fraud waste abuse training by niusheng11


									             CMS-Required Training
For First-Tier, Downstream, and Related Entities
     Welcome to FWA Training
   Asuris contracts with the Centers for Medicare &
    Medicaid Services (CMS) to offer health and prescription
    drug coverage to eligible enrollees
   As an entity or an employee of an entity that contracts
    with Asuris to provide health, prescription, or
    administrative services to Medicare beneficiaries, CMS
    requires you to meet annual training requirements
    related to preventing, detecting, and correcting fraud,
    waste, and abuse (FWA)
   Asuris offers this free webinar for your convenience; you
    may also choose to satisfy these requirements
          Overview & Objectives
   What: Understand CMS’s requirements for preventing, detecting,
    and correcting fraud, waste, and abuse (FWA)
   Who: All first-tier, downstream, and related entities (FDRs), and
    their employees must meet CMS’s FWA training requirements
   When: Every year
   How: You can take this free webinar, conduct your own CMS-
    compliant training, or take CMS-compliant training offered by a third-
    party. Your organization must complete and maintain internal
    training logs, which are subject to audit by Asuris or CMS. Please
    print a copy of this presentation for your records and reference. If
    you conduct your own training or have training by a third-party,
    please keep a copy of those training materials.
   Why: Fraud, waste, and abuse waste precious healthcare dollars
   FDRs are First-Tier, Downstream, or Related Entities of a Plan
    Sponsor. FDRs and their employees must meet CMS’s
    requirement of annual training on fraud, waste, and abuse.
   Plan Sponsor: An entity that has a contract with CMS to offer one
    or more of the following Medicare Products: Medicare Advantage
    (MA) Plans, Medicare Advantage Prescription Drug Plans (PDP) and
    1876 Cost Plans. Asuris is a Plan Sponsor.
   First-Tier Entity: Any party that enters into a written arrangement
    acceptable to CMS with a Sponsor or applicant to provide
    administrative services or health care services for a Medicare-
    eligible individual under Medicare Advantage and/or Part D.
   Downstream Entity: A party that enters into a written arrangement,
    acceptable to CMS, below the level of the arrangement between a
    Plan Sponsor and a first-tier entity. These written arrangements
    continue down to the level of the ultimate provider of both health and
    administrative services.
                FDRs, continued
   Related Entity: Any entity that is related to the MedAdvantage
    organization by common ownership or control and:
      Performs some of the MedAdvantage organization’s
       management functions under contract or delegation:
      Furnishes services to Medicare enrollees under an oral or written
       agreement; or
      Leases real property or sells materials to the MedAdvantage
       organization at a cost of more than $2,500 during a contract
   Fraud is conduct that involves intentional
    deception or misrepresentation, knowingly
    making a false claim, or other intentional
    or willful deception or misrepresentation,
    known to be false or otherwise unlawful or
    improper, in order to receive some
    unauthorized benefit
       “Knowing” can mean actual knowledge or
        acting with reckless disregard or deliberate
        ignorance of truth or falsity
   Waste involves practices that are
    inconsistent with sound fiscal,
    business, or medical practices, and
    that result in an unnecessary cost to
   Abuse is deception or misrepresentation
    that a company or person should know to
    be false, knowing or improper, and should
    know will result in some unauthorized
    benefit to the company or person
    Medicare Fraud Waste & Abuse
   Many laws govern healthcare fraud, waste and
    abuse, among them:
   The False Claims Act, 31 U.S.C. § 3729 et seq.
   The Anti-Kickback Statute, 42 U.S.C. §1320a-
   Physician Self-Referral (“Stark”) Statute, 42
    U.S.C. §1395nn
   Health Insurance Portability and Accountability
    Act of 1996 (“HIPAA”)
           The False Claims Act
   Forbids submitting for reimbursement a claim known to be false;
    making or using a false record or statement material to a false claim
    or obligation; conspiring to defraud by improper submission of false
    claims; or concealing, improperly avoiding, or decreasing an
    obligation to pay money to the government
   No proof is required of specific intent to defraud
   “Knowing” can mean actual knowledge or acting in deliberate
    ignorance or reckless disregard of truth or falsity
   A health care provider’s retention of an overpayment by a federal
    health care program may give rise to False Claims Act liability, if
    retained knowingly and otherwise in violation of the FCA
   Potential penalties for violation:
      Fines of up to $11,000 per false claim
      Treble damages

      Exclusion from participation in federal health programs
     The Anti-Kickback Statute
   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.
   Potential 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 treble
       Exclusion from federal health care programs
          Physician Self-Referral
             (“Stark”) Statute
   Prohibits a physician from making referrals for
    certain designated health services to an entity in
    which the physician, or a member or his/her family,
    has an ownership/investment interest or with which
    he/she has a compensation arrangement.
   Potential 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
      Treble damages
      Exclusion from federal health care programs
   HIPAA established the national Health Care Fraud
    and Abuse Control Program (“HCFAC”), which
    coordinates federal, state, and local law
    enforcement activities with respect to health care
    fraud and abuse
   HIPAA also enacted an additional prohibition of
    health care fraud, forbidding knowing and willful acts
    to defraud a health care benefit program by false or
    fraudulent pretenses 18 USC § 1347
   Potential penalties include:
       Up to ten years imprisonment, except:
       If the violation results in death, life imprisonment
       If the violation results in serious bodily injury, 20 years imprisonment
  Risks for Fraud, Waste &
Everyone involved in the administration of
Medicare benefits is capable of engaging
in fraudulent, wasteful, or abusive
activities. In the following slides are
examples of the kinds of inappropriate
acts that different FDRs might encounter.
             Provider Risks for
           Fraud, Waste & Abuse
   Billing for services/supplies that were not provided or were provided by
   Incorrectly reporting diagnoses, procedures, or modifiers to maximize
   Billing for services/supplies or writing prescriptions for drugs that are
    not medically necessary
   Remuneration schemes that unlawfully induce or reward the provider to
    bill for services/supplies or write prescriptions
   Giving false or misleading information or coaching others to give false
    or misleading information (e.g., on a prior authorization request or re:
    dates of service)
   Unbundling charges
   Violating assignment agreements, fee schedules, or maximum
    allowable actual charge limits
   Failing to return an overpayment
   Continuing to bill for equipment no longer provided to beneficiary
   Manufacturing or altering documentation
   Billing in violation of Asuris contracts or Medicare and Asuris guidelines
         Facility Risks for Fraud,
             Waste & Abuse
   In addition to the general provider risks, facilities can
    have particular risks of FWA, such as:
       SNFs upcoding RUG assignments to inflate reimbursement
        (e.g., by improperly utilizing therapy services)
       SNFs unbundling DME that is part of Medicare A benefit
       Hospitals failing to follow the same day rule, abusing partial
        hospitalization payments and same day discharges and
        readmits, improper billing for observation, and billing outpatient
        for “inpatient only” procedures
       Hospitals or outpatient surgical centers charging for implants that
        are not FDA-approved devices or are not disclosed on the op
       Charging for more implants or surgical supplies than those used
        for the patient
       Embezzlement
               Pharmacy Risks for
              Fraud, Waste & Abuse
   Inappropriate billing practices (e.g., billing for non-existent or non-covered
    prescriptions, billing multiple payors, billing for brand when dispensing
    generics, billing for prescriptions that are never picked up, billing more than
    dispensed, inappropriately billing secondary payors)
   Kickbacks, including remuneration schemes that induce or reward the
    pharmacy to steer patients to certain drugs or plans
   Diverting drugs
   Prescription drug shorting
   Prescription forging or altering
   Dispensing expired or adulterated drugs
   True Out-of-Pocket (“TrOOP”) Costs manipulation
   Bait & switch pricing; failure to offer negotiated prices
   Splitting prescriptions to enhance dispensing fees
   Failure to manage assays to prescribed amount
   Billing in units inconsistent with HCPCS
   Dispensing expired or adulterated drugs
   Failure to follow refill instructions
   Billing for visiting a facility, without specified services
     Pharmaceutical Manufacturer
    Risks for Fraud, Waste & Abuse
   Inappropriate relationships with physicians, including
    “switching” arrangements, offering unlawful incentives,
    and consulting and advisory payments
   Illegal off-label promotion
   Illegal usage of free samples
   Inadequate or inappropriate documentation of pricing
    and reimbursement information
   Inappropriate marketing, product promotion, discounts,
    grants, support services, or other remuneration
   Inappropriate relationships with formulary committee
    members or payments to pharmacy benefit managers
            Beneficiary Risks for
            Fraud, Waste & Abuse
   Misrepresentation of coverage status, health status, or identity
   Identity theft
   Providing false or misleading information
   Prescription forging or altering
   TrOOP manipulation
   Prescription diversion and inappropriate use
   Stockpiling of prescription drugs
   Concealing other coverage
   Obtaining medically unnecessary services
   Submitting false claims
   Theft of DEA number or prescribing pad
Agent/Broker Risks for Fraud,
       Waste & Abuse
   Unlawful marketing
   Forging applications or signatures
   Offering cash inducements
   Unsolicited door-to-door sales
   Use of unlicensed agents
   Enrollment of beneficiaries without knowledge or consent
   Misrepresenting that agent/broker works for CMS or the
    Social Security Administration
   Misrepresenting type of policy
   Requiring premium upfront
   Embezzlement
   Identity theft
      General Risks for Fraud,
         Waste & Abuse
   Misusing beneficiary or provider information for
    personal gain (e.g., identity theft)
   Submission of false or overstated invoices
   Falsification of work performed on behalf of
   Selling counterfeit or adulterated drugs
   Inappropriate or inadequate pricing or
    reimbursement documentation
                 Report It!
   You can report Medicare fraud, waste or
    abuse to:
     The Asuris Special Investigative Unit
     The MEDIC, which is contracted with CMS to
      manage fraud and abuse
     CMS or the Office of the Inspector General
           To Report Suspected
        Medicare FWA to Asuris SIU
   Call 24-hour toll-free hotline:
       Medicare Part D – Prescription Drug: (877) 479-
       Medicare Part C – MedAdvantage: (800) 548-4850
   Or use a confidential, online form, at:
   By phone or online, you can choose to
    remain anonymous
      To Report Suspected
    Medicare FWA to the MEDIC
   Call: (877) 7SAFERX – (877) 772-3379
   Website:
   Fax: (410) 819-8698
    To Report Medicare FWA to
         CMS or the OIG
   Call 1-800-MEDICARE – (800) 633-4227
   Call 1-800-HHS-TIPS – (800) 447-8477
   For more information:
     For Further Info About Doing
        Business With Asuris:
   The Regence Code of Business Conduct and
    Code of Business Conduct Guide outline Asuris’
    business standards and the expectations for
    people working for, or on behalf of, Asuris. See
   The Asuris Fraud & Abuse Web site answers
    commonly asked questions about fraud & abuse
    and gives details on how to report suspected
    fraud or abuse. See
   You have completed this year’s FWA
   Please print this presentation for your
    records and reference

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