error on his EOB…

Correct clerical error

Assigned to an investigator

Correct

slide67

$200,000.00

REAL LIFE

Correct

slide68
Law Litmus Test

Click the box next to the correct answer.

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 (OIG). These exclusions are intended to protect beneficiaries from the risk of harm by untrustworthy individuals by barring them from participation in federal health care programs.

Exclusions may apply to:

Individuals

Almost, but not quite

Organizations

Almost, but not quite

Both

penalties3
PENALTIES

That’s right!

You can check if an individual or company is on the OIG Exclusion list or the System of Award Management (SAM) website search feature.

Remember Mr. Hammerman, the pharmacist? Blue Cross Blue Shield of Illinois worked with the government to help prosecute Mr. Hammerman. He’s in jail now, but the pharmacy also paid the price and was excluded from participating in any government program.

Exclusions may apply to individuals and to organizations. Exclusion periods vary depending on the reason.

The Office of Inspector General’s (OIG) special Advisory Bulletin entitled, “The Effect of Exclusion From Participation in Federal Health Care Programs” is a great resource that lays out some of the details concerning exclusions. Click here to access it.

slide74

Verify information is true

  • Check billing information
  • Put policies in practice
  • Know the law

WHAT YOU CAN DO

Prevent

slide75
Law Litmus Test

Click the box next to the correct answer.

The Health Insurance Portability and Accountability Act (HIPAA):

Mandated that organizations implement safeguards to prevent unauthorized access to protected health information (PHI)

YES, but it did more than that

Required organization to notify individuals if there is a breach of their PHI

YES, but it did more than that

Provided individuals with the right to limit access to their PHI

YES, but it did more than that

All of the above

phi protected health information
PHI = Protected Health Information

THAT’S RIGHT!

Note to self:

I am part of the solution

There is no acceptable excuse for inappropriate use of, disclosure of or access to PHI.

HIPAA does all of these. While it is a crime to knowingly obtain or disclose protected health information (PHI) for fraudulent purposes, it is a HIPAA violation to disclose PHI to an unintended recipient even when there is no criminal intent

slide77

Know and comply with any contractual obligations that apply

  • Protect all health, financial and/or employment information
  • Limit access, use and sharing of information to the minimum amount necessary to achieve the task
  • Avoid using Social Security numbers when sending information out externally unless there is a compelling business need

PROTECT PHI

Prevent

slide78

Examples of unauthorized disclosures

  • Correspondence or a claim goes to the wrong address
  • A company report gets into the wrong hands
  • A data file is sent to the wrong email address

Organizations are required by the HITECH Act to notify individuals within 60 days if there is a breach of their PHI

REPORT

Prevent

slide80

FRAUD WASTE & ABUSE

  • Civil Money Penalties
  • Criminal Conviction / Fines
  • Civil Prosecution
  • Imprisonment
  • Loss of Provider License
  • Exclusion from Federal Health Care Programs

CONSEQUENCES

slide81

Reporting Resources

HCSC Fraud Hotlines (24/7, anonymous)

(877) 272-9741 SID Fraud Hotline (Producers, Vendors, Providers)

(800) 543-0867 SID Fraud Hotline (Members)

(877) 211-2290 Medicare Compliance Hotline

On-line form (anonymous)

https://www.incidentform.com/BCBSFraudHotline.jsp

slide82

Visit our web site at http://hisccompliance.com/and stay current on government programs issues. Check out Kim Green’s quarterly newsletter.

Comments or suggestions concerning training?

HISCCompliance@bcbsil.com

slide83

CONGRATULATIONS!

You have completed the course