VIVA Health Provider Compliance and Fraud, Waste and Abuse (FWA) Training

2 Why We Do Compliance Training? Improve services for our members Define expected conduct Provide guidance on making right decisions Assist in compliance with laws and regulations Quickly identify and resolve compliance concerns Avoid legal and financial penalties CMS requirement

3 New Regulatory Requirements CMS requires Medicare Advantage (MA) plan sponsors to provide Compliance Training MA plans are required to extend training to entities with whom they contract to provide Medicare benefits or services  42 cfr  42 cfr

4 VIVA Health’s Compliance Mission To direct our business in an ethical manner and in accordance with existing state and Federal laws and regulations To promptly and effectively implement regulatory requirements To foster open/honest communications and cooperative relationships between VIVA Health and our Providers To integrate Compliance as an essential part of daily operations

5 VIVA Health’s Code of Conduct Be honest Know the rules Ask questions Don’t be afraid to ask for help Admit mistakes Report concerns

6 Provider Responsibilities VIVA Health Provider Responsibilities: Follow the guidelines specified in this training material, your contract, and the VIVA Health Provider Manual Comply with Federal and state licensing requirements Report any suspected violations of laws, regulations, or our Code of Conduct

7 Provider Responsibilities VIVA Health Provider Responsibilities: Support VIVA Health’s efforts to prevent, detect and eliminate fraud, waste, and abuse (FWA) Cooperate with VIVA Health’s investigations into suspected violations Implement internal policies and procedures to prevent, detect and eliminate FWA

8 Fraud, Waste and Abuse FWA - National problem that affects all of us, directly or indirectly Billions of dollars are lost to FWA each year FWA drives up healthcare costs and premiums We are all responsible for preventing, detecting and eliminating FWA

9 Fraud - misrepresenting information that could benefit you or another person Waste - performing functions in a manner that requires more resources than are necessary Abuse - providing products or services that are inconsistent with accepted practices or are clearly not reasonable or necessary FWA - Definitions

10 Fraud - submitting false claims for healthcare services that were not provided or filing a claim for a more complicated service than the service performed* Waste - unnecessary spending or use of supplies, technology, resources* Abuse - billing for services/supplies that are not medically necessary or providing care that is not consistent with accepted medical practices* * This is a limited set of examples Examples of FWA

11 Anti-Kickback Laws Anti-Kickback Statute and Stark Law are Federal laws Prohibit someone from knowingly or willfully offering, paying or receiving anything of value for a referral Examples of prohibited activities include:  Waiving a copay or deductible for reasons other than real financial hardship (or allowable exceptions)  Accepting payment that is different from fair market value as a means to obtain more business  Demanding or requesting a kickback (e.g. gifts, cash, write-offs, or free supplies for referring patients to specific providers) Failure to comply can result in fines, jail and/or exclusion from Medicare, Medicaid and/or State Health Programs

12 False Claims Act False Claims Act (FCA) is Federal law Prohibits 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 result in significant fines, jail time and/or exclusion from participation in Federal and state programs

13 Everyone is obligated to monitor compliance activities through normal daily operations Any instance of FWA related to your VIVA Health contract must be reported immediately VIVA Health will review claims and other data submitted by each provider as an internal monitoring and auditing control Monitoring and Auditing

14 Compliance and FWA Best Practices Develop a compliance program Monitor claims for accuracy—ensure coding reflects services provided Monitor medical records—ensure documentation supports services rendered Perform regular internal audits

15 Compliance and FWA Best Practices Establish effective lines of communication with colleagues and staff members Ask about potential compliance issues in exit interviews Take action if you identify a problem Remember you are ultimately responsible for claims bearing your name, regardless of whether you submitted the claim

16 Felony convictions or other criminal activity (other than minor traffic violations) occurring prior to or during your contract with VIVA Health must be self-disclosed to VIVA Health Evidence of criminal activity will be reviewed during the initial and re-credentialing processes and at other times as deemed appropriate Criminal Activity (Self Disclosure)

17 Debarment or Exclusion Debarred or excluded individuals/entities:  Participated or engaged in certain impermissible, inappropriate or illegal conducts  Recorded with the Office of Inspector General (OIG) and/or General Service Administration (GSA)  Cannot be employed or contracted by VIVA Health  Cannot be paid through a Federal or state health program for services or products furnished, prescribed, or ordered

18 Debarment or Exclusion VIVA Health reviews the OIG and GSA lists at the following:  Initial credentialing  Re-credentialing  Monthly VIVA Health contractors are required to self- disclose any information concerning debarment, exclusion or any other activities that prevent you from working directly or indirectly with Medicare, Medicaid or Federal health programs

19 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 includes paper, , electronic records, and oral communication PHI should only be shared if the disclosure is specifically allowed by HIPAA Confidential Information

20 CMS regulations require records be kept for at least ten (10) years Records and documents must never be falsified Records

21 Get Assistance or Report a Potential Violation To a sk a question or report a potential violation contact any or all of the following: VIVA Health Customer Service    VIVA Health Attn: Compliance Officer th Avenue South Birmingham, AL OIG Hotline  MEDIC Contractors  See next slide * Use the method that makes you the most comfortable.

22 Get Assistance or Report a Potential Violation MEDIC  FWA issues  Health Integrity Attn: MEDIC 9240 Centreville Road Easton, MD SafeRx ( )  Compliance Issues  SafeGuard Services (SGS) MEDIC 225 Grandview Avenue Mailstop F10 Camp Hill, PA (fax)

23 Whistleblower Protection Whistleblower: An employee, former employee, or member of an organization who reports misconduct to people or entities that have the power to take corrective action False Claims Act allows individuals to:  Report fraud anonymously  Sue an organization on behalf of the government and collect a portion of any resulting settlement Employers cannot threaten or retaliate against whistleblowers.

24 Compliance Investigations VIVA Health investigates every report Your identity can remain anonymous (unless required by law) No retribution for reports made in good faith

25 When an investigation confirms a violation, Corrective Action will be initiated Corrective action may include, but is not limited to:  Mandatory retraining  Required regulatory agency reporting  Contract suspension and/or contract termination Corrective Action

26 CMS Administrative Sanctions Denial or revocation of Medicare provider number application Suspension of provider payments Addition to the OIG List of Excluded Individuals/Entities (LEIE) License suspension or revocation

27 CMPs, Litigation and Settlements Social Security Act authorizes the imposition of civil monetary penalties (CMPs) when individuals or entities violate Medicare rules and regulations  Typically, penalties involve assessments of significant damages such as CMPs up to $25,000 for each Medicare Advantage enrollee adversely affected United States Attorney's Office may file a civil suit or settle a case out of court  The civil suit or settlement may include a Corporate Integrity Agreement (CIA)  A CIA requires the individual or entity to accomplish specific goals (e.g., educational plan, corrective action plan, reorganization) and be subject to periodic audits by the federal government

28 The material and policies set forth in this training material, the VIVA Health Provider Manual, and your VIVA Health contract are mandatory Ethical and compliant behavior can never be sacrificed in the pursuit of business objectives VIVA Health is committed to the highest standards of ethics and compliance You are responsible for your conduct and the conduct of your employees and vendors Summary

29 FWA Resources Department of Health and Human Services Office of Inspector General:  Centers for Medicare and Medicaid Services (CMS):  CMS Information about the Physician Self Referral Law:  CMS’ Prescription Drug Benefit Manual  ads/PDBManual_Chapter9_FWA.pdf ads/PDBManual_Chapter9_FWA.pdf Medicare Learning Network (MLN) Fraud & Abuse Job Aid  edicare_Fraud_and_Abuse_brochure.pdf edicare_Fraud_and_Abuse_brochure.pdf

30 Conclusion Thank you for your cooperation and compliance For more information on any of these topics:  See the VIVA Health Provider Manual  Contact the VIVA Health Compliance Department    