1. Medicare Advantage and Part D General Compliance Training Copyright © 2009 Highmark Inc.

2. Products Covered by this Training Keystone Health Plan West Security Blue Keystone Health Plan West Security Blue Highmark FreedomBlue PPO Pennsylvania Highmark FreedomBlue PPO Pennsylvania Highmark FreedomBlue PFFS Pennsylvania Highmark FreedomBlue PFFS Pennsylvania HHIC FreedomBlue PPO West Virginia HHIC FreedomBlue PPO West Virginia HHIC FreedomBlue PFFS West Virginia HHIC FreedomBlue PFFS West Virginia Highmark Senior Resources Blue Rx Highmark Senior Resources Blue Rx Copyright © 2009 Highmark Inc.

3. General Compliance Training Why this training? Why this training? What will I learn? What will I learn? Fraud, waste, and abuse terms Fraud, waste, and abuse terms Compliance and Fraud, waste, and abuse law Compliance and Fraud, waste, and abuse law Highmark’s expectations of Providers and their staffs Highmark’s expectations of Providers and their staffs Examples of fraud, waste, and abuse Examples of fraud, waste, and abuse Where to ask questions or report potential fraud, waste and abuse violations Where to ask questions or report potential fraud, waste and abuse violations Copyright © 2009 Highmark Inc.

4. Why This Training? CMS amended its Medicare Advantage (MA) and Part D regulations to clarify the obligations of MA organizations and Part D sponsors, such as Highmark, to include general compliance and fraud, waste and abuse training in their education plans for their providers and their providers’ employees, managers and directors. Copyright © 2009 Highmark Inc.

5. Terms You Should Know Theft by deception – The use of deception for unlawful gain or unjust advantage. Theft by deception – The use of deception for unlawful gain or unjust advantage. Fraud – Using intentional deception or misrepresentation for unlawful gain or unjust advantage Fraud – Using intentional deception or misrepresentation for unlawful gain or unjust advantage Waste – Using, consuming, spending, or expending thoughtlessly or carelessly Waste – Using, consuming, spending, or expending thoughtlessly or carelessly Abuse - Using wrongly or improperly Abuse - Using wrongly or improperly Conspiracy – An agreement between two or more persons to perform together an illegal wrongful or subversive act. Conspiracy – An agreement between two or more persons to perform together an illegal wrongful or subversive act. Copyright © 2009 Highmark Inc.

6. Terms You Should Know (Continued) Compliance Program – A program to ensure that Highmark, its employees and contractors comply with all applicable laws and contractual requirements, including those regulating the Medicare Advantage and Part D programs and those prohibiting waste, fraud and abuse. Compliance Program – A program to ensure that Highmark, its employees and contractors comply with all applicable laws and contractual requirements, including those regulating the Medicare Advantage and Part D programs and those prohibiting waste, fraud and abuse. Copyright © 2009 Highmark Inc.

7. Expectations Highmark’s expectations of our providers: Highmark’s expectations of our providers:  Conduct business activities and interactions with our members ethically and with integrity.  Conduct business activities in full compliance with applicable statutory, regulatory and Medicare Program requirements.  Maintain patient records that are accurate and complete and appropriately reflect treatment.  Call the Highmark Integrity Office when you have compliance questions or concerns about potential fraud and abuse. Copyright © 2009 Highmark Inc.

8. Compliance with the Law The activities of Highmark and each of its contracting providers and their employees, managers and directors. must be carried out in accordance with applicable laws and related Highmark policies and procedures. The activities of Highmark and each of its contracting providers and their employees, managers and directors. must be carried out in accordance with applicable laws and related Highmark policies and procedures. Federal and state laws may include matters such as, submission of data, record keeping, access to records, and privacy of protected health information. Federal and state laws may include matters such as, submission of data, record keeping, access to records, and privacy of protected health information. Special provisions apply to government programs such as Medicare Advantage and Part D. Special provisions apply to government programs such as Medicare Advantage and Part D. Violations of laws may subject you to individual civil or criminal liability, as well as to disciplinary action. Violations of laws may subject you to individual civil or criminal liability, as well as to disciplinary action. Copyright © 2009 Highmark Inc.

9. Conflicts of Interest Conflict of interest with Highmark and its members should be avoided. Conflicts of interest may arise when outside personal interests, employment, or affiliations influence or appear to influence business or medical practice decisions. Conflicts of interest may arise when outside personal interests, employment, or affiliations influence or appear to influence business or medical practice decisions. The self-referral law prohibits physicians from referring Medicare patients for certain designated health services to an entity with which the physician or a member of the physician's immediate family has a financial relationship-- unless an exception applies. It also prohibits an entity from presenting or causing to be presented under a Medicare Advantage plan a claim for a designated health service furnished as a result of a prohibited referral. The self-referral law prohibits physicians from referring Medicare patients for certain designated health services to an entity with which the physician or a member of the physician's immediate family has a financial relationship-- unless an exception applies. It also prohibits an entity from presenting or causing to be presented under a Medicare Advantage plan a claim for a designated health service furnished as a result of a prohibited referral. Copyright © 2009 Highmark Inc.

10. Gifts, Gratuities and Entertainment Providers and their employees may not offer any gift or entertainment that might be perceived to be primarily intended to gain favor or to compromise a business or health care decision under a Federal health care program. Providers and their employees may not offer any gift or entertainment that might be perceived to be primarily intended to gain favor or to compromise a business or health care decision under a Federal health care program. For example, providing gifts to Highmark employees in a position to influence decisions about your participation is prohibited. For example, providing gifts to Highmark employees in a position to influence decisions about your participation is prohibited. Offering gifts to Medicare beneficiaries may also violate the prohibition on beneficiary inducements. Offering gifts to Medicare beneficiaries may also violate the prohibition on beneficiary inducements. Accepting gifts from pharmaceutical companies or device manufacturers that are intended to affect the way you practice medicine is strongly discouraged. Accepting gifts from pharmaceutical companies or device manufacturers that are intended to affect the way you practice medicine is strongly discouraged. Copyright © 2009 Highmark Inc.

11. Compliance with Relevant Laws Medicare Advantage organizations and Part D sponsors are paid in part using federal Medicare funds. Therefore, Medicare Advantage plans, Part D sponsors and the providers and facilities that furnish services to their members are subject to laws applicable to individuals and entities receiving federal funds, including but not limited to, the Age Discrimination Act, the American with Disabilities Act, applicable provisions of criminal law and the False Claims Act. Medicare Advantage organizations and Part D sponsors are paid in part using federal Medicare funds. Therefore, Medicare Advantage plans, Part D sponsors and the providers and facilities that furnish services to their members are subject to laws applicable to individuals and entities receiving federal funds, including but not limited to, the Age Discrimination Act, the American with Disabilities Act, applicable provisions of criminal law and the False Claims Act. Copyright © 2009 Highmark Inc.

12. Fraud, Waste, and Abuse Laws The False Claims Act The False Claims Act Prohibits knowingly presenting (or causing to be presented) to the Federal government a false or fraudulent claim for payment or approval. Prohibits knowingly presenting (or causing to be presented) to the Federal government a false or fraudulent claim for payment or approval. Prohibits knowingly making, using, or causing to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government. Prohibits knowingly making, using, or causing to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government. Copyright © 2009 Highmark Inc.

13. The False Claims Act Applies to claims made to Medicare Advantage Organizations and Part D Sponsors Applies to claims made to Medicare Advantage Organizations and Part D Sponsors Has been interpreted to mean that it is a potential violation of federal law if a provider makes little or no effort to validate the truth and accuracy of his or her statements, representations, or claims or otherwise acts in a reckless manner as to the truth. Has been interpreted to mean that it is a potential violation of federal law if a provider makes little or no effort to validate the truth and accuracy of his or her statements, representations, or claims or otherwise acts in a reckless manner as to the truth. Copyright © 2009 Highmark Inc.

14. Fraud, Waste, and Abuse Laws Anti-Kickback Statute Anti-Kickback Statute Prohibits knowingly and willfully paying, offering, soliciting or receiving remuneration (anything of value) Prohibits knowingly and willfully paying, offering, soliciting or receiving remuneration (anything of value) to induce a referral of a patient for items or services for which payment may be made, in whole or in part, under a Federal health care program; or to induce a referral of a patient for items or services for which payment may be made, in whole or in part, under a Federal health care program; or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program. in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program. There are certain exceptions specified in so-called “safe harbors” specified by law. There are certain exceptions specified in so-called “safe harbors” specified by law. Copyright © 2009 Highmark Inc.

15. Fraud, Waste, and Abuse Laws Prohibition on beneficiary remuneration Prohibition on beneficiary remuneration Prohibits offering or providing anything of value to beneficiaries to influence them to receive services from particular providers. Prohibits offering or providing anything of value to beneficiaries to influence them to receive services from particular providers. Copyright © 2009 Highmark Inc.

16. Other Payment Prohibitions Medicare Advantage Organizations and Part D Sponsors are generally prohibited by law from paying: Medicare Advantage Organizations and Part D Sponsors are generally prohibited by law from paying: Providers who have been excluded from participation in a Federal Health Care Program such as Medicare, Medicaid or SCHIP Providers who have been excluded from participation in a Federal Health Care Program such as Medicare, Medicaid or SCHIP Providers who have “opted out” of the Medicare Program Providers who have “opted out” of the Medicare Program except for providing emergency services Providers may not contract with, or employ, such opted out or excluded individuals or entities to furnish services to members of Medicare Advantage Organizations and Part D Sponsors Providers may not contract with, or employ, such opted out or excluded individuals or entities to furnish services to members of Medicare Advantage Organizations and Part D Sponsors Copyright © 2009 Highmark Inc.

17. Examples of Fraud, Waste and Abuse Professional Provider Professional Provider Misreporting/upgrading procedure codes to receive a higher payment Misreporting/upgrading procedure codes to receive a higher payment Inappropriately altering a patient record Inappropriately altering a patient record Inappropriately prescribing drugs Inappropriately prescribing drugs Submitting to Highmark encounter or diagnostic data that the Provider knows is incorrect Submitting to Highmark encounter or diagnostic data that the Provider knows is incorrect Performing or ordering inappropriate or unnecessary procedures/tests. Performing or ordering inappropriate or unnecessary procedures/tests. Accepting remuneration in exchange for prescribing particular drugs Accepting remuneration in exchange for prescribing particular drugs Copyright © 2009 Highmark Inc.

18. Examples of Fraud, Waste and Abuse Facility Facility Patient never receives his/her prescribed take home drugs Patient never receives his/her prescribed take home drugs Billing for drugs never received by the patient Billing for drugs never received by the patient Reselling drugs not used by patients Reselling drugs not used by patients Drug diversion Drug diversion Billing for labs, procedures or services the patient did not receive Billing for labs, procedures or services the patient did not receive Copyright © 2009 Highmark Inc.

19. Examples of Fraud, Waste and Abuse Pharmacy Pharmacy Submitting false claim for payment Submitting false claim for payment Altering prescriptions to receive higher payment Altering prescriptions to receive higher payment Dispensing expired drugs Dispensing expired drugs Collecting higher co-pays than allowed or charging more than the negotiated price Collecting higher co-pays than allowed or charging more than the negotiated price Routinely waiving copays Routinely waiving copays Manipulating the amount of out-of-pocket payments a beneficiary has made Manipulating the amount of out-of-pocket payments a beneficiary has made Accepting illegal payments to convince beneficiaries or physicians to switch drugs Accepting illegal payments to convince beneficiaries or physicians to switch drugs Copyright © 2009 Highmark Inc.

20. Examples of Fraud, Waste and Abuse Beneficiary Beneficiary Permitting another person to use their Medicare ID number/card Permitting another person to use their Medicare ID number/card Falsifying Coordination of Benefits information to collect duplicate payments from multiple insurance plans Falsifying Coordination of Benefits information to collect duplicate payments from multiple insurance plans Participating in schemes that involve conspiracy between a provider/supplier and beneficiary. Participating in schemes that involve conspiracy between a provider/supplier and beneficiary. Copyright © 2009 Highmark Inc.

21. Consequences of Committing Fraud, Waste and Abuse Administrative Recoupment/Restitution Administrative Recoupment/Restitution Criminal and/or civil prosecution Criminal and/or civil prosecution Fines/Penalties Fines/Penalties Imprisonment Imprisonment Suspension/Loss of Provider License Suspension/Loss of Provider License Exclusion from the Medicare program Exclusion from the Medicare program Copyright © 2009 Highmark Inc.

22. Identifying Possible Fraud, Waste and Abuse You are a vital part of the effort to prevent, detect, and report possible fraud, waste and abuse issues. To do that you need to be able to identify various potential misconduct that could rise to the level of fraud. You are a vital part of the effort to prevent, detect, and report possible fraud, waste and abuse issues. To do that you need to be able to identify various potential misconduct that could rise to the level of fraud. Copyright © 2009 Highmark Inc.

23. Read the following situations to better understand how to identify potential fraud, waste or abuse. Copyright © 2009 Highmark Inc.

24. Identifying Possible Fraud, Waste and Abuse Professional Provider situations: Professional Provider situations: A practitioner knowingly misreported a procedure code for medication given to a patient. This misreported code resulted in higher payment to the provider/practitioner. A practitioner knowingly misreported a procedure code for medication given to a patient. This misreported code resulted in higher payment to the provider/practitioner. Patient records, claim forms, electronic claim forms, show signs of alteration to obtain higher payments. Patient records, claim forms, electronic claim forms, show signs of alteration to obtain higher payments. “Double billing” – charging more than once for the same service, for example by an individual code then again as part of an automated or bundled set of services. “Double billing” – charging more than once for the same service, for example by an individual code then again as part of an automated or bundled set of services. Copyright © 2009 Highmark Inc.

25. Identifying Possible Fraud, Waste and Abuse Facility Situations Facility Situations Drug Diversion – Patients not receiving medications (especially pain medications) due to staff substituting another substance for the medication Drug Diversion – Patients not receiving medications (especially pain medications) due to staff substituting another substance for the medication Billing for supplies, medications, procedures or lab services not provided to the patient Billing for supplies, medications, procedures or lab services not provided to the patient Billing for a higher level care than the patient was receiving Billing for a higher level care than the patient was receiving Copyright © 2009 Highmark Inc.

26. Identifying Possible Fraud, Waste and Abuse Pharmacy Situations: Pharmacy Situations: The pharmacist offers to waive a member’s co- pay if he agrees to use this pharmacy for all his prescriptions. The pharmacist offers to waive a member’s co- pay if he agrees to use this pharmacy for all his prescriptions. A pharmacy employee bills the insurance company for a narcotic using the information from the pharmacy database. The patient never received the medication. A pharmacy employee bills the insurance company for a narcotic using the information from the pharmacy database. The patient never received the medication. “Short Filling” – A pharmacy bills for more than the amount of medication dispensed. “Short Filling” – A pharmacy bills for more than the amount of medication dispensed. Copyright © 2009 Highmark Inc.

27. Identifying Possible Fraud, Waste and Abuse Beneficiary Situations: Beneficiary Situations: A member goes to a number of different doctors for prescriptions for the same controlled substance A member goes to a number of different doctors for prescriptions for the same controlled substance A member gets a prescription from her physician allegedly for herself intending that her husband will take it. A member gets a prescription from her physician allegedly for herself intending that her husband will take it. Letting someone use your Medicare Number or ID card to obtain supplies, medications, procedures or lab services Letting someone use your Medicare Number or ID card to obtain supplies, medications, procedures or lab services Copyright © 2009 Highmark Inc.

28. Your Involvement Highmark engages in activities such as auditing, monitoring and other oversight to identify compliance issues. However, we need your assistance: Highmark engages in activities such as auditing, monitoring and other oversight to identify compliance issues. However, we need your assistance: Facilities and Professional Providers: Establish a fraud, waste and abuse prevention policy. Facilities and Professional Providers: Establish a fraud, waste and abuse prevention policy. Management: Educate coworkers of the importance of fraud and abuse prevention. Management: Educate coworkers of the importance of fraud and abuse prevention. All Individuals: Report any potential incidents of fraud waste or abuse to Highmark. All Individuals: Report any potential incidents of fraud waste or abuse to Highmark. Copyright © 2009 Highmark Inc.

29. Policies Regarding Inquiries and Reports All inquiries are confidential, subject to limitations imposed by law. If an individual is unwilling to identify himself or herself despite this protection, they may make an anonymous report. If an individual does not identify himself or herself, we ask that he or she provide some method of future contact. This will allow the internal investigator to ask follow up questions. Highmark policy prohibits retaliation against individuals who raise questions in good faith. All inquiries are confidential, subject to limitations imposed by law. If an individual is unwilling to identify himself or herself despite this protection, they may make an anonymous report. If an individual does not identify himself or herself, we ask that he or she provide some method of future contact. This will allow the internal investigator to ask follow up questions. Highmark policy prohibits retaliation against individuals who raise questions in good faith. Copyright © 2009 Highmark Inc.

30. Where can a provider go to ask questions about potential waste fraud and abuse? Where can a provider go to ask questions about potential waste fraud and abuse? Who should a provider or a member of their staff report potential fraud waste or abuse to? Who should a provider or a member of their staff report potential fraud waste or abuse to? How to Obtain More Information About, or Report Potential Fraud, Waste and Abuse Copyright © 2009 Highmark Inc.

31. Contact Information For information and inquiries or to report potential misconduct contact The Highmark Integrity office Toll –Free hotline available 24-Hour a day/ 7 days a week 1 (800) 985-1056 Confidential U.S. Post Office Box: Confidential U.S. Post Office Box: Highmark Inc. Highmark Inc. Integrity Office Integrity Office P. O. Box 150 P. O. Box 150 Enola, PA 17025 Enola, PA 17025 Confidential Fax Confidential Fax Camp Hill Fax: (717) 302-3650 Camp Hill Fax: (717) 302-3650 Pittsburgh Fax: (412) 544-2475 Pittsburgh Fax: (412) 544-2475 E-Mail: integrity@highmark.com E-Mail: integrity@highmark.comintegrity@highmark.com Copyright © 2009 Highmark Inc.

32. Follow-up For any credible report of potential waste, fraud and/or abuse, Highmark will undertake a reasonable investigation and may refer the issue, as appropriate, to a MEDIC, CMS or law enforcement. For any credible report of potential waste, fraud and/or abuse, Highmark will undertake a reasonable investigation and may refer the issue, as appropriate, to a MEDIC, CMS or law enforcement. The MEDIC ( ( Medicare Drug Integrity Contractor) is an organization assigned by CMS to manage anti-fraud and abuse efforts in the Part D program. The MEDIC will further investigate referrals from Part D Sponsors, develop the investigations, and make referrals to appropriate law enforcement agencies or other outside entities when necessary The MEDIC ( ( Medicare Drug Integrity Contractor) is an organization assigned by CMS to manage anti-fraud and abuse efforts in the Part D program. The MEDIC will further investigate referrals from Part D Sponsors, develop the investigations, and make referrals to appropriate law enforcement agencies or other outside entities when necessary Copyright © 2009 Highmark Inc.