Compliance and Program Integrity Melanie Bicigo, CHC, CEBS

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1 Compliance and Program Integrity Melanie Bicigo, CHC, CEBS

2 Define compliance and compliance program requirements Communicate Upper Peninsula Health Plan (UPHP) compliance requirements which impact network providers Identify laws and regulations applicable to providers as a Medicare/Medicaid participating provider Understand how to identify, address and report any suspected Fraud, Waste and Abuse Communicate available reporting channels

3 Deliver high quality, innovative, and costeffective health care services to the Upper Peninsula while maintaining the integrity of our regional health care system UPHP and our business partners must be held to high ethical standards and conduct UPHP must ensure contractual, legal and regulatory obligations are met and must promote and ensure our business partners are in compliance

4 Conforming to a rule, policy, standard or law Healthcare is compliant when it is*: Documented, charged and billed correctly Is provided in an approved facility Promotes patients rights Is reimbursed correctly Is provided without financial incentives Is medically necessary Is provided by qualified physicians/staff Meets quality standards *Source: Tenet Healthcare Corporation

5 Compliance is everyone s responsibility; Any individual providing health or administrative services for Medicare and/or Medicaid beneficiaries must comply with applicable laws and regulations. This includes: Providers Beneficiaries Employees of Upper Peninsula Health Plan First Tier, Downstream and Related Entities Subcontractors and Vendors

6 Centers for Medicare and Medicaid Services (CMS) requires UPHP to implement an effective compliance program. UPHP must: Create a compliance plan that incorporates measures to prevent, detect and correct noncompliance as well as fraud, waste and abuse Create a compliance plan that consists of training, education and effective lines of communication Apply such training, education and communication requirements to all entities which provide benefits or services under Medicare Advantage (MA) or Prescription Drug Plan (PDP) programs Produce proof (attestations and copies of training logs) from firsttier, downstream and related entities to show compliance with these requirements. Access the Medicare Managed Care Manual: https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS html?DLPage=2&DLEntries=10&DLSort=0&DLSortDir =ascending

7 FDRs provide administrative or health care services for our Medicare enrollees. First Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program. Downstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of the arrangement between an MAO or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services. Related Entity: any entity that is related to an MAO or Part D sponsor by common ownership or control and: Performs some of the MAO or Part D plan sponsors management functions under contract or delegation Furnishes services to Medicare enrollees under an oral or written agreement; or Leases real property or sells material to the MAO or Part D plan sponsor at a cost of more than $2,500 during a contract period.

8 If you are a UPHP contracted provider serving Medicare and Medicaid patients, UPHP and CMS requires your organization to: Distribute Standards of Conduct, Compliance Policies and Compliance information that meet CMS requirements Complete general compliance training and fraud, waste and abuse (FWA) training in accordance with guidelines set by CMS OIG and GSA Exclusion Screening FWA and Compliance reporting mechanisms

9 UPHP must ensure CMS contractual terms are met and may be held accountable if an FDR fails to comply with program requirements and/or state and federal regulations. UPHP is responsible to develop procedures to ensure FDRs are in compliance with all applicable laws, rules, and regulations with respect to their delegated responsibilities. As such, each FDR of UPHP must complete an attestation.

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11 Billing for items or services not actually documented Unbundling Paying or receiving remuneration to induce referrals Inappropriate balance billing Privacy/security/confidential -ity of information/records Proper documentation of services rendered Duty to report misconduct Duplicate Billing Failure to use modifiers Incentives that violate the anti-kickback statute or other similar federal or state statue or regulation Routine waiver of copayments Record retention requirements Proper confirmation of diagnosis Medical record integrity ICD and CPT coding guidelines Specific government reimbursement principles (Medicare/Medicaid)

12 Health Insurance Portability and Accountability Act (HIPAA) Federal False Claims Act Michigan False Claims Act Deficit Reduction Act of 2005 Anti-kickback Statute Stark Statute Exclusion

13 HIPAA Privacy Rule establishes federal protections for individually identifiable health information held by covered entities and their Business Associates. HIPAA gives patients important rights with respect to their health information; at the same time the Privacy Rule is balanced to permit the use and disclosure of health information needed for patient care and other important purposes.

14 Knowingly presents, or involved in presenting, soliciting or receiving a false or fraudulent claim record or statement for payment or approval Defrauds the government by getting a false or fraudulent claim allowed or paid Uses a false record or statement to avoid or decrease an obligation to pay the government And other fraudulent acts enumerated in the statute

15 Penalties include fines from $5,500 to $11,000 per false claims, payment of treble damages, and exclusion from participation in federal healthcare programs. The FCA includes a whistleblower provision, which allows someone with actual knowledge of alleged FCA violations to file suit on the federal government s behalf. The FCA prohibits employers from retaliating against employees who file or participate in the prosecution of a whistleblower suit.

16 The Michigan FCA is similar to the Federal FCA and is designed to combat and recover losses from fraud. It contains a qui tam provision allowing private individuals with unique knowledge of wrongdoing to bring lawsuits on behalf of the state and share in any recovery. It prohibits retaliation against a person who files a whistleblower suit. The Michigan Whistleblower Act (Public Act 469) also creates certain protections and obligations for employees and employers under Michigan law.

17 Under the Deficit Reduction Act, UPHP is required to establish certain policies and provide all employees, contractors, and agents with information regarding: 1. The Federal False Claims Act and similar state law 2. An employee s right to be protected as a whistleblower 3. UPHP s policies and procedures for detecting and preventing fraud, waste and abuse in state and federal healthcare programs

18 The AKS and the Stark law are similar; but the AKS has a far broader reach than Stark Law and prohibits anyone (person or corporate entity) from: Offering, paying, soliciting, or receiving remuneration Directly or indirectly In cash or in kind In exchange for Referring an individual Furnishing or arranging for a good or service For which payment may be made under any federal health care program It is important to remember there are Exceptions and Safe Harbors to the AKS 42 United States Code 1320a-7b(b)

19 Violation of the Anti-Kickback Statute can result in Criminal and/or Civil Penalties. Criminal: Felony, imprisonment up to 5 years and a fine up to $25,000 or both Mandatory exclusion from participating in Federal health care programs Civil: A violation of the Anti-Kickback Statute constitutes a false or fraudulent claim under the Civil False Claims Act (FCA) Penalties are the same as under the FCA

20 Stark Law prohibits: A physician From making a referral Of a Medicare Patient To an entity that furnishes designated health services If the physician has a financial relationship with the entity Unless an exception applies Stark Law regulations are at [42 C.F.R. ' through ' ].

21 Medicare claims tainted by an arrangement that does not comply with Stark are not payable. Up to a $15,000 fine for each service provided. Up to a $100,000 fine for entering into an arrangement or scheme. Other sanctions include: denial of claims for improperly referred DHS, duty to refund, exclusion, and potential False Claims Act Liability.

22 No federal health care program payment (Medicare and/or Medicaid funds) may be made for any item or service furnished, ordered or prescribed by an individual or entity excluded by the Office of the Inspector General.

23 Fraud: An intentional act of deception, misrepresentation, or concealment in order to gain something of value. Fraud occurs when an individual knows or should know that something is false and makes a knowing deception that could result in some unauthorized benefit to themselves or another person. Waste: Over-utilization of services (not caused by criminally negligent actions) and the misuse of resources. Abuse: Excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss.

24 Examples of Fraud Examples of Abuse Examples of Waste Billing for services not furnished Charging in excess for services or supplies Overutilization of services Billing for services at a higher rate than is justified Soliciting, offering or receiving a kickback, bribe or rebate Deliberately misrepresenting services resulting in unnecessary cost, improper payments or overpayment Violation of the Stark or Anti-kickback Statute Providing medically unnecessary services Providing services that do no meet professionally recognized standards Misuse of resources

25 Medicare Advantage or Prescription Drug Plan Sponsor Fraud, Waste or Abuse Failure to provide medically necessary services that MAPD is required to provide under law or contract Inappropriate enrollment/disenrollment Marketing schemes; e.g. unsolicited door-to-door marketing, offering cash for enrollment, enrolling a beneficiary without their knowledge or consent Formulary or Coverage Determinations; making inappropriate coverage/formulary decisions or delaying access to necessary drugs

26 Beneficiary Fraud, Waste and Abuse Identify Theft; using a different member s ID to obtain benefits Doctor Shopping; visiting several doctors to obtain multiple prescriptions Coordination of Benefits; beneficiary does not disclose other coverage Prescription Fraud; resale of drugs or modifying a prescription

27 Provider Fraud, Waste and Abuse Kickbacks; offering, soliciting or receiving a kickback, bribe or rebate False Claims; billing for services not rendered or supplies not provided. False code or service; billing for a covered item or service when the item or service provided was a non-covered item or service Unnecessary Care; providing unnecessary medical care or prescription drugs

28 Pharmacist Fraud, Waste or Abuse Billing for prescriptions that were not picked up Billing for a brand name when generics are dispensed Splitting prescriptions Drug shorting; providing less than prescribed quantity and billing for full amount Forging or altering prescriptions Using expired or tainted drugs Inappropriate documentation of pricing information Counterfeit drugs; including fake, diluted, expired or illegally imported drugs

29 Make sure you are up to date with laws, regulations, policies. Ensure you coordinate with other payers. Ensure data/billing is both accurate and timely. Verify information provided to you. Be on the lookout for suspicious activity. UPHP has policies and procedures in place to address fraud, waste, and abuse. These procedures should assist you in detecting, correcting, and preventing fraud, waste, and abuse. UPHP policies are available at Make sure you are familiar with UPHP s policies and procedures.

30 The actual consequence depends on the violation. Civil Money Penalties Criminal Conviction/Fines Civil Prosecution Imprisonment Loss of Provider License Exclusion from Federal Health Care programs

31 Providers, beneficiaries and employees are responsible for reporting any suspected issues of noncompliance. Issues or concerns maybe be reported by contacting: UPHP Compliance Officer: Melanie Bicigo CMS: MEDICARE State of Michigan Office of Inspector General: MI-FRAUD P.O. Box 30479, Lansing, MI Office of the Inspector General: HHS-TIPS US Department of Health and Human Services Office of the Inspector General, ATTN: OIG HOTLINE OPERATIONS P.O. Box Washington, DC You may report anonymously and retaliation is prohibited when reporting in good faith.

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