1. 2013 Compliance, Fraud, Waste, and Abuse Training

2. Why Do We Have Compliance Training?
To improve services for American Behavioral members
To define expected conduct from providers, members and American Behavioral associates
To provide guidance that helps us make informed decisions concerning what is appropriate and right
To quickly identify and resolve compliance concerns
To assist us in abiding by the laws and regulations that govern our business
To help American Behavioral meet URAC accreditation standards
To avoid legal and financial penalties

3. The American Behavioral Compliance Mission
To direct our business in an ethical manner and in accordance with all regulations and accreditation standards
To foster open, honest and timely communication between American Behavioral and our providers
To integrate compliance as an essential part of daily operations
To promote the cooperative relationship between American Behavioral and our providers
VIVA’S COMPLIANCE MISSION
Direct our business in an ethical manner and in accordance with existing state and federal laws and regulations (for Medicare, this includes CMS Medicare Managed Care and Prescription Drug Benefit Manuals)
Effectively and promptly implement any new regulatory requirements into our operations
Integrate the Compliance Plan as an essential part of daily operations
Foster open, honest, and timely communication internally and with our:
contractors
Board of Directors
regulators

4. The Ultimate Goal
Developing controls and educating providers, members, and associates in order to reduce the amount of fraudulent, wasteful or abusive activities

5. The American Behavioral Code of Conduct
Be honest
Know the applicable American Behavioral guidelines, policies and procedures
Ask questions
Admit mistakes
Report concerns
Don’t be afraid to ask for help

6. Fraud, Waste and Abuse (FWA)
FWA is a nationwide problem that affects everyone either directly or indirectly
National estimates project that billions of dollars are lost due to fraud, waste and/or abuse, resulting in increased health care costs and increased cost for coverage
We have the responsibility to prevent, detect and eliminate FWA

7. Definition of Fraud
Fraud is when a person intentionally misrepresents information, knowing that the misrepresentation could benefit himself/herself or some other person
The most common kind of health care fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of payable benefits

8. Definition of Waste
Performing functions in a manner requiring more resources than are necessary, e.g. using or billing for more supplies, technology or hours than are required

9. Definition of Abuse
Refers to practices that may directly or indirectly cause financial loss to payers of insurance or health care benefits. Abuse often involves administering unnecessary services, improper billing or providing products or services that are not consistent with accepted practices

10. Examples of FWA
Fraud: Submitting false claims for health care services that were not provided or filing a claim for more complicated service than the service performed
Waste: Unnecessary spending or use of office supplies, technology, or resources
Abuse: Billing for services/supplies that are not medically necessary or providing care that is not consistent with accepted medical practices

11. Examples of Health Care Fraud and Abuse by a Provider
Billing for services that were not provided
Double billing: Duplicate submission of a claim for the same service
Misrepresenting the service provided
Up-coding: Charging for a more complex or expensive service that was actually provided
Billing for a covered service when the service actually provided was not covered

12. Examples of Health Care Fraud and Abuse by a Provider--Continued
Kickbacks: Receiving payments or other benefits for making a referral
Ordering excessive or inappropriate testing
Brief or intermediate-length visits coded as lengthy or comprehensive visits
Regularly waiving co-pays or co-insurance for patients, but filing with the insurance company for reimbursement

13. Examples of Health Care Fraud and Abuse by a Member/Client
Using a member ID card that does not belong to that person
Adding someone to a policy that is not eligible for coverage, e.g. a grandchild
Failing to remove someone from a policy when that person is no longer eligible, e.g. a former spouse

14. Examples of Health Care Fraud and Abuse by a Member/Client--Continued
Doctor shopping: Visiting several doctors to obtain multiple prescriptions/services
Providing false employer group and/or group membership information

15. Laws Regulating FWA The Anti-Kickback Statute
The Anti-Kickback Statute is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business.1
Examples of prohibited activities include:
Waiving a co-pay or deductible for reasons other than real financial hardship (or allowable exceptions)
Accepting a payment that is different from fair market value as a means to obtain more business
Demanding or requesting a kickback (i.e. gifts, cash, write-offs, free supplies for referring patients to specific providers)
1http://

16. Laws Regulating FWA--Continued
The Physician Self-Referral Law
(Commonly Known as The Stark Law)
The Stark Law “…prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or an immediate member of his or her family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies.2
Failure to comply with either The Anti-Kickback Statute or The Stark Law can result in fines, jail and/or exclusion from state health programs, Medicare or Medicaid 2

17. The False Claims Act
The False Claims Act is a Federal law that prohibits a provider from knowingly submitting false, fictitious, or fraudulent claims to obtain payment from federal or state programs
Knowingly and/or willfully making a false statement about a claim is a federal felony. Penalties can include significant fines, jail time and/or exclusion from participation in federal and state programs.

18. Self-Disclosure of Criminal Activity
Felony convictions or other criminal activity (other than minor traffic violations) occurring prior to or during a provider’s contract with American Behavioral must be self-disclosed
The provider agrees to notify American Behavioral within seven (7) days of the loss, restriction or recommended adverse action against his or hospital privileges or license

19. Debarment, Exclusion, or Sanctions
The Office of the Inspector General (OIG) and the General Services Administration (GSA) maintain a list of individual providers and entities that have been debarred or excluded from working with federal or state health programs. At the time of the initial credentialing or re-credentialing process, American Behavioral reviews and verifies that the individual or entity is not on that list
The OIG also maintains a list of non-licensed individuals who have had sanctions levied against them preventing them from working with federal or state health programs. On a monthly basis, American Behavioral monitors this list to ensure that no American Behavioral associate has been sanctioned.
As with other criminal activities, American Behavioral requires self-disclosure of any information related to debarment, exclusion or any activity that prevents a provider or American Behavioral associate from working directly or indirectly with Medicare, Medicaid or state health programs

20. Confidential Information
Compliance with HIPAA regulations is mandatory, and the confidentiality of records, documents and business practices must be maintained
Protected Health Information (PHI) and other member information must be appropriately safeguarded This information includes paper, electronic records and oral communication
PHI should only be shared if the disclosure is specifically allowed by HIPAA

21. Monitoring and Auditing
Everyone is obligated to monitor compliance activities and follow all policies and procedures
Any area of suspected non-compliance should be reported immediately
American Behavioral will review claims and other data submitted by each provider as an internal monitoring and auditing control
If compliance issues or concerns are identified during an audit, corrective actions are developed and implemented.

22. Teaching American Behavioral Members to be Aware
Prevention Tips
Teaching American Behavioral Members to be Aware
Review each Explanation of Benefits to ensure the accuracy of the name of the provider, dates of service and types of services reported
Protect his or her insurance card and personal information at all times
Count his or her pills each time they pick up a prescription
Be wary of all advertisements that claim “free” treatments
Check providers’ credentials with the appropriate state licensing board. If a member is unsure of a provider’s credentials, tell them to ask American Behavioral
Members should report all suspected fraud and abuse to the Quality Department at American Behavioral

23. Reporting a Potential Violation
All reports will be investigated. Individuals expressing concerns or reporting violations in “good faith” can do so confidentially without fear of retribution or retaliation as required by law. “Good faith” means to tell the truth when reporting a concern or suspected violation.
False reports, stretching the truth, or making statements made in retaliation against another person, or statements made for the sole purpose of getting someone in trouble will result in disciplinary actions.

24. Reporting a Potential Violation--Continued
Report suspicious practices involving Medicare or other Federal programs to the Office of the Inspector General (OIG) Hotline.
Phone: HHS-TIPS ( )
Fax:
Address: HHS Tips Hotline,
P.O. Box 23489
Washington, DC

25. Getting Assistance When Reporting a Potential Violation
Obtain assistance from a supervisor. If you suspect your immediate supervisor of FWA, you can contact the Quality Department ( ) or another trusted member of management.
Take the route in which you feel most comfortable.

26. What to Do Once Suspected Fraud or Abuse is Reported
To confirm that an allegation against a provider is substantiated:
Research the provider throughout all billings
Research pre-billing and post-billing reviews of the provider
Research submission and payment of claims
Query the provider history
Review contract or benefit language.

27. Potential Investigation/Corrective Actions
A pre-payment investigation may be warranted
Additional documentation may be requested from the provider before claims payment
Possible recovery of over-payments may be recommended. The decision to enact this recommendation would come from upper administration and/or corporate legal counsel
Mandatory retraining
Contract suspension and/or contract termination

28. Summary
Fraud: When a person misrepresents information, knowing that the misrepresentation could benefit himself/herself or some other person
Waste: Using more resources than necessary to complete a task
Abuse: When an associate, vendor, provider or contractor furnishes products or services that are inconsistent with accepted practices or that are clearly not reasonable or necessary

29. Summary--Continued
Compliance: The material and policies in this training are mandatory. Ethical behavior can never be sacrificed in the pursuit of other objectives
American Behavioral is committed to the highest standards of ethics and compliance. Everyone is responsible for their own conduct and behavior. If you are not sure about potential compliance or FWA issues, ask

30. Summary--Continued
If you find yourself in a situation where you are unsure of what is right, ask yourself a few simple questions:
Am I being fair and honest?
Is this in the best interest of American Behavioral and the members we serve?
Are my actions legal?
Is this the right thing to do?
How will I feel about my actions afterwards?
Will my actions stand the test of time?
Would I feel good about my actions if I were to read about it in the newspaper or see it on the news?

31. Summary--Continued Fraud, waste, and abuse are serious problems.
Report suspected fraud, waste, or abuse as soon as possible.

32. Summary--Continued
Remember The Ultimate Goal: Developing controls and educating providers, members, and associates in order to reduce the amount of fraudulent, wasteful or abusive activities

33. Final Words
Watch the little things; a small leak will sink a great ship
--Benjamin Franklin
It takes les timet o do a thing right than it does to explain why you did it wrong.
--Henry Longfellow
Quality means doing it right when no one is looking
--Henry Ford
Act as if what you do makes a difference. It does.
--William James