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Identifying SoonerCare False Claims, Fraud and Abuse Course Introduction 12/01/2014 Version 1.01.

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Presentation on theme: "Identifying SoonerCare False Claims, Fraud and Abuse Course Introduction 12/01/2014 Version 1.01."— Presentation transcript:

1 Identifying SoonerCare False Claims, Fraud and Abuse Course Introduction 12/01/2014 Version 1.01

2 Pre-Assessment Betty and Debra have been co-workers at a large medical billing office for several years. Debra has confided to Betty that she has been having some major financial problems. Recently, Betty has noticed that Debra has been putting copies of billing records in an envelope in her desk drawer. Today Debra put the envelope in her purse and left quickly for lunch. After she returned, Betty saw her counting a large sum of money and putting it in her billfold. Betty thinks Debra might be selling SoonerCare provider numbers. Course Introduction 2

3 Pre-Assessment Could Debra’s actions in this scenario indicate SoonerCare fraud? Do you know the difference between SoonerCare fraud and SoonerCare abuse? If you knew SoonerCare fraud or abuse was occurring would you know how and what to report? Would you lose your job if you reported this incident? Course Introduction 3

4 Introduction Billions of taxpayer dollars are lost every year to health care fraud and abuse. An estimated 10% of national Medicaid costs are inappropriately spent on fraud and abuse incidents. The Oklahoma Health Care Authority and the federal government are aggressively dealing with these issues and are asking for your help as an OHCA employee, employee of another state agency involved in SoonerCare services, or as a contractor in identifying fraud and abuse incidents or other inappropriate payments. Course Introduction 4

5 Introduction The passage of the Deficit Reduction Act (DRA) of 2005 has made Medicaid Fraud and Abuse compliance programs mandatory for many organizations. The Act mandates that any entity which receives at least $5 million in Medicaid payments per year must implement employee education programs and certain written policies related to the detection and prevention of Medicaid fraud and abuse. Course Introduction 5

6 Course Objectives This course will educate you about identifying SoonerCare fraud and abuse. This education will help you protect yourself against accusations of fraud and abuse. SoonerCare is the name most commonly associated with the Medicaid program in Oklahoma. In this course we will be using the terms interchangeably. Course Introduction 6

7 Course Objectives The first lesson in this course is an:  Introduction to SoonerCare fraud and abuse Other lessons include:  Identifying fraud and abuse  Liability and penalties for fraud and abuse  How to safeguard against fraud and abuse  How to report suspected fraud and abuse Before you begin the first module take just a few minutes to complete the Pre-Assessment. It will help us identify what you already know about SoonerCare fraud and abuse. Course Introduction 7

8 Identifying SoonerCare False Claims, Fraud and Abuse Pre-Assessment 12/01/2014 Version 1.01

9 Introduction This Pre-Assessment consists of 15 questions.  The purpose of the Pre- and Post-Assessments is to simply let you see what you currently know concerning SoonerCare fraud and abuse.  After completing the Pre-Assessment, you will proceed to Module 1, Introduction to SoonerCare Fraud and Abuse. Pre-Assessment 2

10 Practice What is the best definition of SoonerCare fraud? Pre-Assessment 3 A – Attempting a scheme against the SoonerCare program B – Knowingly executing a scheme against the SoonerCare program C – Willfully executing a scheme against the SoonerCare program D – All of the above Click the appropriate answer.

11 What is the best definition of SoonerCare fraud? Practice Pre-Assessment 3 The correct answer is D. All are examples of SoonerCare fraud. A – Attempting a scheme against the SoonerCare program B – Knowingly executing a scheme against the SoonerCare program C – Willfully executing a scheme against the SoonerCare program D – All of the above

12 Practice What is the best definition of SoonerCare abuse? Pre-Assessment 4 A – Knowingly defrauding the SoonerCare program B – Intentionally violating SoonerCare guidelines C – Unknowingly violating SoonerCare guidelines D – None of the above Click the appropriate answer.

13 Practice Pre-Assessment 4 The correct answer is C. SoonerCare abuse is unknowingly violating SoonerCare guidelines. What is the best definition of SoonerCare abuse? A – Knowingly defrauding the SoonerCare program B – Intentionally violating SoonerCare guidelines C – Unknowingly violating SoonerCare guidelines D – None of the above

14 Practice If a provider charges a patient for a service that is not covered by SoonerCare, has fraud or abuse occurred? Pre-Assessment 5 A – NO B – YES Click the appropriate answer.

15 If a provider charges a patient for a service that is not covered by SoonerCare, has fraud or abuse occurred? Practice Pre-Assessment 5 A – NO B – YES The correct answer is NO. Charging a patient for a service that is not covered by SoonerCare does not constitute fraud or abuse.

16 Practice If someone completes a certificate of medical necessity without a physician’s involvement in the care of the patient, has SoonerCare fraud or abuse occurred? Pre-Assessment 6 A – NO B – YES Click the appropriate answer.

17 Practice If someone completes a certificate of medical necessity without a physician’s involvement in the care of the patient, has SoonerCare fraud or abuse occurred? Pre-Assessment 6 A – NO B – YES The correct answer is Yes. A physician’s involvement is required for a certificate of medical necessity form.

18 Practice A provider collects more than the established co-payment amounts from a patient for medical treatment. Has SoonerCare fraud or abuse occurred? Pre-Assessment 7 A – NO B – YES Click the appropriate answer.

19 Practice A provider collects more than the established co-payment amounts from a patient for medical treatment. Has SoonerCare fraud or abuse occurred? Pre-Assessment 7 A – NO B – YES The correct answer is Yes. SoonerCare providers are not allowed to collect more than the established co-payment.

20 Practice A SoonerCare provider requires a deposit from a SoonerCare member as a condition for continued care. Is this violation fraud, abuse, or neither? Pre-Assessment 8 A - Fraud B - Abuse C - Neither Click the appropriate answer.

21 A SoonerCare provider requires a deposit from a SoonerCare member as a condition for continued care. Is this violation fraud, abuse, or neither? A - Fraud B - Abuse C - Neither Practice Pre-Assessment 8 The correct answer is A. A provider that requires a deposit from a member as a condition for continued care has committed fraud.

22 Practice A provider intentionally upcodes services to a higher level in order to receive a larger reimbursement from SoonerCare. Is this violation fraud, abuse, or neither? Pre-Assessment 9 A - Fraud B - Abuse C - Neither Click the appropriate answer.

23 A provider intentionally upcodes services to a higher level in order to receive a larger reimbursement from SoonerCare. Is this violation fraud, abuse, or neither? A - Fraud B - Abuse C - Neither Practice Pre-Assessment 9 The correct answer is A. Upcoding services to a higher level to receive a larger SoonerCare reimbursement is an example of fraud.

24 Practice Are providers financially liable if their billing services commit fraud without the provider’s knowledge? Pre-Assessment 10 A – NO B – YES Click the appropriate answer.

25 Practice Are providers financially liable if their billing services commit fraud without the provider’s knowledge? Pre-Assessment 10 A – NO B – YES The correct answer is Yes. Providers are financially liable if their billing services commit fraud, even without the provider’s knowledge.

26 Practice Are providers financially liable for all claims submitted on their behalf that contain their SoonerCare identification number? Pre-Assessment 11 A – NO B – YES Click the appropriate answer.

27 Practice Are providers financially liable for all claims submitted on their behalf that contain their SoonerCare identification number? Pre-Assessment 11 A – NO B – YES The correct answer is Yes. Providers are financially liable for all claims submitted on their behalf that contain their SoonerCare identification number.

28 Practice Which of the following penalties can occur if you are liable for SoonerCare abuse? Pre-Assessment 12 A – You can be obligated to participate in provider education initiatives. B – Your assignment privileges can be revoked. C – You can be imprisoned D – All of the above Click the appropriate answer.

29 Which of the following penalties can occur if you are liable for SoonerCare abuse? Practice Pre-Assessment 12 The correct answer is D. All are penalties that can occur if you are suspected of SoonerCare abuse. A – You can be obligated to participate in provider education initiatives. B – Your assignment privileges can be revoked. C – You can be imprisoned D – All of the above

30 Practice When implementing safeguards to prevent SoonerCare fraud and abuse, you should keep which of the following in mind? Pre-Assessment 13 A – Ensure that your SoonerCare provider number is noted on all documents for all staff to see so that they can verify your SoonerCare provider status. B – Make sure SoonerCare guidelines and updates are regularly circulated among appropriate claim and billing staff and implemented in your systems. C – Make sure that a Waiver of Liability is being provided to patients for all services performed. D – Assume that all employees or providers hired or contracted with are not on the Sanctioned Provider List. Click the appropriate answer.

31 When implementing safeguards to prevent SoonerCare fraud and abuse, you should keep which of the following in mind? A – Ensure that your SoonerCare provider number is noted on all documents for all staff to see so that they can verify your SoonerCare provider status. B – Make sure SoonerCare guidelines and updates are regularly circulated among appropriate claim and billing staff and implemented in your systems. C – Make sure that a Waiver of Liability is being provided to patients for all services performed. D – Assume that all employees or providers hired or contracted with are not on the Sanctioned Provider List. Practice Pre-Assessment 13 The correct answer is B. When implementing safeguards to prevent fraud and abuse you should make sure SoonerCare guidelines and updates are regularly circulated among appropriate billing staff and implemented in your systems and confirm all employees or providers are not on the Sanctioned Providers List.

32 Practice When selecting a billing service to use, you should choose a service that: Pre-Assessment 14 A – Charges for their service on the basis of the number of claims they file rather than at a single monthly rate B – Guarantees the confidentiality of your SoonerCare provider number and other personal information C – Conducts routine audits of patient charge amounts for services rendered by the provider D – All of the above Click the appropriate answer.

33 Practice Pre-Assessment 14 When selecting a billing service to use, you should choose a service that: A – Charges for their service on the basis of the number of claims they file rather than at a single monthly rate B – Guarantees the confidentiality of your SoonerCare provider number and other personal information C – Conducts routine audits of patient charge amounts for services rendered by the provider D – All of the above The correct answer is D. You should always select a billing service that: Charges on the basis of the number of claims filed rather than a monthly rate Guarantees confidentiality Conducts routine audits of patient charge amounts for services rendered by the provider

34 Practice To safeguard from fraud and abuse, providers should choose a laboratory that: Pre-Assessment 15 A – Does not change diagnosis codes on the original test request form B – Monitors the test request forms to ensure that there is a diagnosis code defining the reason why each test was ordered C – All of the above D – None of the above Click the appropriate answer.

35 Practice Pre-Assessment 15 To safeguard from fraud and abuse, providers should choose a laboratory that: A – Does not change diagnosis codes on the original test request form B – Monitors the test request forms to ensure that there is a diagnosis code defining the reason why each test was ordered C – All of the above D – None of the above The correct answer is C. When selecting a lab, you should choose one that does not change diagnosis codes and monitors test request forms to ensure that there is a diagnosis code defining the reason each test was ordered.

36 Practice What is the term used in the False Claims Act that refers to a person reporting fraud and abuse? Pre-Assessment 16 A – Singer B – Tattletale C – Informant D – Whistleblower Click the appropriate answer.

37 What is the term used in the False Claims Act that refers to a person reporting fraud and abuse? A – Singer B – Tattletale C – Informant D – Whistleblower Practice Pre-Assessment 16 The correct answer is D. The term that is used in the False Claims Act that refers to a person reporting fraud and abuse is whistleblower

38 Practice The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. What does this mean? Pre-Assessment 17 A – Persons reporting fraud or abuse may be subject to the same penalties as the person committing the fraud or abuse. B – Persons reporting fraud or abuse can be discharged or demoted. C – Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. D – Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position. Click the appropriate answer.

39 The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. What does this mean? A – Persons reporting fraud or abuse may be subject to the same penalties as the person committing the fraud or abuse. B – Persons reporting fraud or abuse can be discharged or demoted. C – Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. D – Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position. Practice Pre-Assessment 17 The correct answer is C. Persons who are discharged, demoted, suspended, harassed, or discriminated against for reporting fraud or abuse have protection from such actions.

40 Congratulations! You have completed the Pre-Assessment. Pre-Assessment 18

41 Identifying SoonerCare False Claims, Fraud and Abuse Introduction to SoonerCare Fraud and Abuse 12/01/2014 Version 1.01

42 Module Objectives After completing this module, you will be able to:  Define SoonerCare fraud  Define SoonerCare abuse Introduction to SoonerCare Fraud and Abuse 2

43 Scenario Anne Greene, a social worker who is a contracted SoonerCare Provider, has a friend, Susan Young, who works in an inpatient psychiatric facility. Once patients are released, Susan gives their SoonerCare ID numbers to Anne. Anne bills SoonerCare for services she never rendered and splits the proceeds with Susan. Introduction to SoonerCare Fraud and Abuse 3

44 Scenario Are Anne and Susan committing SoonerCare fraud or was it abuse? How do you know the difference? Introduction to SoonerCare Fraud and Abuse 4

45 Definition of SoonerCare Fraud So that you can be vigilant against fraud and abuse, you need to understand the legal definitions of each. Medicaid fraud is legally defined as: Introduction to SoonerCare Fraud and Abuse 5 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, representation, or promises, any of the money or property owned by or under the custody of any health care benefit program.

46 Definition of SoonerCare Fraud Individuals who commit fraud intentionally obtain, or attempt to obtain, money or property through false or fraudulent pretenses. A health care provider may be considered to have committed fraud if they self-identify inappropriate actions or behavior against the SoonerCare program and do not report those actions to the Introduction to SoonerCare Fraud and Abuse 6 OHCA and do not take steps to remedy them. All health care providers who participate in the program furnish and report services in accordance with SoonerCare regulations and policies.

47 Scenario Now that you know the definition, was fraud committed against SoonerCare in the scenario involving the social worker, Anne Greene, and her friend Susan Young? Introduction to SoonerCare Fraud and Abuse 7 A – NO B – YES Click the appropriate answer.

48 Now that you know the definition, was fraud committed against SoonerCare in the scenario involving the social worker, Anne Greene, and her friend Susan Young? Scenario Introduction to SoonerCare Fraud and Abuse 7 A – NO B – YES The correct answer is Yes. This scenario is a good example of fraud. Anne and Susan knowingly and willfully executed a scheme to defraud SoonerCare.

49 Scenario Two billing coders work for a doctor who is a SoonerCare provider. Pamela is new to her job and asks the more experienced coder, Jerry, what code to bill for a venipuncture. Jerry is distracted by other duties and replies with one of the most common codes. However, in this case the code that Jerry provides is wrong. The result is an overcharge to SoonerCare for a procedure that was not performed. Introduction to SoonerCare Fraud and Abuse 8 Now let’s look at another scenario.

50 Scenario Does this scenario indicate fraud? Introduction to SoonerCare Fraud and Abuse 9 A – NO B – YES Click the appropriate answer.

51  Does this scenario indicate fraud? Scenario Introduction to SoonerCare Fraud and Abuse 9 A – NO B – YES The correct answer is No. Remember that by definition, fraud is when a person willfully and intentionally obtains, or attempts to obtain, money or property through false or fraudulent pretenses. This scenario is an example of abuse.

52 Definition of SoonerCare Abuse Medicaid abuse is legally defined as: Obtaining payment for items or services when there is no legal entitlement to that payment, but the person did not knowingly or intentionally misrepresent facts to obtain payment. These actions usually result, directly or indirectly, in unnecessary costs to the SoonerCare program. They may also lead to improper payment, services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Introduction to SoonerCare Fraud and Abuse 10

53 Definition of SoonerCare Abuse Individuals who are responsible for SoonerCare abuse unintentionally follow practices that violate the guidelines of the SoonerCare program which may result in unnecessary costs. Introduction to SoonerCare Fraud and Abuse 11

54 Definition of SoonerCare Abuse It is often difficult to judge the difference between fraud and abuse. Ultimately, in Oklahoma the Attorney General’s Office Medicaid Fraud Control Unit makes this determination. SoonerCare contractors and providers are responsible for correcting any billing or reporting errors that are identified. If the errors result in overpayments, the contractor is required to return the overpaid amounts to SoonerCare. The Office of Inspector General within OKDHS makes fraud and abuse determinations for SoonerCare members. Introduction to SoonerCare Fraud and Abuse 12

55 Module Summary You have completed Module 3 – Introduction to SoonerCare Fraud and Abuse. You learned the legal definitions for fraud and abuse and saw some examples of each in the scenarios. Remember that the main difference between fraud and abuse is that fraud is knowingly and willfully executing a scheme or artifice to defraud any health care benefit program. Abuse is when payment is obtained for items or services but the person did not knowingly or intentionally misrepresent facts to obtain payment. Introduction to SoonerCare Fraud and Abuse 13

56 Identifying SoonerCare False Claims, Fraud and Abuse How to Identify Medicaid Fraud and Abuse 12/01/2014 Version 1.01

57 Objectives After completing this module, you will be able to:  Recognize the most common types of SoonerCare fraud  Recognize the most common types of SoonerCare abuse How to Identify Medicaid Fraud and Abuse 2

58 Introduction Being able to accurately recognize fraud and abuse is one of the first steps to preventing it. The scenarios on the next few frames are based on cases that have recently occurred involving SoonerCare claims. They will give you a chance to think about the differences between fraud and abuse. The distinction might not be as easy as you would think. After the scenarios you’ll learn about some of the most common types of SoonerCare fraud and how to be aware of them. How to Identify Medicaid Fraud and Abuse 3

59 Scenario Tom Fontana, a physical therapist, sets an appointment to see a SoonerCare member. The member does not show up at the appointment. Tom is upset because he held the time open for the member. He bills SoonerCare for the session anyway because he has overhead to cover. Which of the following do you think occurred in this scenario? How to Identify Medicaid Fraud and Abuse 4 A – FRAUD B – ABUSE Click the appropriate answer.

60 Tom Fontana, a physical therapist, sets an appointment to see a SoonerCare member. The member does not show up at the appointment. Tom is upset because he held the time open for the member. He bills SoonerCare for the session anyway because he has overhead to cover. Which of the following do you think occurred in this scenario? A – FRAUD B – ABUSE Scenario How to Identify Medicaid Fraud and Abuse 4 The correct answer is Fraud. Tom has committed SoonerCare fraud. The services were not performed but SoonerCare was billed for the services. Tom is intentionally submitting a fraudulent claim.

61 Scenario Dr. Samuelson sees a SoonerCare member and fills out paperwork but fails to code the level of care. His office manager mistakenly entered the wrong level of service on his behalf. Which of the following do you think occurred in this scenario? How to Identify Medicaid Fraud and Abuse 5 A – FRAUD B – ABUSE Click the appropriate answer.

62 Dr. Samuelson sees a SoonerCare member and fills out paperwork but fails to code the level of care. His office manager mistakenly entered the wrong level of service on his behalf. Which of the following do you think occurred in this scenario? A – FRAUD B – ABUSE Scenario How to Identify Medicaid Fraud and Abuse 5 The correct answer is Abuse. The doctor did see the patient so the service was performed but it was billed with a wrong level of service.

63 Common Types of SoonerCare Fraud Remember the definition of Medicaid fraud from Lesson 1? 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, representation, or promises, any of the money or property owned by or under the custody of any health care benefit program. How to Identify Medicaid Fraud and Abuse 6

64 Common Types of SoonerCare Fraud One of the most common types of SoonerCare fraud is billing for services that were not performed. A mother brings her daughter to the doctor because she suspects that she broke a bone falling out of a tree. However, the doctor realizes the bone is not broken and sends the child on her way with a sling. The doctor bills SoonerCare for an x-ray that was not performed. How to Identify Medicaid Fraud and Abuse 7 Common Types of Fraud Billing for services that were not rendered

65 Common Types of SoonerCare Fraud Here is an example of abuse by misrepresentation. An obstetrician is seeing a pregnant patient. At one of her regular visits she becomes insistent that she have another ultrasound so she can tell people whether to buy pink or blue clothes for the baby. Even though this ultrasound is not medically necessary, the doctor decides to give it to her to make her happy. Since this ultrasound is not a covered service, the doctor bills SoonerCare for IV treatment for dehydration which was not given to the patient. How to Identify Medicaid Fraud and Abuse 8 Common Types of Fraud Misrepresenting as medically necessary non-covered or screening services by reporting covered procedure or revenue codes

66 Common Types of SoonerCare Fraud This can be tricky. Here is another example of fraud and abuse by misrepresentation: A group of nursing home patients were offered free exercise and social activities. However, the free services were billed to SoonerCare as covered Partial Hospitalization services at a Community Health Center or as covered physical therapy at a rehabilitation facility. How to Identify Medicaid Fraud and Abuse 9 Common Types of Fraud Misrepresenting as medically necessary non-covered or screening services by reporting covered procedure or revenue codes

67 Common Types of SoonerCare Fraud Another serious offense is signing blank records so that they can be fraudulently completed at a later date. Following are two examples of this type of SoonerCare fraud. How to Identify Medicaid Fraud and Abuse 10 Common Types of Fraud Signing blank records or certification forms, or falsifying information on records or certification forms for the sole purpose of obtaining payment

68 Common Types of SoonerCare Fraud How to Identify Medicaid Fraud and Abuse 11 Durable Medical Equipment Supplier  A durable medical equipment (DME) supplier has a financial arrangement with a physician who completes Certificates of Medical Necessity (CMN) for patients he has never treated. The completed CMNs are used to falsely document the medical necessity of equipment given to patients who do not need the equipment.  Both the physician and the durable medical equipment company are committing SoonerCare fraud.  In addition, they are in direct violation of the Anti-kickback Statutes, along with other various laws. Common Types of Fraud Signing blank records or certification forms, or falsifying information on records or certification forms for the sole purpose of obtaining payment

69 Common Types of SoonerCare Fraud How to Identify Medicaid Fraud and Abuse 12 Physician  A physician signs blank certification forms for a home health agency. Later that agency uses the forms to falsely represent that skilled nursing services are needed for patients who would not have qualified for home health services without a physician’s certification.  The physician is committing fraud by signing incomplete or blank certification forms. The home health agency is committing fraud by filing false claims for the purpose of obtaining SoonerCare payment.  Both would also be in violation of Anti-kickback Statutes and other laws. Common Types of Fraud Signing blank records or certification forms, or falsifying information on records or certification forms for the sole purpose of obtaining payment

70 Common Types of SoonerCare Fraud Using the incorrect codes is as fraudulent as billing for services that were not rendered. How to Identify Medicaid Fraud and Abuse 13 Common Types of Fraud Intentionally using procedure/revenue codes that describe more extensive services than those actually performed

71 Common Types of SoonerCare Fraud Using the incorrect codes is as fraudulent as billing for services that were not rendered.  A physician was routinely billing using high-level evaluation and management (E&M) service procedure codes (upcoding), although many of the visits he furnished did not meet the requirements for the codes reported.  This doctor committed SoonerCare fraud when he upcoded the service performed to a high-level office visit. How to Identify Medicaid Fraud and Abuse 13 Common Types of Fraud Intentionally using procedure/revenue codes that describe more extensive services than those actually performed

72 Common Types of SoonerCare Fraud Using the incorrect codes is as fraudulent as billing for services that were not rendered.  A hospital falsely reported bacterial pneumonia versus viral pneumonia as the diagnosis for a majority of the inpatient hospital stays billed to SoonerCare. As a result the hospital’s diagnosis-related group DRG payment was significantly higher than it should have been.  The hospital committed fraud by misrepresenting the diagnosis on its claims. How to Identify Medicaid Fraud and Abuse 13 Common Types of Fraud Intentionally using procedure/revenue codes that describe more extensive services than those actually performed

73 Practice Now see if you can spot examples of these types of fraud. Which of the following scenarios describes upcoding? How to Identify Medicaid Fraud and Abuse 14 A – A radiologist routinely bills for chest x-rays with two views, although most of the chest x-rays performed are for single views. B – A physician uses a non-qualified practitioner to perform follow-up visits but bills as though the physician rendered the services. C – A fictitious provider bills for services that were never furnished. Click the appropriate answer.

74 Now see if you can spot examples of these types of fraud. Which of the following scenarios describes upcoding? Practice How to Identify Medicaid Fraud and Abuse 14 The correct answer is A. While all of these describe fraud, upcoding occurs when revenue codes are used that describe more extensive services than those actually performed. A – A radiologist routinely bills for chest x-rays with two views, although most of the chest x-rays performed are for single views. B – A physician uses a non-qualified practitioner to perform follow-up visits but bills as though the physician rendered the services. C – A fictitious provider bills for services that were never furnished.

75 Practice Which of the following describes a provider misrepresenting as medically necessary non-covered or screening services? How to Identify Medicaid Fraud and Abuse 15 A – A home health agency bills for covered home health services for an unqualified patient. B – An ambulance company bills for emergency transportation for scheduled trips from a nursing home to a clinic. C – A physician falsifies the diagnosis for a service that would otherwise be denied coverage if it were correctly reported. Click the appropriate answer.

76 Which of the following describes a provider misrepresenting as medically necessary non-covered or screening services? A – A home health agency bills for covered home health services for an unqualified patient. B – An ambulance company bills for emergency transportation for scheduled trips from a nursing home to a clinic. C – A physician falsifies the diagnosis for a service that would otherwise be denied coverage if it were correctly reported. Practice How to Identify Medicaid Fraud and Abuse 15 The correct answer is C. The physician misrepresented the service as medically necessary that would not have otherwise been covered.

77 Practice Which of the definitions below best describes non-rendered services? How to Identify Medicaid Fraud and Abuse 16 A – Services or items furnished to a patient but not billed to SoonerCare B – Non-covered services under SoonerCare C – Services or items not furnished to a patient but billed to SoonerCare D – None of the above Click the appropriate answer.

78 Which of the definitions below best describes non-rendered services? A – Services or items furnished to a patient but not billed to SoonerCare B – Non-covered services under SoonerCare C – Services or items not furnished to a patient but billed to SoonerCare D – None of the above Practice How to Identify Medicaid Fraud and Abuse 16 The correct answer is C. Non- rendered services are items or services not furnished to a patient but billed to SoonerCare.

79 Practice A physician signed a blank medical necessity certification for a supply company so that the supply company could bill and be paid for durable medical equipment that was falsely documented. Which type of SoonerCare fraud has been committed by the provider in the scenario? How to Identify Medicaid Fraud and Abuse 17 A – Consistently using procedure/revenue codes that describe more extensive services than those actually performed B – Signing, falsifying, or misrepresenting information on records or certification forms for the sole purpose of obtaining payment C – Billing for services that were not rendered D – None of the above Click the appropriate answer.

80 A physician signed a blank medical necessity certification for a supply company so that the supply company could bill and be paid for durable medical equipment that was falsely documented. Which type of SoonerCare fraud has been committed by the provider in the scenario? A – Consistently using procedure/revenue codes that describe more extensive services than those actually performed B – Signing, falsifying, or misrepresenting information on records or certification forms for the sole purpose of obtaining payment C – Billing for services that were not rendered D – None of the above Practice How to Identify Medicaid Fraud and Abuse 17 The correct answer is B. The physician signed and falsified information for the sole purpose of obtaining payment. This allowed the equipment company to bill for non-covered durable equipment.

81 Other Types of SoonerCare Fraud Here are some other types of SoonerCare fraud to be aware of:  Intentionally using an incorrect provider number  Selling or sharing SoonerCare Medical I.D. cards or numbers  Falsifying information on applications  Offering, accepting, or soliciting bribes, rebates, or kickbacks How to Identify Medicaid Fraud and Abuse 18

82 Practice A nursing home administrator was paid a referral fee for allowing a community mental health center representative to provide free social activities to the nursing home’s SoonerCare members. Also, the members were given free meals and shoes for participating in the activities. However, the free services were billed to SoonerCare as group psychotherapy. Which type of fraud occurred in the scenario? How to Identify Medicaid Fraud and Abuse 19 A – Consistently not collecting the co-payment B – Falsifying information on application, medical records, billing statements, or cost reports C – Offering, accepting, or soliciting bribes, kickbacks, or rebates D – Both B and C Click the appropriate answer.

83 A nursing home administrator was paid a referral fee for allowing a community mental health center representative to provide free social activities to the nursing home’s SoonerCare members. Also, the members were given free meals and shoes for participating in the activities. However, the free services were billed to SoonerCare as group psychotherapy. Which type of fraud occurred in the scenario? A – Consistently not collecting the co-payment B – Falsifying information on application, medical records, billing statements, or cost reports C – Offering, accepting, or soliciting bribes, kickbacks, or rebates D – Both B and C Practice How to Identify Medicaid Fraud and Abuse 19 The correct answer is D. Fraud was committed when information was falsified for the free services. The administrator committed fraud by accepting the referral fee.

84 Common Types of SoonerCare Abuse Now that we have discussed some of the most common types of SoonerCare fraud, let’s look at the various types of abuse. Remember the definition of abuse is: Obtaining payment for items or services when there is no legal entitlement to that payment but the person did not knowingly or intentionally misrepresent facts to obtain payment. How to Identify Medicaid Fraud and Abuse 20

85 Common Types of SoonerCare Abuse An example of abuse by adding inappropriate or incorrect information on cost reports: A nursing home incorrectly closes out their books at the end of the fiscal year using an accounting method other than Generally Accepted Accounting Principles (GAAP). This causes a misstatement in their overall cost per day that is used to establish rates. How to Identify Medicaid Fraud and Abuse 21 Common Types Abuse Adding inappropriate or incorrect information on cost reports

86 Common Types of SoonerCare Abuse A hospital has a standard protocol that requires all patients admitted through the emergency room to have the following tests performed, regardless of the patient’s condition:  Electrocardiogram (EKG)  Chest x-ray  Urinalysis  Lab panel How to Identify Medicaid Fraud and Abuse 22 Common Types Abuse Billing for services or items in excess of those needed by the patient

87 Common Types of SoonerCare Abuse This scenario illustrates upcoding: A standard wheelchair with leg rests was furnished to a patient, however, the supplier accidentally billed SoonerCare for a deluxe wheelchair with premium leg rests and other accessories. How to Identify Medicaid Fraud and Abuse 23 Common Types Abuse Upcoding or using procedure or revenue codes that describe more extensive services than those actually furnished

88 Common Types of SoonerCare Abuse Providers must obtain correct information to avoid inaccurate or inappropriate information. For example: A nursing facility reports cable TV, advertising, and penalties expenses on their cost reports when these items are not allowable. A facility reports equipment purchases as an expense rather than as an asset to be depreciated, resulting in an overstatement of their costs. How to Identify Medicaid Fraud and Abuse 24 Common Types Abuse Including inappropriate or inaccurate information on cost reports

89 Common Types of SoonerCare Abuse As you’ve seen, there is a very thin line between abuse and fraud. Although inappropriate or accidental billing or reporting may initially appear abusive, it could evolve into fraud when mistakes continue to be made with no monitoring processes in place or when no effort is made to correct mistakes. We must all be committed to eliminating both abuse and fraud so that the SoonerCare program can provide high- quality service to its members. How to Identify Medicaid Fraud and Abuse 25

90 Practice A durable medical equipment supplier delivers and bills for a wheelchair with several accessories. However, the physician’s order required only a standard wheelchair. Which type of abuse occurred in the following scenario? How to Identify Medicaid Fraud and Abuse 26 A – Billing for services in excess of those needed by the patient B – Intentionally or unintentionally filing duplicate claims to the SoonerCare program, even if it does not result in duplicate payment C – Collecting more than the allowed co-payment amount from a member Click the appropriate answer.

91 A durable medical equipment supplier delivers and bills for a wheelchair with several accessories. However, the physician’s order required only a standard wheelchair. Which type of abuse occurred in the following scenario? Practice How to Identify Medicaid Fraud and Abuse 26 The correct answer is A. The physician ordered a standard wheelchair but a more expensive version was delivered. A – Billing for services in excess of those needed by the patient B – Intentionally or unintentionally filing duplicate claims to the SoonerCare program, even if it does not result in duplicate payment C – Collecting more than the allowed co-payment amount from a member

92 Practice Which of the scenarios below is an example of SoonerCare program abuse by upcoding? How to Identify Medicaid Fraud and Abuse 27 A – Dr. John Slicer billed SoonerCare for a high level E&M visit when a lower level visit was actually performed B – Dr. John Slicer pays his billing service to file SoonerCare claims for him based on the number of claims filed. The billing service often resubmits claims to SoonerCare which result in a denial letter to the doctor indicating that claims were denied for duplicate submission. C – Dr. John Slicer regularly demanded that the SoonerCare patients pay a $ fee before services could be rendered. Click the appropriate answer.

93 Which of the scenarios below is an example of SoonerCare program abuse by upcoding? A – Dr. John Slicer billed SoonerCare for a high level E&M visit when a lower level visit was actually performed B – Dr. John Slicer pays his billing service to file SoonerCare claims for him based on the number of claims filed. The billing service often resubmits claims to SoonerCare which result in a denial letter to the doctor indicating that claims were denied for duplicate submission. C – Dr. John Slicer regularly demanded that the SoonerCare patients pay a $ fee before services could be rendered. Practice How to Identify Medicaid Fraud and Abuse 27 The correct answer is A. Upcoding occurred when Dr. Slicer billed SoonerCare for a higher level E&M when a lower level visit was performed.

94 Practice Which of the following scenarios are examples of abuse by reporting inappropriate or incorrect information on cost reports? How to Identify Medicaid Fraud and Abuse 28 A – Reporting costs that were not incurred or that were attributable to non-program activities, other enterprises, or personal expenses B – Using depreciation methods that have not been approved by SoonerCare C – Using accounting methods other than Generally Accepted Accounting Principles (GAAP) to close a facility’s books at the end of the fiscal year D – ALL of the above Click the appropriate answer.

95 Which of the following scenarios are examples of abuse by reporting inappropriate or incorrect information on cost reports? A – Reporting costs that were not incurred or that were attributable to non-program activities, other enterprises, or personal expenses B – Using depreciation methods that have not been approved by SoonerCare C – Using accounting methods other than Generally Accepted Accounting Principles (GAAP) to close a facility’s books at the end of the fiscal year D – ALL of the above Practice How to Identify Medicaid Fraud and Abuse 28 The correct answer is D. All of these are examples of abuse by reporting inappropriate or incorrect information on cost reports.

96 Other Types of SoonerCare Abuse  Collecting in excess of co-payments due from a patient  Requiring a deposit or other payment from a patient as a condition for admission, continued care, or other provision of services  Unbundling or exploding charges (for example, reporting a series of codes when there is one specific code that describes and includes a payment for all components of the series of codes) How to Identify Medicaid Fraud and Abuse 29 Finally, here are a few more examples of SoonerCare abuse to be aware of:

97 Practice A SoonerCare member arrives at the emergency room with a possible broken arm. The admitting clerk at the hospital tells her she cannot be treated until her co-payment is paid. Which type of abuse occurred in the following scenario? How to Identify Medicaid Fraud and Abuse 30 A – Unbundling or exploding charges B – Billing for non-covered services C – Requiring a deposit or other payment from a patient as a condition for admission, continued care, or other provision of services Click the appropriate answer.

98 A SoonerCare member arrives at the emergency room with a possible broken arm. The admitting clerk at the hospital tells her she cannot be treated until her co-payment is paid. Which type of abuse occurred in the following scenario? A – Unbundling or exploding charges B – Billing for non-covered services C – Requiring a deposit or other payment from a patient as a condition for admission, continued care, or other provision of services Practice How to Identify Medicaid Fraud and Abuse 30 The correct answer is C. A provider cannot require a deposit or payment from a patient as a condition for providing services.

99 Summary You have completed Module 4 – How to Identify Medicaid Fraud and Abuse.  The scenarios used in this module were taken from real situations and events in which either fraud or abuse occurred.  After reading the scenarios in this module, you learned to determine which type of fraud or abuse took place. How to Identify Medicaid Fraud and Abuse 31

100 Identifying SoonerCare False Claims, Fraud and Abuse Liability and Penalties of Fraud and Abuse 12/01/2014 Version 1.01

101 Objectives After completing this module, you will be able to:  Recognize the extent of your liability as a provider for SoonerCare fraud and abuse  Identify the criminal and civil penalties imposed on individuals who are convicted of committing SoonerCare fraud  Identify the administrative actions SoonerCare contractors impose on individuals who abuse the SoonerCare program Liability and Penalties of Fraud and Abuse 2

102 Introduction As a SoonerCare provider, it is important to understand your liability risks so you can protect yourself from SoonerCare fraud and abuse charges. Physicians, medical equipment suppliers, clinical laboratories, other health care providers, and members may be potential candidates for putting you at risk. After you learn about three points of liability, you will read several real scenarios in which fraud and/or abuse was committed. Liability and Penalties of Fraud and Abuse 3

103 Three Points of Liability How do you know when you would be liable when fraud or abuse is committed? There are three points of liability to keep in mind when considering your personal liability or your liability as a provider. 1 – Personal Responsibility for Fraud 2 - Personal Responsibility for Abuse 3 - Provider Liability Liability and Penalties of Fraud and Abuse 4

104 Three Points of Liability How do you know when you would be liable when fraud or abuse is committed? There are three points of liability to keep in mind when considering your personal liability or your liability as a provider. 1 – Personal Responsibility for Fraud 2 - Personal Responsibility for Abuse 3 - Provider Liability Liability and Penalties of Fraud and Abuse 4 Persons are responsible for SoonerCare fraud when the intent to purposely obtain money or property through false or fraudulent pretenses has been clearly determined.

105 Three Points of Liability How do you know when you would be liable when fraud or abuse is committed? There are three points of liability to keep in mind when considering your personal liability or your liability as a provider. 1 – Personal Responsibility for Fraud 2 - Personal Responsibility for Abuse 3 - Provider Liability Liability and Penalties of Fraud and Abuse 4 Persons are responsible for SoonerCare abuse for all claims submitted that violate the SoonerCare program guidelines. This includes claims submitted by employees, agents, and contractors.

106 Three Points of Liability How do you know when you would be liable when fraud or abuse is committed? There are three points of liability to keep in mind when considering your personal liability or your liability as a provider. 1 – Personal Responsibility for Fraud 2 - Personal Responsibility for Abuse 3 - Provider Liability Liability and Penalties of Fraud and Abuse 4 SoonerCare contractors and providers may also be held responsible for fraudulent or abusive claims submitted when they are noted as the referring physician for the service performed, such as on the claims submitted by clinical laboratories. If a provider discovers they received an inappropriate payment for any reason, they must disclose to OHCA within 60 days, in accordance with the False Claims Act.

107 Practice To give you some practice, read the following three scenarios, then determine if fraud or abuse was committed and who is responsible. SoonerCare member Walter Jones’ Aunt Judy is contracted under the Developmental Disabilities Services Waiver as a transportation provider. Aunt Judy took Walter to the doctor’s office and then to Wal-Mart to buy groceries. Aunt Judy claimed mileage for the entire trip, including the 20 miles extra to go grocery shopping. She claimed that with the price of gasoline, she needed the money. Liability and Penalties of Fraud and Abuse 5 A – Aunt Judy is responsible for fraud B – Walter is responsible for abuse C – Aunt Judy and Walter are both responsible for fraud D – Aunt Judy did not do anything wrong Click the appropriate answer.

108 To give you some practice, read the following three scenarios, then determine if fraud or abuse was committed and who is responsible. SoonerCare member Walter Jones’ Aunt Judy is contracted under the Developmental Disabilities Services Waiver as a transportation provider. Aunt Judy took Walter to the doctor’s office and then to Wal-Mart to buy groceries. Aunt Judy claimed mileage for the entire trip, including the 20 miles extra to go grocery shopping. She claimed that with the price of gasoline, she needed the money. A – Aunt Judy is responsible for fraud B – Walter is responsible for abuse C – Aunt Judy and Walter are both responsible for fraud D – Aunt Judy did not do anything wrong Practice Liability and Penalties of Fraud and Abuse 5 The correct answer is A. Aunt Judy is responsible for fraud because she knew the 20 extra miles to go grocery shopping would not be covered.

109 Practice Sara Brown goes to her local Department of Human Services Office to apply for SoonerCare for her son, Edward. She tells the case worker that Edward, who is now 22, was seriously injured in an automobile accident at age 15. He is no longer eligible for Sara’s private insurance. The caseworker, Bob Denver, knows that Edward is eligible for the Developmental Disabilities Services Waiver, but there is currently a waiting list for those services. Since he is eligible for coverage anyway, Bob signs him up for the Advantage Waiver, which currently does not have a waiting list, even though his disability occurred when he was 15 years old. Who is responsible and for what? Liability and Penalties of Fraud and Abuse 6 A – Sara is responsible for fraud B – Edward is responsible for abuse C – Bob is responsible for fraud Click the appropriate answer. The Advantage Waiver serves the “frail elderly” (Oklahomans age 65 years and older) and adults 21 years of age or older with physical disabilities who would otherwise qualify for placement in a nursing facility. Approximately 14,100 persons receive services through this

110 Sara Brown goes to her local Department of Human Services Office to apply for SoonerCare for her son, Edward. She tells the case worker that Edward, who is now 22, was seriously injured in an automobile accident at age 15. He is no longer eligible for Sara’s private insurance. The caseworker, Bob Denver, knows that Edward is eligible for the Developmental Disabilities Services Waiver, but there is currently a waiting list for those services. Since he is eligible for coverage anyway, Bob signs him up for the Advantage Waiver, which currently does not have a waiting list, even though his disability occurred when he was 15 years old. Who is responsible and for what? Practice Liability and Penalties of Fraud and Abuse 6 The correct answer is C. Bob is responsible for fraud because he knew the Advantage Waiver is for those who became disabled as adults. If Sara and Edward also knew this, they would be responsible as well. A – Sara is responsible for fraud B – Edward is responsible for abuse C – Bob is responsible for fraud

111 Practice After reviewing his monthly billing statement from his contracted billing service, Dr. Anderson notices several errors, but is too busy to get them corrected. He also realizes that correcting the errors will result in him having to repay a large sum of money. Several months pass and these mistakes continue without correction. Who is responsible and for what? Liability and Penalties of Fraud and Abuse 7 A – Dr. Anderson is responsible for abuse since it was not intentional B – Dr. Anderson is responsible for fraud since he knew about the errors and did not correct them and did not disclose them within 60 days C – The billing service is responsible for abuse D – All the above Click the appropriate answer.

112 After reviewing his monthly billing statement from his contracted billing service, Dr. Anderson notices several errors, but is too busy to get them corrected. He also realizes that correcting the errors will result in him having to repay a large sum of money. Several months pass and these mistakes continue without correction. Who is responsible and for what? Practice Liability and Penalties of Fraud and Abuse 7 The correct answer is D. Initially it was abuse and the doctor and billing service were responsible. Once Dr. Anderson noted the errors and did not disclose them within 60 days, it becomes fraud. A – Dr. Anderson is responsible for abuse since it was not intentional B – Dr. Anderson is responsible for fraud since he knew about the errors and did not correct them and did not disclose them within 60 days C – The billing service is responsible for abuse D – All the above

113 Practice Which of the following actions may be considered fraudulent and the provider considered responsible? Liability and Penalties of Fraud and Abuse 8 A – Claims are submitted that contain mistakes resulting in an overpayment B – Claims are submitted in which the provider unintentionally upcoded charges C – Claims are submitted that contain mistakes resulting in an overpayment that the provider identifies, but the provider does not correct the errors Click the appropriate answer.

114 Which of the following actions may be considered fraudulent and the provider considered responsible? Practice Liability and Penalties of Fraud and Abuse 8 The correct answer is C. Just because a claim is submitted that contains mistakes does not mean fraud has been committed. A – Claims are submitted that contain mistakes resulting in an overpayment B – Claims are submitted in which the provider unintentionally upcoded charges C – Claims are submitted that contain mistakes resulting in an overpayment that the provider identifies, but the provider does not correct the errors

115 Practice A provider’s actions may be considered fraudulent or abusive and the provider may be considered responsible in which of the following scenarios? Liability and Penalties of Fraud and Abuse 9 A – A billing service uses the provider’s SoonerCare number to bill for non-rendered services without the provider knowing it B – The provider signs blank prescription forms for a medical supply company so that the company can bill SoonerCare for non-rendered services C – The provider receives kickbacks from the company for signing blank prescription forms D – All the above Click the appropriate answer.

116 A provider’s actions may be considered fraudulent or abusive and the provider may be considered responsible in which of the following scenarios? Practice Liability and Penalties of Fraud and Abuse 9 A – A billing service uses the provider’s SoonerCare number to bill for non-rendered services without the provider knowing it B – The provider signs blank prescription forms for a medical supply company so that the company can bill SoonerCare for non-rendered services C – The provider receives kickbacks from the company for signing blank prescription forms D – All the above The correct answer is D. The provider may be considered responsible in all three scenarios.

117 Fraud and Abuse Investigation Fraud and abuse are identified and investigated through a coordinated network of federal and state agencies and contractors. The Attorney General’s office Medicaid Fraud Control Unit and the Office of Inspector General (OIG) are primarily responsible for SoonerCare fraud investigations and provide support to the U.S. Attorney’s Office for cases that lead to prosecution. In addition, the OIG coordinates its efforts with other entities such as the Federal Bureau of Investigation, the Internal Revenue Service, OHCA, other state agencies, and SoonerCare contractors and providers. Liability and Penalties of Fraud and Abuse 10

118 Fraud and Abuse Investigation SoonerCare contractors and providers participate in the fight against fraud, waste, and abuse by referring potential cases of fraud to law enforcement and by preventing and detecting fraud and abuse through education programs like this one, a review of claims and cost reports, and coordination with other organizations. Liability and Penalties of Fraud and Abuse 11

119 Penalties for Fraud and Abuse Law enforcement agencies investigating and prosecuting for fraud can choose between criminal or civil prosecution. The penalties for each type differ.  In either case, individuals or entities who have been convicted of fraud may be excluded from participating in any federal health care program for a specified period or indefinitely. In addition, practitioners may have their licenses revoked by the state. Liability and Penalties of Fraud and Abuse 12 Criminal Penalties vs. Civil Liabilities

120 Penalties for Fraud and Abuse Law enforcement agencies investigating and prosecuting for fraud can choose between criminal or civil prosecution. The penalties for each type differ.  In either case, individuals or entities who have been convicted of fraud may be excluded from participating in any federal health care program for a specified period or indefinitely. In addition, practitioners may have their licenses revoked by the state. Liability and Penalties of Fraud and Abuse 12 Criminal Penalties Those found guilty may be subject to substantial penalties, fines, restitution, or imprisonment.

121 Penalties for Fraud and Abuse Law enforcement agencies investigating and prosecuting for fraud can choose between criminal or civil prosecution. The penalties for each type differ.  In either case, individuals or entities who have been convicted of fraud may be excluded from participating in any federal health care program for a specified period or indefinitely. In addition, practitioners may have their licenses revoked by the state. Liability and Penalties of Fraud and Abuse 12 Civil Liabilities In these cases, individuals or entities face substantial monetary damages for each violation of program rules, including repayment of up to three times the amount of damages to the SoonerCare program and large fines.

122 Penalties for Fraud and Abuse The Department of Health and Human Services (HHS), which includes the Centers for Medicare and Medicaid Services (CMS) and OIG, has the authority to impose remedial action or administrative sanctions against individuals who consistently fail to comply with Medicaid law or are deemed abusive to the SoonerCare program. Liability and Penalties of Fraud and Abuse 13

123 Penalties for Fraud and Abuse The sanctions include the following:  Provider education and warning  Withholding the provider’s payments and recovery of overpayments  Termination of the SoonerCare contract  Exclusion of the provider from the SoonerCare program and posting of the provider’s name on a national Sanctioned Provider list that is sponsored by the U.S. government  Repayment of Federal funds  Employee discipline, up to and including termination  Loss of medical or other professional license Liability and Penalties of Fraud and Abuse 14

124 Practice Now try answering a few questions about SoonerCare liability and penalties. What are the penalties that may be imposed on individuals and providers who are convicted of fraud? Liability and Penalties of Fraud and Abuse 15 A – Loss of their medical license B – Substantial penalties, fines, and restitution C – Civil penalties, plus triple damages D – Imprisonment E – All of the above Click the appropriate answer.

125 Now try answering a few questions about SoonerCare liability and penalties. What are the penalties that may be imposed on individuals and providers who are convicted of fraud? A – Loss of their medical license B – Substantial penalties, fines, and restitution C – Civil penalties, plus triple damages D – Imprisonment E – All of the above Practice Liability and Penalties of Fraud and Abuse 15 The correct answer is E. These are all penalties that may be imposed on individuals and providers who are convicted of fraud.

126 Practice A provider consistently bills for services in excess of those needed by her patients. What are the possible penalties that can be imposed for her actions? Liability and Penalties of Fraud and Abuse 16 A – Withholding of her SoonerCare payments and the recovery of SoonerCare’s overpayment B – Civil penalties, including assessments per violation C – Provider education and warning D – Exclusion of the provider from the SoonerCare program E – All of the above Click the appropriate answer.

127 A provider consistently bills for services in excess of those needed by her patients. What are the possible penalties that can be imposed for her actions? Practice Liability and Penalties of Fraud and Abuse 16 The correct answer is E. All of these items are possible penalties that could be imposed if SoonerCare is billed for services in excess of the patient’s needs. A – Withholding of her SoonerCare payments and the recovery of SoonerCare’s overpayment B – Civil penalties, including assessments per violation C – Provider education and warning D – Exclusion of the provider from the SoonerCare program E – All of the above

128 Summary You have completed Module 5 – Liability and Penalties of Medicaid Fraud and Abuse.  In the first part of the module you learned how you could be personally responsible for fraud and abuse as a SoonerCare provider.  This module presented scenarios which helped you learn to identify fraudulent and abusive activities.  You also learned about the penalties and administrative actions SoonerCare contractors impose on individuals who commit fraud or abuse to the SoonerCare program. Liability and Penalties of Fraud and Abuse 17

129 Identifying SoonerCare False Claims, Fraud and Abuse Safeguarding Against Fraud and Abuse 12/01/2014 Version 1.01

130 Objectives After completing this module, you will be able to:  Identify the safeguarding practices for protecting yourself from SoonerCare fraud and abuse  Identify the safeguarding practices for protecting yourself from SoonerCare fraud and abuse initiated by other entities  Identify the safeguarding practices for protecting your patients Safeguarding Against Fraud and Abuse 2

131 Fraud and Abuse Safeguarding Checklist  Ensure that services furnished under the supervision of the physician are furnished by individuals who are appropriately qualified or licensed.  Ensure that processes are in place that guarantee confidentiality  Ensure that only authorized individuals file claims on the physician’s behalf  Duplicate medical records, bills, and claims forms should be shredded or otherwise destroyed. Safeguarding Against Fraud and Abuse 3

132 Introduction to Safeguarding Abusive actions and practices could cost your business money and result in potential fines, penalties, or sanctions. In some instances, these actions could evolve into fraud if not remedied. Fraudulent behavior could result in severe monetary and legal penalties, imprisonment, or exclusion from the SoonerCare program, depending on the level of wrongdoing. Safeguarding Against Fraud and Abuse 4

133 Introduction to Safeguarding The Oklahoma Health Care Authority recognizes that most SoonerCare providers and contractors conduct their business in accordance with established policies. Unfortunately, accusations of fraud and abuse have been made against physicians, medical equipment suppliers, clinical labs, members, and other health care providers. You can protect yourself by understanding how you are vulnerable and who is a potential wrongdoer in the SoonerCare program. It is recommended that you implement as many safeguard practices as possible to prevent the occurrence of SoonerCare fraud and abuse at your location. Safeguarding Against Fraud and Abuse 5

134 Safeguarding Your Office Note: This section applies primarily to SoonerCare contractors, but employees should also be aware of these safeguards. Safeguarding begins by making sure you have the appropriate systems in place to follow SoonerCare guidelines. Safeguarding Against Fraud and Abuse 6

135 SoonerCare Payment Premises When providing services to SoonerCare members, you are responsible as a provider to abide by the three SoonerCare Payment Premises: 1.Recognize what services are covered by SoonerCare 2.Recognize what services are medically necessary and reasonable for the treatment of the patient’s condition 3.Document and properly report services according to SoonerCare guidelines and procedures Note Correct documentation and proper reporting are common areas where health care providers fall short in safeguards for SoonerCare fraud and abuse Safeguarding Against Fraud and Abuse 7

136 Safeguarding Your Office  SoonerCare provider education  Billing and Procedures Manual  Provider Update Newsletter  “Dear Provider” letters  SoonerCare website  OHCA Call Center Safeguarding Against Fraud and Abuse 8 The following resources are available to help you comply with the SoonerCare Payment Premises:

137 Practice Which of the following are SoonerCare Payment Premises? Safeguarding Against Fraud and Abuse 9 A – Recognize which services are covered by SoonerCare B – Recognize which services are medically necessary and reasonable for the treatment of the patient’s condition C – Document and properly report services according to SoonerCare guidelines and procedures D – All of the Above Click the appropriate answer.

138 Which of the following are SoonerCare Payment Premises? Practice Safeguarding Against Fraud and Abuse 9 The correct answer is D. All are SoonerCare Payment Premises. A – Recognize which services are covered by SoonerCare B – Recognize which services are medically necessary and reasonable for the treatment of the patient’s condition C – Document and properly report services according to SoonerCare guidelines and procedures D – All of the Above

139 Safeguarding Against Billing Service Fraud and Abuse As a provider, you are responsible for all SoonerCare payments that are generated from all claims filed on your behalf. You can safeguard against billing service fraud and abuse by:  Carefully selecting your billing service  Regularly monitoring the service and performance of the billing service Safeguarding Against Fraud and Abuse 10

140 Safeguarding Against Billing Service Fraud and Abuse Safeguarding Against Fraud and Abuse 10 When selecting a billing service, verify that the service meets the following criteria: The service has reputable past experience billing SoonerCare claims. You can check references from other providers and the Better Business Bureau. The service’s electronic filing system or program is compatible with SoonerCare. The service performs extensive claim edits that check all claims prior to their submission to SoonerCare for invalid diagnosis and procedure codes, duplicate claims, and unbundled procedures. As a provider, you are responsible for all SoonerCare payments that are generated from all claims filed on your behalf. You can safeguard against billing service fraud and abuse by:  Carefully selecting your billing service  Regularly monitoring the service and performance of the billing service

141 Safeguarding Against Billing Service Fraud and Abuse Safeguarding Against Fraud and Abuse 10 Regularly check the accuracy of records and claims receipts for claims submitted by your billing service by confirming that: Procedure, diagnosis, and revenue codes were not altered prior to submission to SoonerCare. Services were not inappropriately unbundled. Patients were charged the appropriate amount. As a provider, you are responsible for all SoonerCare payments that are generated from all claims filed on your behalf. You can safeguard against billing service fraud and abuse by:  Carefully selecting your billing service  Regularly monitoring the service and performance of the billing service

142 Practice Which of the following is the criteria for selecting a billing service? Safeguarding Against Fraud and Abuse 11 A – Checks claims prior to submission to SoonerCare for invalid diagnosis and procedure codes, duplicate claims, and unbundled procedures B – Has a reputable past experience billing SoonerCare claims C – Files and remits claims electronically to SoonerCare in a compatible format D – All of the above Click the appropriate answer.

143 Which of the following is the criteria for selecting a billing service? Practice Safeguarding Against Fraud and Abuse 11 The correct answer is D. All are criteria for selecting a billing service. A – Checks claims prior to submission to SoonerCare for invalid diagnosis and procedure codes, duplicate claims, and unbundled procedures B – Has a reputable past experience billing SoonerCare claims C – Files and remits claims electronically to SoonerCare in a compatible format D – All of the above

144 Physician Responsibilities Physicians are entrusted with and expected to engage in activities that promote the health and well-being of their patients. When someone uses a physician’s name, license, or provider number (with or without the physician’s knowledge) to take advantage of patients and health care programs, it becomes a concern to the health care industry. A physician who reassigns benefits to another entity may be at risk of having false claims filed with the physician’s SoonerCare number, with or without the physician’s knowledge. Safeguarding Against Fraud and Abuse 12

145 Physician Responsibilities Each of the following scenarios are based on real situations. Safeguarding Against Fraud and Abuse 13

146 Physician Responsibilities Carla is an extremely organized office manager for a pediatric practice. However, the nurses and doctors she works with are not organized. One weekend Carla came in to the office to get it cleaned up and organized. In this process, she threw duplicate medical records, bills, and claims forms in the office dumpster. Did Carla’s actions expose the practice to fraud and abuse? How? What should she have done differently? Could the doctor be responsible if her actions resulted in fraud or abuse? Safeguarding Against Fraud and Abuse 13

147 Physician Responsibilities Dr. Love is looking to expand the office staff by adding a physician’s assistant (PA) to the practice. Dr. Love is introduced to a PA, Kerri, who attends the same church. Kerri seems very professional and competent. Because Dr. Love is so busy, he hires Kerri and immediately puts her to work seeing SoonerCare members, without verifying credentials. Did Dr. Love do everything he could to properly safeguard his practice? How does he know Kerri is a licensed P.A.? Is Dr. Love responsible if Kerri performs services and is not licensed? Safeguarding Against Fraud and Abuse 13

148 Physician Responsibilities As you have probably guessed, Dr. Love and Carla may have left their patients and the practices susceptible to fraud and abuse. Before he hired Kerri, Dr. Love should have checked the following:  Kerri’s license and credentials  The sanctioned provider list to see if Kerri’s name was on it  The status of Kerri’s current contract with SoonerCare Safeguarding Against Fraud and Abuse 14

149 Physician Responsibilities Carla should not have thrown the documents in the dumpster. Someone could retrieve the documents and sell either the provider numbers or patient information. All documents containing confidential information should be shredded or otherwise destroyed. The checklist on the following page can be helpful when safeguarding your office. Safeguarding Against Fraud and Abuse 15

150 Fraud and Abuse Safeguarding Checklist  Ensure that services furnished under the supervision of the physician are furnished by individuals who are appropriately qualified or licensed.  Ensure that processes are in place that guarantee confidentiality  Ensure that only authorized individuals file claims on the physician’s behalf  Duplicate medical records, bills, and claims forms should be shredded or otherwise destroyed. Safeguarding Against Fraud and Abuse 16

151 Safeguarding Members In addition to protecting medical practices, it is also important to safeguard members against fraud and abuse. A common type of fraud can occur when a member’s SoonerCare number is lost or stolen and then used to gain money or services from the SoonerCare program. Fraud can occur with or without the member’s voluntary participation in the scheme. Safeguarding Against Fraud and Abuse 17

152 Safeguarding Patients One of the best ways to protect patients is to maintain confidentiality of their SoonerCare numbers and medical records. Remember Carla? She threw documents containing confidential information in the dumpster. Shred or otherwise destroy reports that include the patient names and SoonerCare numbers so that the confidentiality of the patient’s SoonerCare information is protected. This will ensure that information does not get into the wrong hands. Safeguarding Against Fraud and Abuse 18

153 Practice Which of the following are examples of fraud? Safeguarding Against Fraud and Abuse 19 A – A patient’s SoonerCare number is lost, stolen, or sold and then used to gain illegal money or services from the SoonerCare program B – A SoonerCare provider number is sold and used to bill SoonerCare for unrendered services C – Patients become professional patients. That is, they seek out medically unnecessary health care services or items in exchange for a fee. D – All the above Click the appropriate answer.

154 Which of the following are examples of fraud? A – A patient’s SoonerCare number is lost, stolen, or sold and then used to gain illegal money or services from the SoonerCare program B – A SoonerCare provider number is sold and used to bill SoonerCare for unrendered services C – Patients become professional patients. That is, they seek out medically unnecessary health care services or items in exchange for a fee. D – All the above Practice Safeguarding Against Fraud and Abuse 19 The correct answer is D. All are examples of fraud.

155 The Fraud, Waste, and Abuse Compliance Program As an integral part of our commitment to prevent fraud, waste, and abuse, SoonerCare has adopted a Fraud Waste and Abuse Compliance Program which defines the procedures for effective internal monitoring and auditing of fraud, waste, abuse, and risk assessment. Safeguarding Against Fraud and Abuse 20

156 The Fraud, Waste, and Abuse Compliance Program  Automatic claims monitoring through computer systems edits  Unannounced audits or “spot checks” Safeguarding Against Fraud and Abuse 21 All phases of the SoonerCare program are monitored and audited. The Oklahoma Health Care Authority periodically monitors and audits all types of claims using a variety of methods. Two of these methods are:

157 The Fraud, Waste, and Abuse Compliance Program Formal audits and monitoring may also be implemented. These may be:  Random  Complaint-based  Topic area Safeguarding Against Fraud and Abuse 22

158 The Fraud, Waste, and Abuse Compliance Program Audits and monitoring may also be conducted by various departments within the agency including but not limited to:  Finance  Quality Assurance  Program Integrity  Recovery Audit Contractor Safeguarding Against Fraud and Abuse 23

159 The Fraud, Waste, and Abuse Compliance Program The Oklahoma Health Care Authority, other state agencies, and contractors that administer the SoonerCare Program can be audited by several groups at the state and federal level. Safeguarding Against Fraud and Abuse 24 State Level Audit Group Federal Level Audit Groups

160 The Fraud, Waste, and Abuse Compliance Program The Oklahoma Health Care Authority, other state agencies, and contractors that administer the SoonerCare Program can be audited by several groups at the state and federal level. Safeguarding Against Fraud and Abuse 24 State Level Audit Group Office of State Auditor and Inspector

161 The Fraud, Waste, and Abuse Compliance Program The Oklahoma Health Care Authority, other state agencies, and contractors that administer the SoonerCare Program can be audited by several groups at the state and federal level. Safeguarding Against Fraud and Abuse 24 Federal Level Audit Groups Office of Inspector General of the Department of Health and Human Services Centers for Medicare and Medicaid Services

162 The Fraud, Waste, and Abuse Compliance Program  Education  If the item in question resulted in an overpayment of SoonerCare funds, that money must be repaid, including the federal portion Audit results may be appealed Safeguarding Against Fraud and Abuse 25 Member issues are monitored and audited by the Office of Inspector General of the Oklahoma Department of Human Services and OHCA Program Integrity Member Audit Division Once an audit identifies an abusive or fraudulent item, it may be dealt with by:

163 Practice Are all of the following methods used to periodically monitor SoonerCare claims?  Automatic claims monitoring through computer systems edits  Unannounced audits or “spot checks”  Formal audits and monitoring  Audits and monitoring conducted by various departments within the agency  Audits by various departments at the state and federal levels Safeguarding Against Fraud and Abuse 26 A – NO B – YES Click the appropriate answer.

164 Are all of the following methods used to periodically monitor SoonerCare claims?  Automatic claims monitoring through computer systems edits  Unannounced audits or “spot checks”  Formal audits and monitoring  Audits and monitoring conducted by various departments within the agency  Audits by various departments at the state and federal levels Practice Safeguarding Against Fraud and Abuse 26 A – NO B – YES The correct answer is Yes. All of these are methods used by the Oklahoma Health Care Authority to periodically monitor and audit SoonerCare claims.

165 General Self-check Are you ready to see if your practice is safe from SoonerCare fraud and abuse? Complete these self-check questions that will raise your awareness about safeguarding against fraud and abuse in your office. Safeguarding Against Fraud and Abuse 27

166 Practice When disposing of records, do you shred or otherwise destroy reports that include patient names and SoonerCare numbers? Safeguarding Against Fraud and Abuse 28 A – NO B – YES Click the appropriate answer.

167 When disposing of records, do you shred or otherwise destroy reports that include patient names and SoonerCare numbers? Practice Safeguarding Against Fraud and Abuse 28 A – NO B – YES The correct answer is Yes.

168 Practice Do you review the reports of sanctioned individuals and entities to ensure that those individuals or entities are not employed by or contracted with you, or that you are not doing business with them? Safeguarding Against Fraud and Abuse 29 A – NO B – YES Click the appropriate answer.

169 Do you review the reports of sanctioned individuals and entities to ensure that those individuals or entities are not employed by or contracted with you, or that you are not doing business with them? Practice Safeguarding Against Fraud and Abuse 29 A – NO B – YES The correct answer is Yes.

170 Practice Is your provider number kept confidential and shared only with those with an operational need to know? Safeguarding Against Fraud and Abuse 30 A – NO B – YES Click the appropriate answer.

171 Is your provider number kept confidential and shared only with those with an operational need to know? Practice Safeguarding Against Fraud and Abuse 30 A – NO B – YES The correct answer is Yes.

172 Practice Do you carefully review all documentation before certifying the medical necessity of services or supplies needed by your SoonerCare patients? Safeguarding Against Fraud and Abuse 31 A – NO B – YES Click the appropriate answer.

173 Do you carefully review all documentation before certifying the medical necessity of services or supplies needed by your SoonerCare patients? Practice Safeguarding Against Fraud and Abuse 31 A – NO B – YES The correct answer is Yes.

174 Practice If you have authorized someone else to bill SoonerCare for your services, do you have a process in place to ensure that those billings accurately reflect the service furnished? Safeguarding Against Fraud and Abuse 32 A – NO B – YES Click the appropriate answer.

175 If you have authorized someone else to bill SoonerCare for your services, do you have a process in place to ensure that those billings accurately reflect the service furnished? Practice Safeguarding Against Fraud and Abuse 32 A – NO B – YES The correct answer is Yes.

176 Practice Have you done background checks on companies and people you have contracted with or hired in connection with your SoonerCare business? Safeguarding Against Fraud and Abuse 33 A – NO B – YES Click the appropriate answer.

177 Have you done background checks on companies and people you have contracted with or hired in connection with your SoonerCare business? Practice Safeguarding Against Fraud and Abuse 33 A – NO B – YES The correct answer is Yes.

178 Practice Do you have a process in place to effectively keep up with the changes in SoonerCare’s guidelines and policies? Safeguarding Against Fraud and Abuse 34 A – NO B – YES Click the appropriate answer.

179 Do you have a process in place to effectively keep up with the changes in SoonerCare’s guidelines and policies? Practice Safeguarding Against Fraud and Abuse 34 A – NO B – YES The correct answer is Yes. The OHCA has web alerts for updates, provider letters and policy changes.

180 Practice Do you periodically check to ensure that services you order for patients are the only ones actually performed and billed to SoonerCare? Safeguarding Against Fraud and Abuse 35 A – NO B – YES Click the appropriate answer.

181 Do you periodically check to ensure that services you order for patients are the only ones actually performed and billed to SoonerCare? Practice Safeguarding Against Fraud and Abuse 35 A – NO B – YES The correct answer is Yes.

182 Practice Do you notify SoonerCare, the state licensing agency, or both, prior to making any changes to the location of your business? Safeguarding Against Fraud and Abuse 36 A – NO B – YES Click the appropriate answer.

183 Do you notify SoonerCare, the state licensing agency, or both, prior to making any changes to the location of your business? Practice Safeguarding Against Fraud and Abuse 36 A – NO B – YES The correct answer is Yes.

184 Practice Do you update your provider information on OHCA’s provider portal? Safeguarding Against Fraud and Abuse 37 A – NO B – YES Click the appropriate answer.

185 Do you update your provider information on OHCA’s provider portal? Practice Safeguarding Against Fraud and Abuse 37 A – NO B – YES The correct answer is Yes.

186 Practice Do you fully document the services you bill to SoonerCare, and do you have a process for maintaining your records? Safeguarding Against Fraud and Abuse 38 A – NO B – YES Click the appropriate answer.

187 Do you fully document the services you bill to SoonerCare, and do you have a process for maintaining your records? Practice Safeguarding Against Fraud and Abuse 38 A – NO B – YES The correct answer is Yes.

188 Practice Do you require appropriate approval before billing staff makes changes to the billing record? Safeguarding Against Fraud and Abuse 39 A – NO B – YES Click the appropriate answer.

189 Do you require appropriate approval before billing staff makes changes to the billing record? Practice Safeguarding Against Fraud and Abuse 39 A – NO B – YES The correct answer is Yes.

190 Practice Do you have internal audits in place to detect billing inaccuracies promptly? Safeguarding Against Fraud and Abuse 40 A – NO B – YES Click the appropriate answer.

191 Do you have internal audits in place to detect billing inaccuracies promptly? Practice Safeguarding Against Fraud and Abuse 40 A – NO B – YES The correct answer is Yes.

192 Practice You have completed the self-check questions for this module.  If you follow all these guidelines, you should reduce your risk of SoonerCare fraud and abuse. Safeguarding Against Fraud and Abuse 41

193 Summary You have completed Module 6 – How to Safeguard Against Fraud and Abuse.  This module covered the use of specific safeguarding practices to protect yourself from SoonerCare fraud and abuse, as well as from fraud and abuse initiated by other entities.  Now you know the practices for safeguarding that will protect you, your practice, and your patients Safeguarding Against Fraud and Abuse 42

194 Identifying SoonerCare False Claims, Fraud and Abuse Reporting SoonerCare Fraud and Abuse 12/01/2014 Version 1.01

195 Objectives After completing this module, you will be able to:  Identify the resources to use when reporting suspected SoonerCare fraud and abuse.  Identify the types of information needed to report suspected fraud and abuse of the SoonerCare program.  Identify the Whistleblower Protections provided by the False Claims Act. Reporting SoonerCare Fraud and Abuse 2

196 Introduction to Reporting If you should see or know about any cases of SoonerCare fraud or abuse, you should report these cases to the appropriate SoonerCare authorities. Reporting SoonerCare Fraud and Abuse 3

197 Introduction to Reporting Direct your reports to your SoonerCare contractor or to the Office of the Inspector General (OIG) fraud hotline. Numbers to call include the following:  OHCA’s Program Integrity  Attorney General’s Medical Fraud Control Unit (MFCU) OKC Tulsa  HHS-TIPS, OIG’s fraud hotline number Reports to these numbers can be anonymous. Reporting SoonerCare Fraud and Abuse 4

198 Helpful Information to Provide When Reporting Fraud and Abuse When reporting instances of fraud or abuse, you may not have all the information but it is important to provide as much of what you know as possible, including:  Patient name  Patient health insurance claim number  Date(s) of service  Description of service or item  Name of provider  Address of provider  Provider’s SoonerCare number  An explanation or description of the alleged fraudulent or abusive activity Reporting SoonerCare Fraud and Abuse 5

199 Whistleblower Protections The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. The False Claims Act basically says that any employee who is discharged, demoted, suspended, harassed, or discriminated against for reporting fraud and abuse will be reinstated with full seniority, paid twice the amount of back pay with interest on the back pay, and compensated for any special damages including litigation costs and reasonable attorneys’ fees. You can read the actual text regarding whistleblower protection provided by the False Claims Act on the next screen. Reporting SoonerCare Fraud and Abuse 6

200 False Claims Act of 1986 Any employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by his or her employer because of lawful acts done by the employee on behalf of the employee or others in furtherance of an action under this section, including investigation for, initiation of, testimony for, or assistance in an action filed or to be filed under this section, shall be entitled to all relief necessary to make the employee whole. Such relief shall include reinstatement with the same seniority status such employee would have had but for the discrimination, 2 times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys' fees. An employee may bring an action in the appropriate district court of the United States for the relief provided in this subsection.” Reporting SoonerCare Fraud and Abuse 7

201 Scenario The following three scenarios each describe real events involving reporting SoonerCare fraud and abuse. After reading each one, think about what each person should do. Reporting SoonerCare Fraud and Abuse 8

202 Scenario 1 Bart is an employee of a state agency that provides services to SoonerCare members. While reviewing some paperwork, he notices that his agency overstated the services provided when billing the Oklahoma Health Care Authority. Bart isn’t sure whether to report it or not since the money is just going from one state agency to another. Should Bart report this? Is it fraud or abuse? Reporting SoonerCare Fraud and Abuse 9

203 Scenario 1 Bart is an employee of a state agency that provides services to SoonerCare members. While reviewing some paperwork, he notices that his agency overstated the services provided when billing the Oklahoma Health Care Authority. Bart isn’t sure whether to report it or not since the money is just going from one state agency to another. Should Bart report this? Is it fraud or abuse? Reporting SoonerCare Fraud and Abuse 9 Yes, Bart should report this. It may be unintentional at this point and qualify as abuse. Reporting it will bring out the facts.

204 Scenario 2 Jessica, an employee of the Oklahoma Health Care Authority, received a phone call one day from someone who did not want to identify himself, but said that he worked at a nursing home that bills for services not rendered to its SoonerCare members. To whom should Jessica report this violation? Reporting SoonerCare Fraud and Abuse 10

205 Scenario 2 Jessica, an employee of the Oklahoma Health Care Authority, received a phone call one day from someone who did not want to identify himself, but said that he worked at a nursing home that bills for services not rendered to its SoonerCare members. To whom should Jessica report this violation? Reporting SoonerCare Fraud and Abuse 10 Jessica should report it to OHCA’s Program Integrity.

206 Scenario 3 Vanessa works in the billing department for a large hospital. She notices that newborn males who are SoonerCare members are transferred to another unit in the hospital for their circumcisions and the hospital consequently bills twice for the same patient, calling the move a transfer. The transfer results in two diagnostic related grouping (DRG) payments to the hospital, which she believes violates SoonerCare policy. Vanessa would like to report this information, but is afraid she will lose her job. Should Vanessa report this information? Could she lose her job? Reporting SoonerCare Fraud and Abuse 11

207 Scenario 3 Vanessa works in the billing department for a large hospital. She notices that newborn males who are SoonerCare members are transferred to another unit in the hospital for their circumcisions and the hospital consequently bills twice for the same patient, calling the move a transfer. The transfer results in two diagnostic related grouping (DRG) payments to the hospital, which she believes violates SoonerCare policy. Vanessa would like to report this information, but is afraid she will lose her job. Should Vanessa report this information? Could she lose her job? Reporting SoonerCare Fraud and Abuse 11 Vanessa knows she is responsible for reporting fraud and abuse so she should report it. No, she will not lose her job. The whistleblower protections in the False Claims Act will protect her job.

208 Practice Which of these resources can you use to report suspected cases of SoonerCare fraud and abuse? Reporting SoonerCare Fraud and Abuse 12 A – OHCA’s Program Integrity or OIG’s Fraud Hotline, HHS-TIPS B – Federal Safety Administration C – Oklahoma Department of Human Services hotline D – All of the above Click the appropriate answer.

209 Which of these resources can you use to report suspected cases of SoonerCare fraud and abuse? A – OHCA’s Program Integrity or OIG’s Fraud Hotline, HHS-TIPS B – Federal Safety Administration C – Oklahoma Department of Human Services hotline D – All of the above Practice Reporting SoonerCare Fraud and Abuse 12 The correct answer is A. You may report suspected cases of SoonerCare fraud and abuse to the OHCA’s Program Integrity or OIG’s Fraud Hotline.

210 Practice Should try to provide all of these the types of information when reporting suspected fraud or abuse.  Patient name  Patient SoonerCare number  Date(s) of service(s)  Description of service or item  Name of provider  Provider’s SoonerCare number  Address of provider Reporting SoonerCare Fraud and Abuse 13 A – NO B – YES Click the appropriate answer.

211 Practice Should try to provide all of these the types of information when reporting suspected fraud or abuse.  Patient name  Patient SoonerCare number  Date(s) of service(s)  Description of service or item  Name of provider  Provider’s SoonerCare number  Address of provider Reporting SoonerCare Fraud and Abuse 13 A – NO B – YES The correct answer is Yes. When reporting suspected fraud or abuse, you should provide as much information as possible.

212 Summary You have completed Module 07 – Reporting SoonerCare Fraud and Abuse.  In this module, you learned about the available resources to use when reporting suspected SoonerCare fraud and abuse.  In addition, you now know the types of information needed when you are reporting fraud and abuse, as well as the  Whistleblower Protections provided by the False Claims Act. The bottom line is if you know fraud or abuse is going on, you should have no fear of retribution. It’s everyone’s responsibility to report it and it’s the right thing to do. Reporting SoonerCare Fraud and Abuse 14

213 Identifying SoonerCare False Claims, Fraud and Abuse Post-Assessment 12/01/2014 Version 1.01

214 Introduction This Post-Assessment consists of 15 questions.  Take just a few minutes to complete this Post-Assessment.  The assessment consists of 15 questions.  The purpose of the Post-Assessment is to see what you’ve learned concerning SoonerCare fraud and abuse. Post-Assessment 2

215 Practice What is the best definition of SoonerCare fraud? Post-Assessment 3 A – Attempting a scheme against the SoonerCare program B – Knowingly executing a scheme against the SoonerCare program C – Willfully executing a scheme against the SoonerCare program D – All of the above Click the appropriate answer.

216 What is the best definition of SoonerCare fraud? Practice Post-Assessment 3 The correct answer is D. All are examples of SoonerCare fraud. A – Attempting a scheme against the SoonerCare program B – Knowingly executing a scheme against the SoonerCare program C – Willfully executing a scheme against the SoonerCare program D – All of the above

217 Practice What is the best definition of SoonerCare abuse? Post-Assessment 4 A – Knowingly defrauding the SoonerCare program B – Intentionally violating SoonerCare guidelines C – Unknowingly violating SoonerCare guidelines D – None of the above Click the appropriate answer.

218 Practice Post-Assessment 4 The correct answer is C. SoonerCare abuse is unknowingly violating SoonerCare guidelines. What is the best definition of SoonerCare abuse? A – Knowingly defrauding the SoonerCare program B – Intentionally violating SoonerCare guidelines C – Unknowingly violating SoonerCare guidelines D – None of the above

219 Practice If a provider charges a patient for a service that is not covered by SoonerCare, has fraud or abuse occurred? Post-Assessment 5 A – NO B – YES Click the appropriate answer.

220 If a provider charges a patient for a service that is not covered by SoonerCare, has fraud or abuse occurred? Practice Post-Assessment 5 A – NO B – YES The correct answer is NO. Charging a patient for a service that is not covered by SoonerCare does not constitute fraud or abuse.

221 Practice If someone completes a certificate of medical necessity without a physician’s involvement in the care of the patient, has SoonerCare fraud or abuse occurred? Post-Assessment 6 A – NO B – YES Click the appropriate answer.

222 Practice If someone completes a certificate of medical necessity without a physician’s involvement in the care of the patient, has SoonerCare fraud or abuse occurred? Post-Assessment 6 A – NO B – YES The correct answer is Yes. A physician’s involvement is required for a certificate of medical necessity form.

223 Practice A provider collects more than the established co-payment amounts from a patient for medical treatment. Has SoonerCare fraud or abuse occurred? Post-Assessment 7 A – NO B – YES Click the appropriate answer.

224 Practice A provider collects more than the established co-payment amounts from a patient for medical treatment. Has SoonerCare fraud or abuse occurred? Post-Assessment 7 A – NO B – YES The correct answer is Yes. SoonerCare providers are not allowed to collect more than the established co-payment.

225 Practice A SoonerCare provider requires a deposit from a SoonerCare member as a condition for continued care. Is this violation fraud, abuse, or neither? Post-Assessment 8 A - Fraud B - Abuse C - Neither Click the appropriate answer.

226 A SoonerCare provider requires a deposit from a SoonerCare member as a condition for continued care. Is this violation fraud, abuse, or neither? A - Fraud B - Abuse C - Neither Practice Post-Assessment 8 The correct answer is A. A provider that requires a deposit from a member as a condition for continued care has committed fraud.

227 Practice A provider intentionally upcodes services to a higher level in order to receive a larger reimbursement from SoonerCare. Is this violation fraud, abuse, or neither? Post-Assessment 9 A - Fraud B - Abuse C - Neither Click the appropriate answer.

228 A provider intentionally upcodes services to a higher level in order to receive a larger reimbursement from SoonerCare. Is this violation fraud, abuse, or neither? A - Fraud B - Abuse C - Neither Practice Post-Assessment 9 The correct answer is A. Upcoding services to a higher level to receive a larger SoonerCare reimbursement is an example of fraud.

229 Practice Are providers financially liable if their billing services commit fraud without the provider’s knowledge? Post-Assessment 10 A – NO B – YES Click the appropriate answer.

230 Practice Are providers financially liable if their billing services commit fraud without the provider’s knowledge? Post-Assessment 10 A – NO B – YES The correct answer is Yes. Providers are financially liable if their billing services commit fraud, even without the provider’s knowledge.

231 Practice Are providers financially liable for all claims submitted on their behalf that contain their SoonerCare identification number? Post-Assessment 11 A – NO B – YES Click the appropriate answer.

232 Practice Are providers financially liable for all claims submitted on their behalf that contain their SoonerCare identification number? Post-Assessment 11 A – NO B – YES The correct answer is Yes. Providers are financially liable for all claims submitted on their behalf that contain their SoonerCare identification number.

233 Practice Which of the following penalties can occur if you are liable for SoonerCare abuse? Post-Assessment 12 A – You can be obligated to participate in provider education initiatives. B – Your assignment privileges can be revoked. C – You can be imprisoned D – All of the above Click the appropriate answer.

234 Which of the following penalties can occur if you are liable for SoonerCare abuse? Practice Post-Assessment 12 The correct answer is D. All are penalties that can occur if you are suspected of SoonerCare abuse. A – You can be obligated to participate in provider education initiatives. B – Your assignment privileges can be revoked. C – You can be imprisoned D – All of the above

235 Practice When implementing safeguards to prevent SoonerCare fraud and abuse, you should keep which of the following in mind? Post-Assessment 13 A – Ensure that your SoonerCare provider number is noted on all documents for all staff to see so that they can verify your SoonerCare provider status. B – Make sure SoonerCare guidelines and updates are regularly circulated among appropriate claim and billing staff and implemented in your systems. C – Make sure that a Waiver of Liability is being provided to patients for all services performed. D – Confirm that all employees or providers hired or contracted with are not on the Sanctioned Provider List. Click the appropriate answer.

236 When implementing safeguards to prevent SoonerCare fraud and abuse, you should keep which of the following in mind? A – Ensure that your SoonerCare provider number is noted on all documents for all staff to see so that they can verify your SoonerCare provider status. B – Make sure SoonerCare guidelines and updates are regularly circulated among appropriate claim and billing staff and implemented in your systems. C – Make sure that a Waiver of Liability is being provided to patients for all services performed. D – Assume that all employees or providers hired or contracted with are not on the Sanctioned Provider List. Practice Post-Assessment 13 The correct answer is B. When implementing safeguards to prevent fraud and abuse you should make sure SoonerCare guidelines and updates are regularly circulated among appropriate billing staff and implemented in your systems and confirm all employees or providers are not on the Sanctioned Providers List.

237 Practice When selecting a billing service to use, you should choose a service that: Post-Assessment 14 A – Charges for their service on the basis of the number of claims they file rather than at a single monthly rate B – Guarantees the confidentiality of your SoonerCare provider number and other personal information C – Conducts routine audits of patient charge amounts for services rendered by the provider D – All of the above Click the appropriate answer.

238 Practice Post-Assessment 14 When selecting a billing service to use, you should choose a service that: A – Charges for their service on the basis of the number of claims they file rather than at a single monthly rate B – Guarantees the confidentiality of your SoonerCare provider number and other personal information C – Conducts routine audits of patient charge amounts for services rendered by the provider D – All of the above The correct answer is D. You should always select a billing service that: Charges on the basis of the number of claims filed rather than a monthly rate Guarantees confidentiality Conducts routine audits of patient charge amounts for services rendered by the provider

239 Practice To safeguard from fraud and abuse, providers should choose a laboratory that: Post-Assessment 15 A – Does not change diagnosis codes on the original test request form B – Monitors the test request forms to ensure that there is a diagnosis code defining the reason why each test was ordered C – All of the above D – None of the above Click the appropriate answer.

240 Practice Post-Assessment 15 To safeguard from fraud and abuse, providers should choose a laboratory that: A – Does not change diagnosis codes on the original test request form B – Monitors the test request forms to ensure that there is a diagnosis code defining the reason why each test was ordered C – All of the above D – None of the above The correct answer is C. When selecting a lab, you should choose one that does not change diagnosis codes and monitors test request forms to ensure that there is a diagnosis code defining the reason each test was ordered.

241 Practice What is the term used in the False Claims Act that refers to a person reporting fraud and abuse? Post-Assessment 16 A – Singer B – Tattletale C – Informant D – Whistleblower Click the appropriate answer.

242 What is the term used in the False Claims Act that refers to a person reporting fraud and abuse? A – Singer B – Tattletale C – Informant D – Whistleblower Practice Post-Assessment 16 The correct answer is D. The term that is used in the False Claims Act that refers to a person reporting fraud and abuse is whistleblower

243 Practice The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. What does this mean? Post-Assessment 17 A – Persons reporting fraud or abuse may be subject to the same penalties as the person committing the fraud or abuse. B – Persons reporting fraud or abuse can be discharged or demoted. C – Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. D – Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position. Click the appropriate answer.

244 The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. What does this mean? A – Persons reporting fraud or abuse may be subject to the same penalties as the person committing the fraud or abuse. B – Persons reporting fraud or abuse can be discharged or demoted. C – Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. D – Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position. Practice Post-Assessment 17 The correct answer is C. Persons who are discharged, demoted, suspended, harassed, or discriminated against for reporting fraud or abuse have protection from such actions.

245 Congratulations! You have completed the Post-Assessment and the Identifying SoonerCare False Claims, Fraud and Abuse online course. Close this window and return to to view and/or print your certificate of completion.www.ok.train.org Post-Assessment 18


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