Presentation Transcript

1. COMPLIANCE

2. SOUNDPATH Health Compliance Program Overview Compliance Program outlines the company’s culture of compliance and contains 7 key elements as outlined by Office of Inspector General (OIG): Written policies, procedures, and standards of conduct Designation of a Compliance Officer and Compliance Committee Effective training and education Effective lines of communication Enforcement of standards through well publicized disciplinary guidelines Internal monitoring and auditing Procedures for ensuring prompt response to detected offenses
3. Compliance Officer role The Compliance Officer is responsible for: Implementing and operating SPH’s Compliance program Keeping CEO and Board fully informed of compliance matters on a regular basis Ensuring that compliance training is provided to all employees, managers and theBoard Conducting risk analyses, audits and monitoring Investigating compliance matters Developing compliance-related policies
4. Overview of Laws/Regulations applicable to SPH* Regulated by Centers for Medicare and Medicaid (CMS) Medicare Managed Care Manual and Prescription Drug Benefit Manual Processes required to ensure federal dollars not misused due to violations of: Stark I, II, III Anti-Kickback False Claims Act HIPAA Affordable Care Act Washington State Rules and Regulations as pertain to a Health Care Services Contractor *not all inclusive
5. This training focuses on two areas: Fraud, Waste and Abuse HIPAA
6. Fraud, Waste and Abuse
7. FWA Why Do I Need Training? Every year millions of dollars are improperly spent because of fraud, waste, and abuse. It affects everyone. Including YOU. This training will help you detect, correct, and prevent fraud, waste, and abuse. You are part of the solution. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
8. FWA cont. Where Do I Fit In? As a person who provides health or administrative services to a Part C or Part D enrollee you are either: Part C or D Sponsor Employee First Tier Entity Examples: PBM, a Claims Processing Company, contracted Sales Agent Downstream Entity Example: Pharmacy Related Entity Example: Entity that has a common ownership or control of a Part C/D Sponsor Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
9. FWA cont. What are my responsibilities as an employee or a person who provides health and administrative services in the Part C and Part D program? You are a vital part of the effort to prevent, detect, and report Medicare non-compliance as well as possible fraud, waste, and abuse. FIRST you are required to comply with all applicable statutory, regulatory, and other Part C or Part D requirements, including adopting and implementing an effective compliance program. SECOND you have a duty to the Medicare Program to report any violations of laws that you may be aware of. THIRD you have a duty to follow your organization’s Code of Conduct that articulates your and your organization’s commitment to standards of conduct and ethical rules of behavior. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
10. Prevention
11. FWA cont.How Do I Prevent Fraud, Waste, and Abuse? Make sure you are up to date with laws, regulations, policies. Ensure you coordinate with other payers. Ensure data/billing is both accurate and timely. Verify information provided to you. Be on the lookout for suspicious activity. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
12. FWA cont. Policies and Procedures Every sponsor, first tier, downstream, and related entity must have policies and procedures in place to address fraud, waste, and abuse. These procedures should assist you in detecting, correcting, and preventing fraud, waste, and abuse. Make sure you are familiar with your entity’s policies and procedures. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
13. Detection
14. FWA cont. What is Fraud, Waste, and Abuse? In order to detect fraud, waste, and abuse you need to know the Law Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
15. FWA cont. Criminal FRAUD Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program; or 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. 18 United States Code §1347 Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
16. FWA cont. What Does That Mean? Intentionally submitting false information to the government or a government contractor in order to get money or a benefit. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
17. FWA cont. Waste and Abuse Requesting payment for items and services when there is no legal entitlement to payment. Unlike fraud, the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
18. FWA cont. Differences Between Fraud, Waste, and Abuse There are differences between fraud, waste, and abuse. One of the primary differences is intent and knowledge. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
19. FWA cont. Report Fraud, Waste, and Abuse Do not be concerned about whether it is fraud, waste, or abuse. Just report any concerns to the compliance department. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
20. FWA cont. Indicators of Potential Fraud, Waste, and Abuse Now that you know what fraud, waste, and abuse are, you need to be able to recognize the signs of someone committing fraud, waste, or abuse. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
21. FWA cont. Indicators of Potential Fraud, Waste, and Abuse The following slides present issues that may be potential fraud, waste, or abuse. Each slide provides areas to keep an eye on, depending on your role as a sponsor, pharmacy, or other entity involved in the Part C and/or Part D programs. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
22. FWA cont. Key Indicators:Potential Beneficiary Issues Does the prescription look altered or possibly forged? Have you filled numerous identical prescriptions for this beneficiary, possibly from different doctors? Is the person receiving the service/picking up the prescription the actual beneficiary(identity theft)? Is the prescription appropriate based on beneficiary’s other prescriptions? Does the beneficiary’s medical history support the services being requested? Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
23. FWA cont. Key Indicators:Potential Provider Issues Does the provider write for diverse drugs or primarily only for controlled substances? Are the provider’s prescriptions appropriate for the member’s health condition (medically necessary)? Is the provider writing for a higher quantity than medically necessary for the condition? Is the provider performing unnecessary services for the member? Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
24. FWA cont. Key Indicators:Potential Pharmacy Issues Are the dispensed drugs expired, fake, diluted, or illegal? Do you see prescriptions being altered (changing quantities or Dispense As Written)? Are proper provisions made if the entire prescription cannot be filled (no additional dispensing fees for split prescriptions)? Are generics provided when the prescription requires that brand be dispensed? Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
25. FWA cont. Key Indicators:Potential Pharmacy Issues Are PBMs being billed for prescriptions that are not filled or picked up? Are drugs being diverted (drugs meant for nursing homes, hospice, etc. being sent elsewhere)? Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
26. FWA cont. Key Indicators:Potential Wholesaler Issues Is the wholesaler distributing fake, diluted, expired, or illegally imported drugs? Is the wholesaler diverting drugs meant for nursing homes, hospices, and AIDS clinics and then marking up the prices and sending to other smaller wholesalers or to pharmacies? Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
27. FWA cont. Key Indicators:Potential Manufacturer Issues Does the manufacturer promote off label drug usage? Does the manufacturer provide samples, knowing that the samples will be billed to a federal health care program? Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
28. FWA cont. Key Indicators:Potential Sponsor Issues Does the sponsor offer cash inducements for beneficiaries to join the plan? Does the sponsor lead the beneficiary to believe that the cost of benefits are one price, only for the beneficiary to find out that the actual costs are higher? Does the sponsor use unlicensed agents? Does the sponsor encourage/support inappropriate risk adjustment submissions? Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
29. FWA cont. Reporting Fraud, Waste, and Abuse Every MA-PD and PDP sponsor is required to have a mechanism in place in which potential fraud, waste, or abuse may be reported by employees, first tier, downstream, and related entities. Each sponsor must be able to accept anonymous reports and cannot retaliate against you for reporting. Review your sponsor’s materials for the ways to report fraud, waste, and abuse. When in doubt, call the MA-PD or PDP fraud, waste, and abuse Hotline or the Compliance Department. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
30. Soundpath Health’s Compliance Hotline (877) 864-2028
31. FWA cont. Laws The following slides provide very high level information about specific laws. For details about the specific laws, such as safe harbor provisions, consult the applicable statute and regulations concerning the law. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
32. FWA cont. Civil FraudCivil False Claims Act Prohibits: Presenting a false claim for payment or approval; Making or using a false record or statement in support of a false claim; Conspiring to violate the False Claims Act; Falsely certifying the type/amount of property to be used by the Government; Certifying receipt of property without knowing if it’s true; Buying property from an unauthorized Government officer; and Knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay the Government. 31 United States Code § 3729-3733 Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
33. FWA cont. Civil False Claims Act Damages and Penalties The damages may be tripled. Civil Money Penalty between $5,000 and $10,000 for each claim. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
34. FWA cont. Criminal Fraud Penalties If convicted, the individual shall be fined, imprisoned, or both. If the violations resulted in death, the individual may be imprisoned for any term of years or for life, or both. 18 United States Code §1347 Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
35. FWA cont. Anti-Kickback Statute Prohibits: Knowingly and willfully soliciting, receiving, offering or paying remuneration (including any kickback, bribe, or rebate) for referrals for services that are paid in whole or in part under a federal health care program (which includes the Medicare program). 42 United States Code §1320a-7b(b) Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
36. FWA cont. Anti-Kickback Statute Penalties Fine of up to $25,000, imprisonment up to five (5) years, or both fine and imprisonment. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
37. FWA cont. Stark Statute(Physician Self-Referral Law) Prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or a member of his or her family) has an ownership/investment interest or with which he or she has a compensation arrangement (exceptions apply). 42 United States Code §1395nn Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
38. FWA cont. Stark Statute Damages and Penalties Medicare claims tainted by an arrangement that does not comply with Stark are not payable. Up to a $15,000 fine for each service provided. Up to a $100,000 fine for entering into an arrangement or scheme. Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
39. FWA cont. Exclusion 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. 42 U.S.C. §1395(e)(1) 42 C.F.R. §1001.1901 Medicare Parts C and D Fraud, Waste and Abuse Training, developed by CMS
40. HIPAA
41. HIPAA Regulated by Office of Civil Rights/Department of Health and Human Services (DHHS) Portability of health insurance Allows short break (63 days) in coverage preventing pre-existing condition exclusion application Requires group health plans to attest to prior coverage to prevent application of pre-existing conditions (creditable coverage) Later amended to include provisions on Privacy, Security and Administrative Simplification
42. HIPAA Privacy Compliance with Privacy Rule required April 14, 2003 Established national standards to protect individuals’ medical records and personal health information Sets limits and conditions on uses and disclosures without patient authorization Also gave patients rights over their health information, including right to examine and obtain a copy of their health records and to request corrections Applies to health plans, healthcare providers and healthcare clearinghouses, defined as “Covered Entities” Person or organization that performs a function or activity on behalf of a CE, defined as “Business Associate”
43. HIPAA Privacycont. Defined Protected Health Information (PHI) as: individually identifiable health information held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper or oral. Individually identifiable health information is “information, including demographic data, that relates to: The individual’s past, present or future physical or mental health or condition, The provision of health care to the individual, or The past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable information includes many common identifiers (e.g., name, address, birth date, Social Security Number).”
44. HIPAA Privacy cont. Permitted Disclosures include (but not limited to): Upon individual’s request Treatment, Payment and Healthcare Operations (TPO) Public interest and Benefit activities Authorized Uses and Disclosures Individual must provide authorization to release his/her PHI for any reason other than those allowed as “Permitted Disclosures”
45. HIPAA Security Compliance with Security Rule required April 20, 2005 Covered Entities must have appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity and security of e-PHI: Administrative – e.g., security risk assessment (i.e. external penetration testing), P&Ps re access to PHI based on role Physical – e.g., Access to work areas monitored using a check-in sheet and escorting of guests, such areas behind locked doors, shred-it bins accessible, etc. Technical – e.g., frequent changing of system passwords, secured email, adherence to P&Ps re access to PHI (i.e. providing or removing PHI access as people change jobs within the company), monitoring of workforce’s use of e-PHI, etc.
46. HIPAA Security cont. Administrative Simplification Rules Electronic standards for Electronic Data Interchange (EDI) Current version of transaction is 5010, includes: Claim and Encounter - 837 and NCPDP (pharmacy) Remittance Advice - 835 Eligibility and Benefit Inquiry and Response - 270/271 Claims Status Inquiry and Response - 276/277 Adoption of 5010 required July 1, 2012 (after delays) 5010 paves the way for adoption of ICD-10 ICD-10 adoption required by October 1, 2014 (delayed from October 1, 2013)
47. HIPAA HITECH The HITECH Act (included in passage of American Recovery and Reinvestment Act of 2008 - ARRA) further expanded compliance requirement to Business Associates (BAs) BAs previously obligated to comply through BA Agreements HHS can now assess penalties on BAs Pre-HITECH, Security Rule permitted “commercially reasonable safeguards” Post-HITECH, HHS provides annual guidance on what the National Institutes for Standards and Technology (NIST) considers appropriate technical safeguards
48. HIPAA BREACH EXAMPLES The California Department of Public Health fined Kaiser’s Bellflower Hospital $187,500.00 based upon findings that 8 hospital employees accessed medical records of patients without a legitimate need. 6 of the 8 employees have since resigned, 1 was fired, and disciplinary action was taken against the remaining employee. A front desk office coordinator at The Cleveland Clinic in Weston, Florida, improperly obtained Medicare information and other demographic information about Cleveland Clinic patients in Naples, Florida, and sold that information to her cousin of Naples, for $5.00 to $10.00 each. The office coordinator improperly obtained the patient information of approximately 1,130 patients. That data let to $7 million in fraudulent Medicare claims. A clinic nurse accessed an unnamed patient’s medical file and shared the contents with her husband who had a lawsuit against the patient. The husband later told the patient he planned to use the private information in an upcoming legal proceeding, according to the indictment.
49. Attestation Needed! Thank you for completing Soundpath’s Required Annual Training on HIPAA and Fraud, Waste and Abuse!!! Please complete the Attestation included in the email sent and either: Scan and return to s.nishimoto@soundpathhealth.com Return to Christine Tomcala at 12/13/12 BOD meeting