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Medicare Fraud, Waste and Abuse (FWA) Compliance Training. CMS Requirements.
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The Centers for Medicare and Medicaid Services (CMS) requires annual fraud, waste, and abuse training for organizations providing health, prescription drug, or administrative services to Medicare Advantage (MA) or Prescription Drug Plan (PDP) enrollees on behalf of a health plan.
Medicare Advantage and Part D Sponsors must provide FWA training to first tier entities and first tier entities must ensure that the FWA training is distributed to their downstream entities (and such distribution must be documented).
CMS requires that Medicare Advantage and Part D Sponsors have a compliance plan that guards against potential fraud, waste, and abuse.42C.F.R. §422.503 (b)(4)(vi) and 42 C.F. R. § 423.504 (b)(4)(vi)
Federal law requires MA and Part D Sponsors to have a Compliance Plan*.
An MA or Part D Sponsor must:
*Federal Register, Part V Department of Health and Human Services Centers for Medicare and Medicaid Services 42 CFR
422 and 423, Wednesday, December 5, 2007.
An effective Compliance Plan includes seven core elements:
1. Written Standards of Conduct: development and distribution of written
Standards of Conduct and Policies & Procedures that promote the MA Organization or Part D Plan Sponsor’s commitment to compliance and that address specific areas of potential fraud, waste, and abuse.
2. Designation of a Compliance Officer: designation of an individual and a
committee charged with the responsibility and authority of operating and monitoring the compliance program.
3. Effective Compliance Training: development and implementation of regular,
effective education, and training, such as this training.
4. Internal Monitoring and Auditing: use of risk evaluation techniques and audits to monitor compliance and assist in the reduction of identified problem areas.
5. Disciplinary Mechanisms: policies to consistently enforce standards and addresses dealing with individuals or entities that are excluded from participating in CMS programs.
6.Effective Lines of Communication: between the compliance officer and the
organization’s employees, managers, and directors and members of the compliance committee, as well as first tier, downstream and related entities.
7. Procedures for responding to Detected Offenses and Corrective Action:
policies to respond to and initiate corrective action to prevent similar offenses
including a timely, responsible inquiry.
Fraud: an intentional act of deception, misrepresentation, or concealment in
order to gain something of value.
Waste: over-utilization of services (not caused by criminally negligent
actions) and the misuse of resources.
Abuse: excessive or improper use of services or actions that are
inconsistent with acceptable business or medical practice.
Refers to incidents that, although not fraudulent, may directly
or indirectly cause financial loss.
Pharmacies and pharmacists
Subcontractors such as claims processing firms
DentistsFWA Training Requirement
FWA training is required for all Part C and D first tier, downstream, related and delegated entities, including Medicare Advantage providers who administer the Part D drug benefit or provide health care services to Medicare Advantage enrollees.
Pharmacists may engage in inappropriate billing practices such as:
Misrepresenting personal information by:
Forging and altering prescriptions.
Doctor shopping is when a beneficiary consults a number of doctors for the purpose of obtaining multiple prescriptions for narcotic painkillers or other drugs.
Doctor shopping might be indicative of an underlying scheme, such as stockpiling or resale on the black market.
The False Claims Act, or FCA was enacted in 1863 to fight procurement fraud in the Civil War. The FCA has historically prohibited knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval.
The FCA was recently amended through the American Recovery and Reinvestment Act of 2009 (ARRA) to expand the scope of liability and give the government enhanced investigative powers. FCA liability now extends to subcontractors working on government funded projects as well as those who submit claims for reimbursement to government agents and state agencies. This may indicate FCA liability for claims submitted to MAO and Medicaid HMOs.
The Anti-Kickback Statute makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program.
Remuneration includes anything of value, directly or indirectly, overtly or covertly, in cash or in kind.
The Beneficiary Inducement Statute prohibits certain inducements to Medicare beneficiaries. i.e. waives the coinsurance and deductible amounts after determining in good faith that the individual is in financial need; or fails to collect coinsurance or deductible amounts after making reasonable collection efforts.
Self-Referral Prohibition Statute (Stark Law):
Red Flag Rule (Identity Theft Protection):
Health Insurance Portability and Accountability Act (HIPAA):
Excluded Entities and Individuals:
Everyone has the right and responsibility to report possible
fraud, waste, or abuse.
Report issues or concerns to:
Whistleblower: An employee, former employee, or member of an organization who reports misconduct to people or entities that have the power to take corrective action.
A provision in the False Claims Act allows individuals to:
Employers cannot threaten or retaliate against whistleblowers.
Federal government web sites are sources of information regarding detection, correction, and prevention of fraud, waste, and abuse: