Presentation is loading. Please wait.

Presentation is loading. Please wait.

Fraud, Waste & Abuse TRAINING COURSE As of March 2015 Provided by Health Care Service Corporation & its subsidiaries Click here to enter the course.

Similar presentations


Presentation on theme: "Fraud, Waste & Abuse TRAINING COURSE As of March 2015 Provided by Health Care Service Corporation & its subsidiaries Click here to enter the course."— Presentation transcript:

1 Fraud, Waste & Abuse TRAINING COURSE As of March 2015 Provided by Health Care Service Corporation & its subsidiaries Click here to enter the course.

2 The Bottom Line WHY? FRAUD WASTE & ABUSE is this training so important

3 Who Am I In the Big Picture WHO? FRAUD WASTE & ABUSE

4 The Action Steps FRAUD WASTE & ABUSE WHAT? can I do to stop fraud, waste & abuse

5 Know the Law FRAUD WASTE & ABUSE LAW? What do I need to know about the

6 FRAUD WASTE & ABUSE The Bottom Line Who Am I In the Big Picture? The Action Steps Know the Law Start here Return to this page by clicking the Home icon

7 Know the Law The Action Steps Who Am I In the Big Picture? The Bottom Line THE BOTTOM LINE Why is this training so important? WHY? Home Back / Forward

8 THE BOTTOM LINE CMS requires training New & Existing Employees for Work on a government contract who

9 THE BOTTOM LINE 7 CMS Core Requirements 1.Written Policies, Procedures and Standards of Conduct 2.Compliance Officer, Compliance Committee and High Level Oversight 3.Effective Training and Education 4.Effective Lines of Communication 5.Well Publicized Disciplinary Standards 6.Effective System for Routine Monitoring and Identification of Compliance Risks 7.Procedures and System for Prompt Response to Compliance Issues

10 THE BOTTOM LINE 7 CMS Core Requirements 1.Written Policies, Procedures and Standards of Conduct 2.Compliance Officer, Compliance Committee and High Level Oversight 3.Effective Training and Education 4.Effective Lines of Communication 5.Well Publicized Disciplinary Standards 6.Effective System for Routine Monitoring and Identification of Compliance Risks 7.Procedures and System for Prompt Response to Compliance Issues Click here to view Chapter 9here Click here to view the Federal Sentencing Guidelineshere Click here to view HCSC’s Compliance Programhere

11 Ms. B. Skloss Click on the magnifying glass

12 Ms. B. Skloss Every patient has the same diagnosis

13 Ms. B. Skloss Billing for more than 24 hours/day Every patient has the same diagnosis

14 Ms. B. Skloss Billing for Individual, Group & Family Therapy for most clients Billing for more than 24 hours/day Every patient has the same diagnosis

15 Ms. B. Skloss Every patient has the same diagnosis Billing for Individual, Group & Family Therapy for most clients Billing for more than 24 hours/day Billing for in-person visits when speaking with them on the phone

16 Ms. B. Skloss Billing for Individual, Group & Family Therapy for most clients Billing for more than 24 hours/day Every patient has the same diagnosis Billing for 7 days/week even on holidays Billing for in-person visits when speaking with them on the phone

17 Ms. B. Skloss HCSC

18 Ms. B. Skloss Explanation of Benefits

19 WHO AM I IN THE BIG PICTURE?

20 RESPONSIBILITIES Know and abide by terms of government contract 1 2 Stay true to your company’s code Click here to view HCSC’s Code of Conduct. Save this page to your favorites.here Cooperate fully and truthfully with government agencies 3

21  I have been hired within the past 90 days.  This is my annual training. I work directly or indirectly on a government program, such as Medicare or Medicaid. DIRECTLY ON GOVERNMENT PROGRAM INDIRECTLY

22 Report improper payment to government officials 4 5 Comply with the laws that impact government programs Violations regarding gifts to government employees can result in serious consequences RESPONSIBILITIES

23 Avoid conflicts of interest 6 GOOD FOR ME GOOD FOR MY COMPANY RESPONSIBILITIES

24 Recognize and report fraud, waste & abuse 7 How do I report fraud, waste and abuse? RESPONSIBILITIES

25 WHO AM I? Corporate Integrity Compliance Program HCSC/HISC/GHS

26 WHO AM I? TOM LUBBEN HCSC’s Chief Compliance & Privacy Officer Corporate Integrity Compliance Program HCSC/HISC/GHS

27 WHO AM I? TOM LUBBEN HCSC’s Chief Compliance & Privacy Officer Corporate Integrity Compliance Program HCSC/HISC/GHS

28 WHO AM I? KIM GREEN HCSC’s Government Programs Compliance Officer Specific policies Oversees compliance Government contracts

29 WHO AM I? HCSC/HISC/GHS Plan Sponsor Independent Practice Associations Providers Call Centers Health Services/ Hospital Groups Radiology Hospitals Providers Mental Health Providers Fulfillment Vendors Field Marketing Organization Agents Credentialing PBM Pharmacy Quality Assurance Firm Claims Processing Firm First Tier Down- stream Downstream Monitor & Audit Implement policies & procedures Comply with the law Set high ethical standards Report suspected FWA to the Plan Sponsor FDR RESPONSIBILITIES Monitor and audit themselves & downstream

30 WHO AM I? HCSC/HISC Plan Sponsor Independent Practice Associations Providers Call Centers Health Services/ Hospital Groups Radiology Hospitals Providers Mental Health Providers Fulfillment Vendors Field Marketing Organization Agents Credentialing PBM Pharmacy Quality Assurance Firm Claims Processing Firm First Tier First Tier Down- stream Down- stream Downstream Downstream

31 HCSC

32 Detect Report Correct Prevent THE ACTION STEPS

33 ACTION STEPS Detect FraudWaste Abuse Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice— (1) To defraud any health care benefit program or (2) To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program US Code Title 18, Section 1347

34 ACTION STEPS Detect Fraud Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice— (1) To defraud any health care benefit program or (2) To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program US Code Title 18, Section 1347 False information is intentionally submitted to the government to get money or a benefit

35 ACTION STEPS Detect Fraud HCSC $43,904 FRAUD

36 Law Litmus Test ● Click the box next to the correct answer. Which of the following laws prohibits knowingly submitting or causing someone else to submit a claim for payment with government funds using false information or making false statements in order to get a claim paid or approved by the government? Stark Statute False Claims Act HIPAA NO, but we’ll talk about this later. Anti-Kickback Statute NO, but we’ll talk about this later.

37 That’s right! There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud. There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud. Ms. Skloss was found guilty of Theft related to the false claims filed with both the Texas Medicaid Program and BCBSTX. Damages may be triple the amount of the claim and the government may impose a civil penalty of $5,500 - $11,000 for each false claim. It may also carry heavy criminal penalties. If convicted, depending upon the circumstances, the individual may be fined and/or imprisoned for a number of years up to and including life. There may be additional penalties required due to state governments based on the state False Claims Acts. PENALTIES It’s important to note that the False Claims Act applies if the person knew or even should have known that the claim was false.

38 ACTION STEPS Detect FraudWaste Abuse IntentionalNot intentional UNNECESSARY COSTS

39 ACTION STEPS Detect Waste Abuse Overutilization of services Generally not considered to be criminally negligent Misuse of resources Request for payment No legal entitlement Not knowingly misrepresented facts

40 ACTION STEPS Detect Which prescription is suspicious? NO, not this one.

41 ACTION STEPS Detect CORRECT! It appears that the date on this prescription has been altered.

42 ACTION STEPS Detect FRAUD CLUES Many identical prescriptions in a short time Prescription does not match the beneficiary’s medical history Generics are being provided when prescription requires a brand Drugs are expired. PRESCRIPTIONS & MEDICINE

43 ACTION STEPS Detect Which scenario is suspicious? This is a simple case of tonsillitis. You’ll be out of the hospital today. All of that for tonsillitis ? I’m going to run a series of 12 tests: an MRI, blood work, CAT Scan… NO, not this one.

44 ACTION STEPS Detect CORRECT! All of that for tonsillitis ? I’m going to run a series of 12 tests: an MRI, blood work, CAT Scan… Does the treatment match the diagnosis?

45 ACTION STEPS Detect FRAUD CLUES Bills for services not provided Prescriptions for a higher quantity than medically necessary for the condition PHYSICIAN

46 ACTION STEPS Detect Read the sales scenarios below. Which one is suspicious? If you sign up for Medicare today and make Dr. Popper your primary physician, you’ll get a $100 gift card. These are the services you can expect if you sign up for Medicare. I’ve also provided a list of doctors in your area who accept Medicare. NO, not this one.

47 ACTION STEPS Detect CORRECT! If you sign up for Medicare today and make Dr. Popper your primary physician, you’ll get a $100 gift card. Offering monetary rewards to sign up for a government health plan

48 Law Litmus Test ● Click the box next to the correct answer. Which of the following prohibits willfully receiving or offering a bribe or rebate for referrals for services that are paid under a federal health care program? HIPAA Anti-Kickback Statute Exclusion NO, but we’ll talk about this later. Stark Statute NO, but we’ll talk about this later.

49 PENALTIES THAT’S RIGHT! These 9 cardiologists paid the government over $3.2 million to settle their case for entering into the kickback scheme with the hospital. Two of them also plead guilty to criminal embezzlement charges involving the same conduct. Fines up to $25,000, imprisonment up to 5 years or both. If the sales rep offering a $100 gift card for beneficiaries to join the plan with Dr. Popper is receiving money from the doctor in return for referring patients to him, he is violating the Anti-Kickback Statute. Sales agents must always be honest and truthful in presenting products as outlined in the benefit guides, without adding anything to it. This law applies to more than sales people. The real live case below involves providers. Nine cardiologists and a local hospital entered into a kickback agreement, under which the cardiologists received payment from the hospital (even though they did not perform services for the hospital) in exchange for referring their patients to the hospital for surgery. $100

50 Detect

51 Report

52 ACTION STEPS Report Explanation of Benefits

53 ACTION STEPS Report What’s suspicious about these claims? Multiple almost identicalOne provider / Same dayExceed normal costs Hm…these claims are all the same! All submitted by XYZ Diagnostics on March 31.

54 ACTION STEPS Report HCSC CODE “Our Company is committed to the policy that all employees have an obligation to report problems or concerns involving ethical or compliance violations…without fear of retaliation.” Click here to view HCSC’s Code of Conduct.here

55 ACTION STEPS Report Plan Sponsor Reporting is everyone’s responsibility.

56 Reporting Resources HCSC Fraud Hotlines (24/7, anonymous) (877) SID* Fraud Hotline (Producers, Vendors, Providers) (800) SID* Fraud Hotline (Members) (877) Government Programs Hotline On-line form (anonymous) https://www.incidentform.com/BCBSFraudHotline.jsp Report *SID = Special Investigations Department

57 ACTION STEPS Report Talk to a Manager or Supervisor Report through the Website or Hotline Call the Medicare Compliance Officer Employees of Plan Sponsor HCSC/HISC Talk to a Manager or Supervisor Call Your Ethics/Compliance Help Line Report through the Sponsor FDR Employees Call the Sponsor’s compliance hotline Make a report through Sponsor’s website Call Medicare Beneficiaries

58 LAW LITMUS TEST Stark Statute Click the box next to the correct answer Which of the following is also known as the Physician Self-Referral Law? Exclusion HIPAA NO, but we’ll cover this shortly.

59 That’s right! A physician is prohibited from making a referral for health services to an entity in which the physician or a relative may have an ownership or compensation interest Up to $15,000 for each service provided. $100,000 fine for entering into an arrangement or scheme. Medicare claims tainted by an arrangement that does not comply with Stark are not payable. The Stark Statute is also known as the Physician Self-Referral Law. PENALTIES In a recent case, a physician routinely referred his Medicare patients to an oxygen supply company. No problem, right? Actually, he owned the oxygen supply company and violated the Stark Statute. He paid the government $203,000 to settle the allegations.

60 Report

61 Correct

62 ACTION STEPS Correct Immediate ReportingQuick Correction KIM GREEN HCSC’s Government Programs Compliance Officer

63 ACTION STEPS Correct Which is the correct response? This sounds suspicious. It might be fraud. This guy probably doesn’t remember what drugs he’s taken. I found a drug listed on my Explanation of Benefits that I was never given. No. The member’s concern should be reported, not ignored. This is possible fraud.

64 ACTION STEPS Correct CORRECT! What should she do now? This sounds suspicious. It might be fraud. Call her company’s fraud hotline Notify her supervisor Call the member’s provider Call the pharmacy that filled the member’s prescription Contact her compliance officer No, the CSR should not contact the member’s provider. No, the CSR should not contact the member’s pharmacy.

65 ACTION STEPS Correct CORRECT! Call her company’s fraud hotline Notify her supervisor Contact her compliance officer HCSC Fraud Hotlines (24/7, anonymous) (877) SID Fraud Hotline (Producers, Vendors, Providers) (800) SID Fraud Hotline (Members) (877) Government Programs Hotline On-line form (anonymous) https://www.incidentform.com/BCBSFraudHotline.jsp

66 ACTION STEPS Correct What happens after the suspected fraud is reported? One of our members called to report an error on his EOB… Correct clerical errorAssigned to an investigator

67 ACTION STEPS Correct REAL LIFE $200,000.00

68 Law Litmus Test ● Click the box next to the correct answer. No federal health care program payment may be made for any item or service furnished, ordered or prescribed by an individual or entity excluded by the Office of Inspector General (OIG). These exclusions are intended to protect beneficiaries from the risk of harm by untrustworthy individuals by barring them from participation in federal health care programs. Exclusions may apply to: Individuals Both Organizations Almost, but not quite

69 That’s right! You can check if an individual or company is on the OIG Exclusion list or the System of Award Management (SAM) website search feature. OIG Exclusion list (SAM) website Remember Mr. Hammerman, the pharmacist? Blue Cross Blue Shield of Illinois worked with the government to help prosecute Mr. Hammerman. He’s in jail now, but the pharmacy also paid the price and was excluded from participating in any government program. PENALTIES Exclusions may apply to individuals and to organizations. Exclusion periods vary depending on the reason. The Office of Inspector General’s (OIG) special Advisory Bulletin entitled, “The Effect of Exclusion From Participation in Federal Health Care Programs” is a great resource that lays out some of the details concerning exclusions. Click here to access it. here

70 Correct

71 Prevent

72 ACTION STEPS Prevent Detect ReportCorrect Monitor Audit Prevent

73 ACTION STEPS High Risk Areas Appeals & Grievances Sales & Marketing Enrollment & Disenrollment Claims Processing Formulary Administration Agent / Broker Prevent

74 ACTION STEPS WHAT YOU CAN DO Verify information is true Put policies in practice Know the law Check billing information Prevent

75 Law Litmus Test ● Click the box next to the correct answer. The Health Insurance Portability and Accountability Act (HIPAA): Required organization to notify individuals if there is a breach of their PHI All of the above Provided individuals with the right to limit access to their PHI YES, but it did more than that Mandated that organizations implement safeguards to prevent unauthorized access to protected health information (PHI) YES, but it did more than that

76 PHI = Protected Health Information THAT’S RIGHT! Note to self: I am part of the solution There is no acceptable excuse for inappropriate use of, disclosure of or access to PHI. HIPAA does all of these. While it is a crime to knowingly obtain or disclose protected health information (PHI) for fraudulent purposes, it is a HIPAA violation to disclose PHI to an unintended recipient even when there is no criminal intent

77 ACTION STEPS PROTECT PHI Prevent Know and comply with any contractual obligations that apply Protect all health, financial and/or employment information Limit access, use and sharing of information to the minimum amount necessary to achieve the task Avoid using Social Security numbers when sending information out externally unless there is a compelling business need

78 ACTION STEPS REPORT Prevent Correspondence or a claim goes to the wrong address A company report gets into the wrong hands A data file is sent to the wrong address Examples of unauthorized disclosures Organizations are required by the HITECH Act to notify individuals within 60 days if there is a breach of their PHI

79

80 FRAUD WASTE & ABUSE CONSEQUENCES Civil Money Penalties Criminal Conviction / Fines Civil Prosecution Imprisonment Loss of Provider License Exclusion from Federal Health Care Programs

81 Reporting Resources HCSC Fraud Hotlines (24/7, anonymous) (877) SID Fraud Hotline (Producers, Vendors, Providers) (800) SID Fraud Hotline (Members) (877) Government Programs Hotline On-line form (anonymous) https://www.incidentform.com/BCBSFraudHotline.jsp

82 Visit our web site at and stay current on government programs issues. Check out Kim Green’s quarterly newsletter.http://hisccompliance.com/ Comments or suggestions concerning training?

83 CONGRATULATIONS! You have completed the course


Download ppt "Fraud, Waste & Abuse TRAINING COURSE As of March 2015 Provided by Health Care Service Corporation & its subsidiaries Click here to enter the course."

Similar presentations


Ads by Google