1. Northern Michigan Regional Entity Region 2
Compliance Training 2017
Northern Michigan Regional Entity
Region 2

2. Welcome & Introduction
This training is a federal and state requirement for all employees, contractors and agents of all agencies who provide and report over $5 million a year of services to Medicaid and/or Medicare.
This training is also part of the Northern Michigan Regional Entity’s Compliance Plan.
At the end of this training, you will be asked to specifically respond to statements regarding your knowledge of fraud & abuse.

3. Outline of the training
What are the regulations we need to follow?
What are some examples of a false claim?
Who is responsible for reporting alleged fraud, waste or abuse?
Who do I contact if I suspect wrongdoing?
Anonymous reporting
Compliance Attestation
Certification of no sanctions or prohibitions

4. What Are the Laws We Need to Follow?
Deficit Reduction Act (DRA)
Federal False Claims Act
State of Michigan False Claims Act
Federal Whistleblowers Act
State of Michigan Whistleblowers Act
Affordable Care Act

5. Deficit Reduction Act (DRA)
The 2005 Act made massive cuts to many federal budget line items, including Medicaid.
DRA reformed Medicaid by providing monetary incentives for states to enact similar false claims acts; and
Requires compliance programs for health care entities, including mandatory annual training for all employees and contractors.

6. Deficit Reduction Act (DRA)
Established new audit procedures for Medicaid services by 3rd party companies called Recovery Audit contractors (RAC).
RACs are paid a percentage of all claims found as overpayment or underpayments.
Non-compliance with the Act include: Fines up to $500,000 for entities, civil penalties of $10,000 per claim AND exclusion as a provider.
This Act also requires health care entities to have an effective compliance program.

7. Federal False Claims Act
Prohibits any person from knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval of government funds.
Any person convicted under the Act is liable for 3 times the amount of the government damages plus penalties of $5,000 to $10,000 per false or fraudulent claim.

8. Federal False Claims Act
Includes whistleblower provisions that rewards citizens who report offenders (known as Qui Tam);
Provisions also give Federal Office of Inspector General (OIG) the authority to audit and investigate health care programs;
If OIG determines there is credible evidence, the case is turned over to Dept. of Justice for prosecution.

9. What is Qui Tam?
In a qui tam action, a private party called a relator brings an action on the government's behalf. The government, not the relator, is considered the real plaintiff. If the government succeeds, the relator receives a share of the award. Also called a popular action.
For example, the federal False Claims Act authorizes qui tam actions against parties who have defrauded the federal government.  If successful, a relator in a False Claims Act qui tam action may receive up to 30% of the government's award. 

10. Michigan False Claims Act
Amended in 2009 to add provisions that mirror federal False Claim Act.
Imposes liability on persons who knowingly submit false/fraudulent claims to Michigan’s Medicaid Program.
Made is illegal to pay or receive bribes or incentives for medical referrals.
If convicted under the Act, fines include $5,000 to $10,000 each violation.

11. Michigan False Claims Act
Authorizes State Attorney General to investigate alleged violations and recover funds from fraudulent conduct.
Also protects whistleblowers from retaliation by their employers.
Whistleblowers recover 15-25% of recovered amounts if state intervenes and 25-30% if the state does not intervene.

12. Federal Whistleblower’s Act
Provides protection to employees who report a violation of law;
States that an employer shall not discharge, threaten, or discriminate against an employee who reports a violation;
Law requires a person to bring civil action within 90 days after any employer action;

13. Michigan Whistleblower’s Act
(Much the same protections as the federal Act)
It is illegal for an employer to discharge, threaten or discriminate against an employees because they reported a violation or suspected violation;
Penalties for employers found to be in violation include fines plus fully reinstate, pay back wages and additional damages including attorney fees.

14. Affordable Care Act The program integrity requirements include:
Increased screening and enrolling of providers;
If a provider is terminated from Medicare program, they are also terminated from Medicaid;
States can suspend payments of any provider under investigation of credible allegations of fraud;
Expanded Recovery Audit Contractors to audit Medicaid services.

15. Examples of a False Claim
Reporting two encounters when only one was provided;
Reporting services not rendered (if there is no documentation, the service wasn’t provided);
Billing for medically unnecessary services (not authorized in the plan of service);
Unbundling or billing separately for services that should be billed as one (reporting nursing services same day as physician’s office visit);
Failing to report and refund overpayments;

16. Who is Responsible for Reporting Non-Compliance?
All individuals are responsible for reporting suspected abuse, fraud or misuse of Medicaid dollars.
If you report non-compliance, you may be eligible for a monetary reward.
If you know something and don’t report it, you will be held responsible.
If you knowingly make a false report, you will be disciplined.

17. If I suspect Fraud or Abuse, what should I do?
Contact your CMH Compliance Coordinator……. OR
Jodie Balhorn
NMRE Compliance Coordinator
Telephone: (231) ,
Mailing: 1420 Plaza Drive , Petoskey, MI 49770
Website: go to nmre.org, click Resources>Compliance>Report Compliance Issues, enter summary of your issue.

18. Anonymous Reporting Your initial inquiry can remain anonymous.
However, if the inquiry has merit and bears a fuller review, your identity will need to be added to the reporting process.
You will also need to be available to answer questions or make statements on the record as a result from you report.
Remember! If you make a good faith report of fraud, waste, or abuse, you are protected from retaliation by the Whistleblower’s Act and the False Claim Act.

19. Compliance Reporting Attestation
In the quiz portion of this training, you will be asked to agree to two separate statements. The first statement deals with acknowledging your responsibility for reporting Medicaid fraud, waste and abuse.
The second one involves verifying that you are not prohibited (sanctioned) from providing Medicaid services.
Both are required by the federal & state regulations, so they are a condition of employment or contact to provide Medicaid services.

20. Compliance Reporting Attestation
I affirm that as an employee/staff member of the NMRE Region, I recognize and acknowledge my obligation to report any incidence of fraud, abuse or waste of public funding to the organization.
I understand that this obligation is explained in the NMRE Compliance Plan. This plan gives guidance on what is reportable, where to direct questions, and how to report.

21. Compliance Reporting Attestation
As of this date, I am not aware of any reportable compliance incident,
Or I have reported any/all incidences of non-compliance of which I am aware and it has been objectively reviewed and I have received a response from the organization.
Answer true/false

22. Excluded Provider Certification
I also certify that I have never had a professional license revoked or suspended and have never been sanctioned, whether personally or through an entity, by the Medicare or Medicaid programs.

23. Excluded Provider Certification
I also understand that I am under obligation to report to the NMRE CEO within three business days any conviction of or civil judgment rendered against me for any of the above offenses.
Answer true/false