Preventing Fraud, Waste, and Abuse

Transcription

1 2013 Compliance Training for Contractors and Vendors Module 2 Preventing Fraud, Waste, and Abuse For Internal Training Purposes Only 1

2 Learning Objectives After completing this training, learners will understand: What is Fraud, Waste and Abuse? Guidelines, Statutes, and Laws Reporting Responsibilities and Options 2

3 On the Next Slide. What is Fraud, Waste and Abuse? 3

4 PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: 8/26/2010 After viewing all the steps Show upon completion Next For Slide Internal Training Purposes Only 4

5 More Examples of Fraud, Waste, and Abuse Consumer Pharmacy Prescriber Sales Agent Doctor Shopping Prescription Diversion and inappropriate use Medical Identity Theft Prescription Drug Switching, Shorting, or Splitting Billing for brand name when generics are dispensed Billing for noncovered prescriptions as covered items Billing for prescriptions that are never picked up Script mills Illegal remuneration schemes Prescription drug switching Marketing Schemes Cash Payments or Rewards Inappropriate Use of Information Agents splitting commissions or agent referral fees 5

6 PROPERTIES On passing, 'Finish' button: On failing, 'Finish' button: Allow user to leave quiz: User may view slides after quiz: Goes to Next Slide Goes to Next Slide After user has completed quiz At any time

7 On the Next Slide. Guidelines, Statutes, and Laws 7

8 Centers for Medicare & Medicaid Services (CMS) Guidelines Center for Medicare and Medicaid Services (CMS) is an agency within HHS. CMS administers (among others) the Medicare program. Medicare provides health insurance to ~44.6 million people. 8

9 Federal False Claims Act The Rule Establishes liability on persons and companies who knowingly present or causes to be presented a false or fraudulent claim to the government for payment. This law includes a "qui tam" provision that allows private citizens to file actions on behalf of the government (Whistleblowers) Example A provider submits a bill to Medicare for services that she knows she did not provide. Consequences Personal Civil Liability, including monetary penalties ranging from $5,000 to $10,000 per false claim submitted, in addition to three times the amount of the claim. Exclusion from participating in federal health care programs

10 Anti-Kickback Statute The Rule It is illegal for a person or entity to knowingly and willfully offer, pay, solicit, or receive something of value to induce or reward referrals of business under Federal health care programs. It is intended to ensure that referrals for healthcare services are based on medical need and not based on financial or other types of incentives to individuals or groups. Example A physician receives a credit toward airline frequent flier mileage for each questionnaire completed for a new patient placed on a drug company's product. Consequences Civil Liability, including monetary penalties up to $25,000 per violation Criminal Liability, including a felony conviction up to five years in prison Exclusion from participating in federal health care programs

11 PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: 8/26/2010 After viewing all the steps Show upon completion Next For Slide Internal Training Purposes Only 11

12 PROPERTIES On passing, 'Finish' button: On failing, 'Finish' button: Allow user to leave quiz: User may view slides after quiz: Goes to Next Slide Goes to Next Slide After user has completed quiz At any time

13 Your Compliance Team WellMed Medical Group, Compliance Department 8637 Fredericksburg Rd, Suite 360 San Antonio, TX General Questions: Teresa Jacobs, Corporate Compliance Officer:

14 Your Responsibility Know what s right. Ask for clarification if necessary Do what s right. Follow policies and procedures Tell us if you think something isn t right. Every contractor, consultant, or vendor has an obligation to make a good faith report of any activity within the agency that appears to violate compliance policies, procedures or statutes Zero tolerance for retaliation Your Reporting Options Talk to your hiring manager Contact the Compliance Dept compliance@wellmed.net Call Directly Submit an Anonymous Report: Confidentiality is protected to the extent allowed by law. For Internal Training Purposes Only

15 Additional Resources The Office of Inspector General has developed excellent training on Fraud, Waste, and Abuse issues 15

16 This course requires a 100% passing score to receive credit for completing the training. Please click on the below link to access the quiz or copy/paste the address into your web browser: Module 2: Preventing Fraud, Waste, and Abuse Quiz Hands-On Compliance