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CAREPOINT HEALTH PLANS Part C and Part D Medicare Fraud, Waste and Abuse Comprehensive Training.

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Presentation on theme: "CAREPOINT HEALTH PLANS Part C and Part D Medicare Fraud, Waste and Abuse Comprehensive Training."— Presentation transcript:

1 CAREPOINT HEALTH PLANS Part C and Part D Medicare Fraud, Waste and Abuse Comprehensive Training

2 Why Do I need Training Every year millions of dollars are improperly spent because of fraud, waste, and abuse. It affects everyone. Including YOU and YOUR JOB This training is designed to help you detect, correct, and prevent fraud, waste, and abuse. YOU are part of the solution.

3 Overview and Objective The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations and Part D Plan Sponsors to provide annual fraud, waste, and abuse training to their employees. As part of the CarePoint Health Plans Compliance Program, we are actively engaged in preventing, detecting and resolving any and all Medicare related Fraud, Waste and Abuse It is important that all internal employees and related FDR’s are made aware of their responsibility in reporting discovered issues of FWA to the CarePoint Health Plans Compliance Department Provide information on laws governing issues of Fraud, Waste and Abuse Provide information on how to report Fraud, Waste and Abuse

4 Understanding Fraud, Waste and Abuse To be properly equip YOU to detect, prevent and report issues of FWA, it is important to understand the specific definitions of Fraud, Waste and Abuse Fraud: is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)

5 Understanding Fraud, Waste and Abuse Waste: is over-utilization of services or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions but rather misuse of resources. Abuse: includes payments, actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Source: Definitions’ section of Chapter 9 of the CMS Prescription Drug Benefit Manual and Chapter 21 of the CMS Medicare Managed Care Manual.

6 Governing Laws on FWA Several federal laws prohibits issues of Fraud, Waste and Abuse; some of the main ones are as follows False Claims Act: Prohibits presenting or causing to present a false claim to the government for payment or approval FCA also includes knowingly concealing or knowingly and improperly avoiding or decreasing and obligation to pay the government Anti Kickback Statute: Strictly prohibits offering, paying, soliciting or receiving anything of VALUE for the referral of services paid in whole under a Federal Health Program (ex:Medicare) Violation of this law results in fines of up to $25,000, imprisonment of up to five (5)years, or both fines and imprisonment

7 Governing Laws on FWA Health Insurance Portability and Accountability Act: Passed by congress in 1996, the law is provides the following Ability to transfer and continue health insurance coverage for families or individuals who lose and change jobs Mandates industry wide standards for health care information on electronic billing and patient information Reduces health care fraud and abuse Beneficiary Inducement Law: Prohibits the offering of inducement or incentives that the giver should know or have known would influence the beneficiaries selection of a provider Waiver of co-insurance Wavier of deductible amounts Transfer of items or services for fees

8 Governing Laws- Exclusions Federal agencies like the HHS, OIG, OPM have the authority to exclude specific individuals cited for FWA violations from participating in Federal Health Care Programs These agencies also have the authority to suspend or debar individuals receiving government contracts and grants to provide services under any Federal Health Care Program (ex. Medicare, Medicaid) FDR’s may not employ or contract with entities or individuals included in the federal debarment list

9 Governing Laws Cont. As an MCO (Managed Care Organization), CarePoint Health Plans is required to ensure that all employees and FDR related entities are cross checked against the DHHS OIG LEIE and GSA EPLS reports Individuals or entities found on these reports are excluded from participating or receiving payments for services issued under any Federal Health Care Program In addition any entity that knowingly employs or contracts with an excluded or debarred individual for services under the Federal Health Care Program is subject to monetary penalties.

10 Exclusions Database The names of all individuals and entities excluded or debarred from federal and state health care programs are listed in databases maintained by the HHS OIG at and by the General Services Administration at For more information, see the HHS OIG Special Advisory Bulletin on the Effect of Exclusion From Federal Health Care Program Participation, available on the HHS OIG web site at or the OPM web site on OPM Administrative Sanctions and Debarment

11 Who Can Commit Health Care FWA The reality is that many individuals can commit health care related Fraud Waste and Abuse violations Fraud Waste and Abuse violations can be committed by Pharmacy Managed Care Organization(s) Medicare Beneficiaries Providers FDR and/or Vendors

12 Examples and Common Types of Health Care FWA Health Care FWA varies and can occur in many forms. Listed below are common types of FWA Routinely waiving co-payments and deductibles Providing treatment that is inconsistent with the diagnosis Withholding medically necessary services “Unbundling Claims” Misrepresenting facts affecting eligibility for benefits, such as employment status, health history, martial status or identity Illegal promotion of off-label drug usage Inappropriate marketing or promotion of products Lack of data integrity to establish payment or reimbursement Prescription Shortfills/ Bait and Switch Pricing Doctor Shopping

13 Examples and Common Types of Health Care FWA Identity theft Improper Coordination of Benefits( Beneficiary failure to disclose multiple benefits) Prescription Fraud (Falsifying or modifying prescription) Inappropriate enrollment and disenrollment practices MAO marketing schemes Delaying access to necessary covered drugs Patient dumping Altering Medical Records Dispensing expired drugs or Tainted Drugs

14 Reporting FWA Remember CarePoint Health Plans requires all employees and related entities to comply will all outlined federal, state and local laws, regulations and compliance program requirements. If you suspect any CarePoint Health Plans employee or vendor to be violating laws, engaging in misconduct or unethical behavior, you must immediately report them to one of the following:

15 Reporting FWA Your direct line supervisor/department director CarePoint Health Plans Compliance Officer CarePoint Health Plans legal and Regulatory director CarePoint Health Plans Special Investigations Unit CarePoint Health Plans compliance address The CarePoint Health Plans compliance hotline (All calls can be made anonymously) Compliance Hotline Compliance –

16 Non-Retaliation Policy To encourage and protect processes in reporting violations of FWA, CarePoint Health Plans maintains a non-retaliation policy that specifically states that individuals reporting violations of FWA will be protected from any retaliation or reprisals by any involved parties. A copy of this policy is readily available Additionally these individuals are also protected by the whistleblower clause provision outlined in the Federal Claims Act

17 Internal Review CarePoint Health Plans Compliance Department facilitates an on-going Risk Management forum to discuss and resolves all operational risk areas alongside issues of Fraud Waste and Abuse. CarePoint Health Plans also conducts periodic reviews of its operations For example, the Medicare Compliance Program maintains an internal audit work plan with scheduled and unscheduled audits of the Medicare operations. These audits include, but are not limited to, marketing, enrollment, data submitted to the Center for Medicare and Medicaid Standards (referred to as CMS), appeals and oversight of delegated vendors.

18 CONCLUSION CarePoint Health Plans is highly committed to abiding by all applicable laws, rules and regulations that govern our business. CarePoint Health Plans compliance program is designed to provide sound education and safeguards on the operational functions of health care provision. Thank you for your completing this CMS required training course on the detecting and preventing issues of Health Care Fraud, Waste and Abuse


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