Fraud, Waste and Abuse Training Presentation

 What is Independent Care (iCare) Health Plan?

What products does iCare currently offer? −In Wisconsin Medicaid Medicare Advantage (Part C) MA Special Needs Plan

As a health plan that receives both federal and state healthcare funds, iCare is required by the Centers for Medicare and Medicaid Services (CMS) to conduct fraud, waste and abuse training with iCare’s first tier, downstream and related entities. Why is iCare conducting first tier, downstream and related entities fraud, waste and abuse training?

1.The Fraud and Abuse policy for iCare 2.The laws and regulations related to fraud, waste and abuse 3.The obligations of first tier, downstream and related entities to have appropriate policies and procedures to address fraud, waste and abuse 4.The types of fraud, waste and abuse that can occur in first tier, downstream and related entities 5.The process for reporting suspected fraud, waste and abuse in first tier, downstream and related entities to the Medicare Advantage Organization (MAO) or Prescription Drug Plan (PDP) sponsor 6.The protections for employees of first tier, downstream and related entities who report suspected fraud, waste and abuse 7.Complete Attestation confirming completion of training What should the training consist of?

The Fraud and Abuse policy for iCare is CO-013. The policy can be obtained by logging onto and clicking on the Fraud and Abuse link located at the bottom of the page. 1.What is the Fraud and Abuse Policy for iCare and how can you access it?

Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR 42 §455.2) Waste - Over-utilization of services, or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Abuse - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid, Medicare Advantage or Medicare Part D program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes recipient practices that result in unnecessary cost to the Medicaid, Medicare Advantage or Medicare Part D program. (42 CFR § 455.2) 2.How do the laws define Fraud, Waste and Abuse?

Suspected violations of the False Claims Act; 31 U.S.C. §3729 of the False Claims Act Suspected violations of the Medicaid Fraud; Wis. Stats. §§ and of the Wisconsin Medicaid Fraud Statute Suspected violations of the Stark Law Suspected violations of the Anti-Kickback Statute Suspected marketing violations, including inducements Any act identified in any act defined in 18 U.S.C. Chapter 47, especially §1001 and §1035 Any act defined in the Prescription Drug Benefit Manual, Chapter 9, “Part D Program to Control Fraud, Waste, and Abuse,” Section 70 Any act defined in Wis. Stat. § as a “Provider Prohibited Act” Any act defined in Wis. Stat. §49.49 (1) as a “Recipient Prohibited Act” Health Insurance Portability and Accountability Act (HIPAA) 2.What are the Laws and Regulations Related to Medicare Advantage and Part D Fraud, Waste and Abuse?

All iCare subcontractors‘ shall comply with all fraud, waste and abuse policies and procedures of iCare and any appropriate regulatory agency for the detection and prevention of fraud and abuse committed by providers, employees, or iCare members. The subcontractor should have and maintain policies and procedures addressing fraud, waste and abuse 3.What are the obligations of the first tier, downstream and related entities to retain policies and procedures addressing fraud, waste and abuse?

Changing, forging or altering any of the following: prescriptions medical records referral forms Lending the iCare insurance card to another person Using transportation services for something other than medical services Misrepresentation of eligibility status Identity theft Resale of medications on the black market Medication stockpiling Doctor shopping 4.What types of member / recipient fraud, waste and abuse can occur in first tier, downstream and related entities?

Falsifying credentials Billing for services that were not rendered Inappropriate billing Double billing, upcoding and unbundling  Collusion among providers  Providers agreeing on minimum fees they will charge and accept  Underutilization  Not ordering services that are medically necessary Script mills Falsifying information (not consistent with medical record) submitted through a prior authorization or other formulary oversight mechanism in order to justify coverage Remuneration for prescription drug-switching 4.What types of provider fraud, waste and abuse can occur in first tier, downstream and related entities?

Inappropriate formulary decisions Pressuring providers to change medications  Shorting medications PBM-owned mail order Pharmacies  Drug switching  PBM-owned mail order Pharmacies Failure to offer negotiated prices Inappropriate documentation of pricing information Kickbacks, inducements and other illegal remunerations Inappropriate relationships with providers Illegal off-label promotion Illegal use of samples Counterfeit and adulterated drugs through black market purchase Diverting drugs Inappropriate documentation of pricing information 4.What types of Pharmacy Benefit Manager (PBM), pharmaceutical manufacturer and wholesaler fraud, waste and abuse can occur in first tier, downstream and related entities?

Inappropriate billing practices Billing multiple payers for the same prescription Billing for brand when a generic is dispensed Billing for prescriptions that are never picked up Inappropriate use of Dispense As Written (DAW) codes Billing for non-existent prescriptions Billing non-covered items as covered items Drug diversion Prescription drug shorting Bait and switch pricing Dispensing expired or adulterated prescription drugs Prescription refill errors TrOOP manipulation Illegal remuneration schemes Failure to offer negotiated prices 4.What types of pharmacy fraud, waste and abuse can occur in first tier, downstream and related entities?

All iCare employees and Board of Directors All iCare First Tier, Downstream and Related Entities 5.Who is responsible for Identifying Fraud and Abuse?

The Compliance Department performs the following activities to protect iCare from potential fraud, waste and abuse: o Perform random audits o Perform monthly reviews of State and Federal provider exclusion lists 5.Who is responsible for monitoring and auditing fraud, waste and abuse at iCare?

Standardized Referral Process Form Method  Retrieve and complete the Referral Process Form from the Fraud and Abuse Policy Fraud and Abuse Hotline - the dedicated 24/7 hotline to report suspected incidents of fraud, waste and abuse. (877) (Toll Free) or web hotline reporting at Be sure to include the following: Subject (s) of Fraud, Waste or Abuse Subject (s) Identification Information Description of Fraud, Waste or Abuse Any other pertinent information 5.What are the methods for reporting Fraud, Waste and Abuse?

Whistle blowers are offered certain protections against retaliation for bringing an action under the False Claims Act (31 U.S.C. 3729). Employees who are discharged, demoted, harassed, or otherwise confront discrimination in furtherance of such an action or as a consequence of whistle blowing activity are entitled to all relief necessary to make the employee whole. 6.What are the protections for individuals of first tier, downstream and related entities who report suspected fraud, waste and abuse?

6.Who to contact for General Compliance-related Questions/Issues? Kim Mellen – Compliance Director; (414) Catherine Walker – Compliance Specialist; (414) Irma Love – Grievance & Appeals Specialist; (414) THANK YOU!!

7.Attestation of Training Completion As a first tier, downstream or related entity, ___________________________________________ (Organization Name and ID #) attests that it has administered appropriate education and training to detect, correct, and prevent potential fraud, waste, and abuse, as required by the final rule issued in the Federal Register for 42CFR Parts 422 and 423 of the Medicare Program on December 5, Your organization completed the education and training to comply with the final rule requirement. This completed Fraud, Waste and Abuse training and education was provided by _______________________________________________ (Organization Name). By signing below, you attest that your organization will furnish training logs and certifications from downstream entities upon request to your local Plan Sponsors to validate that training was completed. ________________________________________ ______________________________________________ Print name of organization representative Organization ________________________________________ Representative’s title ________________________________________ ___________________________________ Signature Date signed This attestation is valid through Dec. 31 of the calendar year. (Complete the Attestation located on the internet, sign and return by mail to iCare, 1555 N. RiverCenter Drive, Suite 206; Milwaukee, WI or via fax at )