PREVENTION OF FRAUD, WASTE AND ABUSE

Transcription

1 PREVENTION OF FRAUD, WASTE AND ABUSE INITIAL AND 2015 ANNUAL TRAINING UConn Health Office of Audit, Compliance and Ethics

2 annual training Introduction Welcome to UConn Health. This training is part of a comprehensive Compliance Program training plan and is required by the Centers for Medicare and Medicaid (CMS) Medicare Compliance Program. Thank you for completing this important education.

3 You do not wake up one morning a bad person. It happens by a thousand tiny surrenders of self-respect to self-interest. Robert Brault

4 Introduction Fraud, waste and abuse cost institutions as well as state and federal governments millions of dollars each year. As UConn Health employees, we have a collective responsibility to minimize waste, avoid abuse of valuable UConn Health and state resources and particularly, to prevent actions that would constitute fraud.

5 What is Waste? Waste is defined as a misuse or overutilization of resources or practices that result in extravagant or careless expenditure of UConn Health, state or federal funds, including healthcare benefits. It may stem from individuals being uninformed, poor decisions, deficient processes, patient demands or even defensive medicine to avoid litigation. Examples of waste include: Purchasing unneeded equipment or supplies. Purchasing goods at inflated prices. Replacing equipment unnecessarily or failing to recycle equipment appropriately. Duplicate billing Billing separately for services that are included in a primary procedure or within a global surgery period.

6 What is Abuse? Abuse is the improper use of funds, resources or authority that results in unnecessary or higher costs to UConn Health, the state or federal governments and healthcare programs. Examples of abuse include: Misusing paid time or manipulating expense reimbursements. Using your state position or authority for personal financial gain. Accepting gifts or favors for awarding contracts to vendors. Providing services that are medically unnecessary. Overcharging for supplies. Routine overuse of modifiers.

7 Preventing waste and abuse Waste can be prevented by avoiding purchases or other practices that unnecessarily consume time, money or resources. Purchasing and contract decisions should be made only by individuals with adequate information and appropriate authority. Abuse can be prevented by using UConn Health/state time, personnel and resources appropriately and only for business purposes. Key Point : If it s not related to your UConn Health job responsibilities, it is not an appropriate use of state resources.

8 UConn Health Asset Control As members of the UConn Health workforce, we must safeguard and protect the State s property and other assets entrusted to us. Responsibility for asset control is a partnership between employees, managers and Office of Logistics Management (OLM). Lack of accountability can result in damaging publicity, negative audit findings, reputational harm, and loss of funding.

9 UConn Health Asset Control OLM will take responsibility for: Tagging capital and controllable assets when they are received by UConn Health. Note: In situations where items do not pass through the receiving dock, departments must notify OLM. Scanning asset tags on equipment located in each department during the physical inventory. Maintaining and updating UConn Health s official asset list based on physical inventory results and Inventory Control forms submitted by departments throughout the year. Please refer to the new Asset Control policy.

10 Asset Control: Staff Member Accountability Staff should assist OLM to locate their departments assets during each physical inventory. Also, remember to always submit the applicable Inventory Control Form to OLM before disposing of any asset.

11 Asset Control: Administrator Accountability Department Heads are accountable for all assets listed as belonging to their respective departments. Managers must submit the appropriate Inventory Control Forms to OLM when assets are moved, transferred, disposed of, lost, or damaged and collaborate with OLM to reconcile their departments asset lists as soon as it is received. Key Point : Even if you no longer have the asset, it will remain assigned to your department on the official asset list. You will continue to be responsible for the asset until OLM receives the completed form.

12 Appropriate use of electronic equipment Workforce members are provided electronic resources to enable faculty, students and staff to accomplish work in accordance with UConn Health s mission. Electronic, computing and networking equipment and software must be used for business purposes only. Please review: Information Technology Computer/Electronic Resource Use Policy

13 What is Fraud? Fraud is an intentional misrepresentation of information, such as submitting false claims to the federal government, for unauthorized financial gain or to derive some other benefit. Examples of fraud include: Falsifying a time report or credentials. Offering, soliciting or receiving a bribe or kickback. Diverting cash, equipment or supplies. Altering an accounting record or supporting documents. Deliberate misstatements or omissions on financial statements. Identity theft/medical identity theft. Billing for services that were not provided or for a higher level of treatment than was provided. Billing for services provided by a practitioner who has been excluded from participation in Federal health care programs.

14 The Who, What, When, and Why of Fraud Who commits fraud? Anyone is capable as long as there is a means, a motive and an opportunity including beneficiaries, providers, manufacturers or sales agents. What are the circumstances of fraud? Situations motivated by internal and external pressures such as financial stress, performance expectations, or even well-meaning institutional goals.

15 The Who, What, When, and Why of Fraud When does fraud occur? Whenever an opportunity exists where there are weak internal controls, breakdowns in processes, confusing practices or lack of definitive process owners. Why does fraud happen? Eventually, improper actions become justified in the eyes of the individual or entity.

16 Identity Theft Identity theft is one of the most common types of fraud. Guard against identity theft by: Remaining vigilant regarding proper identification of patients, vendors and others on campus. Recognizing situations that signal potential identity theft. Taking immediate action to prevent further risk and reduce harm. Notifying a supervisor, the Compliance Office or REPORTLINE For identity theft questions or assistance contact: The UConn Health Office of Audit, Compliance and Ethics: compliance.officer@uchc.edu For more information, refer to the University s Identity Theft Prevention Program

17 Waste, Abuse and Fraud can be a slippery slope Fraud requires intent and knowledge: Intent to obtain payment and the knowledge that the action is wrong. However, abuse of federal healthcare funds cannot be differentiated categorically from fraud. The determination depends on specific facts and circumstances, intent and prior knowledge, and available evidence. Abuse of federal dollars has the potential to quickly become fraud.

18

19 Fraud prevention begins with you In order to minimize the opportunity for fraud to occur at UConn Health it is crucial that all employees follow established policies and appropriate departmental procedures. Avoid short cuts or other practices that compromise processes and assume responsibility only for activities for which you are authorized. Above all, ask questions and seek guidance if you are unclear or uncomfortable with a task or responsibility.

20 Fraud prevention continues with managers Managers have a particular responsibility to prevent fraud by delegating responsibilities appropriately, answering questions, providing appropriate guidance, supervision and oversight of department processes, ensuring proper checks and balances throughout established processes, and correcting procedural weaknesses.

21 What are the laws related to fraud and abuse? Anti-kickback Statute Physician Self-Referral Law (Stark) Criminal Health Care Fraud Statute Exclusion Statute Federal and Connecticut False Claims Acts

22 Laws related to fraud and abuse Anti-Kickback Statute Federal statute that prohibits knowingly and willfully offering, paying, soliciting or receiving anything of value to induce or reward referrals for items or services reimbursed by a Federal health care program. Certain safe harbors exist but their use must be carefully reviewed. Physician Self-referral Law (Stark) Federal statute that prohibits a physician from making a referral for certain designated health services (DHS) to an entity in which the physician or an immediate family member has an ownership/investment interest or a compensation arrangement. There are certain Stark exceptions that may be considered only after careful review.

23 Laws related to fraud and abuse Criminal Health Care Fraud Statute Federal statute that prohibits knowingly and willfully executing or attempting to execute a scheme to defraud any health care benefit program or obtain, under false pretenses, money or property owned by or under the control of any health care benefit program. Proof of actual knowledge or specific intent to violate the law is not required.

24 Laws related to fraud and abuse Exclusion Statute Exclusion from participation in federal healthcare programs is mandatory for any provider or supplier convicted of Medicare fraud or other Medicarerelated offenses as well as patient abuse/neglect, theft/financial misconduct or unlawful conduct associated with controlled substances. Exclusion presents both individual and institutional liability. Claims submitted for services by a provider whom UConn Health knows or should have known is excluded may result in significant institutional penalties. Criminal background and Federal sanctions checks prior to employment or the initiation of a contract and regularly thereafter are essential. Refer to the Background and Sanctions Checks policy.

25 Laws related to fraud and abuse Federal and State False Claims Acts Federal Law: Imposes civil and criminal liability on any person who knowingly submits or causes to be submitted a fraudulent claim to the government. Knowingly includes ignoring facts that may reveal false information or disregarding the need to verify information related to a claim. Connecticut Law: Imposes liability on individuals and corporations who knowingly submit false claims to any state-administered health or human services program.

26 Penalties for Statute Violations Violations of any federal or state statutes may result in civil monetary penalties, fines, imprisonment, or the exclusion of an individual/entity from participation in Federal healthcare programs.

27 Fraud Prevention: Provider relationships To avoid violations of Stark and Anti-kickback laws, when considering working with or investing in any business, providers should ask questions such as: Am I being offered an investment interest for a nominal capital contribution? Is the venture promising high rates of return for little or no financial risk? Am I being asked to guarantee referrals or orders of supplies as part of the contract? Will I be more likely to refer patients or refer more patients to the venture as a result of this relationship?

28 Fraud Prevention: Documentation and coding In order to reduce the risk of fraud, waste and abuse, UConn Health has focused its attention on documentation and coding including: Choosing the correct level of Evaluation and Management (E & M) service. Determining medical necessity in a given encounter. Appropriately documenting split/shared E & M services. Avoiding upcoding or undercoding services. Assisting teaching physicians to properly document resident/student supervision. Assigning DRGs appropriately. Using modifiers appropriately (e.g. Modifiers 25 and 59). Documenting accurately in the electronic health record (EHR) (e.g. when using copy and paste to bring documentation forward).

29 Documentation and Coding Assistance A Coding Help is available to assist providers to document and code services and procedures accurately and appropriately. Providers can questions such as What are the documentation requirements for the administration of an injection or What CPT code should I use for excision of a hand lesion? Certified coding staff will answer all questions as quickly as possible, generally within 1-2 business days.

30 Professional Services Documentation and Coding Assistance For questions please contact: Janice McDonnell Compliance Specialist Katherine Rudolewicz Coding Trainer Marcie Hamel Coding Trainer Katalin Kerekes Coding Trainer

31 Accurate Billing is Crucial Healthcare billing involves multiple processes: Patient Registration Insurance Verification Documentation and Coding of Service Charge Entry Claims Submission Reimbursement Payment Posting Every step in the billing process requires attention to detail, accountability for an individual s contribution to the overall process, and a commitment to the honesty and accuracy of each claim.

32 Recognizing Potential Fraud and Abuse The key to prevention is an awareness of the signs of potential fraud such as: missing or altered documentation of transactions or financial statements. unreconciled inventory discrepancies or shortages. unusual or improper bidding or contract negotiation processes. omitted or incomplete documentation of a provider encounter. lack of documentation to support a diagnosis. inappropriate coding of services. misuse of modifiers. any situation in which required business processes are bypassed.

33 Reporting Fraud If you notice questionable activity or signs of potential fraud, report your concerns immediately to: Your Supervisor Office of Audit, Compliance and Ethics: or REPORTLINE at Individuals also have the option to report concerns of potential fraud to the State of Connecticut Auditors of Public Accounts at: Locally: Toll free in Connecticut at Key point: UConn Health strictly prohibits retaliation against individuals who, in good faith, report a compliance issue. For more information, refer to the Non-Retaliation policy.

34 Additional Resources For more information, refer to: Department of Health and Human Services/Department of Justice: Stop Medicare Fraud Department of Health and Human Services/Centers for Medicare and Medicaid: Avoiding Medicare Fraud & Abuse: A Roadmap For Physicians

35 The UConn Health Office of Audit, Compliance and Ethics is here to help.. David Galloway University of Connecticut Chief Audit and Compliance Officer Iris Mauriello Compliance Integrity and Privacy Officer Kim Bailot Associate Compliance Officer Margaret DeMeo Associate Compliance Officer Ginny Pack Associate Compliance Officer

36 Thank you for completing Fraud, Waste and Abuse Prevention Training. Please complete the training acknowledgment and return the signed form to your company supervisor. Training Questions? Contact the Office of Audit, Compliance and Ethics at or Ginny Pack at or