Anytime you see the information button, click on it for more information Click on the home button if you need to return to this instruction page At the end of the training, take the quiz. Once you pass the quiz the answers will be submitted automatically-no need to do anything further. A couple of things to note as you proceed through the class: If a screen does not proceed on its own you may need to click the next button located at the bottom of your screen

Hi June, I wanted to talk to you about our Fraud, Waste and Abuse policy Oh good! I’ve been hearing about it and wanted to know more…

It is required by federal law that we have refreshers each year You’re right Paul

What exactly do we mean by Fraud? Fraud is… The intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to oneself or someone else…NOT GOOD!

Let’s take a closer look at what is and isn’t Fraud

Examples of Fraud 1.Billing for No ShowsBilling for No Shows 2.Misrepresenting a diagnosis in order to justify the servicesMisrepresenting a diagnosis in order to justify the services 3.Misrepresenting who, what, or where the services occurredMisrepresenting who, what, or where the services occurred 4.Duplicate billing and billing for non-covered servicesDuplicate billing and billing for non-covered services 5.Substituting ServicesSubstituting Services 6.Incorrect coding to generate more revenueIncorrect coding to generate more revenue 7.OverutilizationOverutilization If slide does not advance automatically please manually click the next slide from the “Outline” to the left

The False Claims “Whistleblower” Employee protection Act Laws Regulating Fraud Deficit Reduction Act False Claims Act (FCA) HIPAA The Anti- Kickback Statute Physician Self-Referral (“Stark”) Statute Administrative Remedies for False Claims and Statements

The False Claims “Whistleblower” Employee protection Act Laws Regulating Fraud Deficit Reduction Act False Claims Act (FCA) HIPAA The Anti- Kickback Statute Physician Self-Referral (“Stark”) Statute Administrative Remedies for False Claims and Statements

…remember, every employee is protected from retribution for reporting Fraud, Waste or Abuse It is especially important to… The law about Whistleblower Protection sounds very important

…health care spending that can be eliminated without reducing quality of care That makes sense…so what is Waste then? Waste is…

Yes Paul. There are two types of Waste… …and, “Inefficiency Waste” is redundancy, delays, and unnecessary process complexity …“Quality Waste” is over, under or ineffective use

Zack and Angi are both correct Tell her about Abuse

Abuse is… …inconsistent practices that result in an unnecessary cost to Medicaid, Medicare or the MVBCN Abuse can also be reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care

False Claims Act Under the False Claims Act (FCA), 31 U.S.C , those who knowingly submit, or cause another person or entity to submit false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim –The FCA applies to any health care entity that receives more than $5 million in Medicaid funds MCHD receives in excess of $5 million annually Back

HIPAA The Health Insurance Portability and Accountability Act (HIPAA), 45 CFR, Title II, , provides clear definition for Fraud & Abuse control programs, establishment of criminal and civil penalties and sanctions for noncompliance Established the national Health Care Fraud and Abuse Control Program (“HCFAC”) that coordinates Federal, state, and local law enforcement activities with respect to health care Fraud, Waste and Abuse. It created the offense of “health care Fraud” and established criminal penalties for violation. Penalties: Fines Imprisonment Back

Deficit Reduction Act The Deficit Reduction Act (DRA), Public Law No , 6032, passed in 2005, is designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries The Act requires compliance for continued participation in the programs. The development of policies and education relating to false claims, whistleblower protections and procedures for detecting and preventing Fraud & Abuse must be implemented Back

The False Claims “Whistleblower” Employee protection Act The False Claims Act Whistleblower Employee Protection Act, 31 U.S.C 3730(h), states that a company is prohibited from discharging, demoting, suspending, threatening, harassing or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer Every employee is protected with ZERO retribution for making referrals whether they are made anonymously or not Back

The False Claims “Whistleblower” Employee protection Act The False Claims Act Whistleblower Employee Protection Act, 31 U.S.C 3730(h), states that a company is prohibited from discharging, demoting, suspending, threatening, harassing or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer Every employee is protected with ZERO retribution for making referrals whether they are made anonymously or not Back Whistleblower #2

Administrative Remedies for False Claims and Statements Administrative Remedies for False Claims and Statements, 31 U.S.C Chapter 8, 3801, states that any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim Back

The Anti-Kickback Statute The Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b), prohibits knowingly or willfully soliciting, receiving, offering, or paying any remuneration (including any kickback, bribe or rebate) in order to induce or reward business that is payable under a Federal health care program. Penalties for violation: Criminal penalty of fines of up to $25,000; and/or imprisonment of up to 5 years Civil penalty of up to $50,000 per act plus 3 times the amount of remuneration Exclusion from Federal health care programs Back

Physician Self-Referral (“Stark”) Statute Back The Physician Self-Referral, “Stark” Statute, 42 U.S.C. 1395nn, prohibits a physician, from making referrals for certain designated health services to an entity in which the physician, or a member of his/her family, has an ownership/investment interest or with which he/she has a compensation arrangement. Penalties for violation: Up to $15,000 for each claim submitted in violation of the law Up to $100,000 for each “scheme” that violates the law Penalties of up to 3 times the amount claimed Exclusion from Federal health care programs

MCHD has it’s own Anti-Fraud Strategy. Let’s take a closer look…

I suspect Fraud, now what do I do? That’s a very important question, Ming.

Reporting Fraud  Anonymous Hotline :   Mail, submit or fax the Fraud, Waste and Abuse Referral Form located on both the MCHD Internet and Intranet) to:Fraud, Waste and Abuse Referral Form Mail: Marion County Health Dept Attn: FWA Compliance Officer 3180 Center St NE Salem, OR Fax:(503)

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Additional Contacts  Medicaid Fraud Control Unit (971) SW 5 th Ave Suite 410 Portland, OR  DHS Fraud Investigation Unit (503) PO Box Salem, OR  MCHD Compliance Officer  Remember: there is never a ‘bad’ referral and failure to report may result in disciplinary action.

Employee Rights and Responsibilities  Have the right to remain anonymous  To the extent allowed by the law  Protection from retaliation  Employees are obligated to report potential Fraud, Waste or Abuse  Failure to report could require MCHD to pay excessive fines and potentially be excluded from Federal health care programs Back

MCHD Compliance Officer Division Director:  Roy Deede (503)  His duties:  Represent the Health Department on external Fraud and Abuse Committees  May act as the lead on internal or external investigations of Fraud, Waste and Abuse Back

Maintain appropriate and legible documentation Understand which services are covered and which are not covered Don’t submit duplicate claims How do I make sure I stay in compliance? Record start and stop times accurately

Avoid ‘up-coding’ or ‘down-coding’ Cooperate with any audits or reviews Comply with State licensure regulations

As your supervisor, feel free to contact me if you have questions about Fraud, Waste or Abuse or reporting requirements. I’ll be glad to help!

YEAH! Together, we can eliminate Fraud, Waste and Abuse!

Quiz Instructions 1.You have just completed the Fraud, Waste, and Abuse training. To receive credit please complete the 10 question quiz by clicking on the link below.You have just completed the Fraud, Waste, and Abuse training. To receive credit please complete the 10 question quiz by clicking on the link below. 2.It is very important that you enter your first and last name at the end of the quiz to receive credit.It is very important that you enter your first and last name at the end of the quiz to receive credit. 3.Your results are electronically submitted. You do not need to print them.Your results are electronically submitted. You do not need to print them. Click HERE to proceed to the quiz