Fraud, Waste and Abuse Network Pharmacy Training 2011
|
|
- Jayson Bishop
- 8 years ago
- Views:
Transcription
1 Fraud, Waste and Abuse Network Pharmacy Training 2011
2 Table of Contents Centers for Medicare & Medicaid Services (CMS) Role Important Federal Statutes for Medicare Participants Fraud, Waste and Abuse Defined Medicare Prescription Drug Benefit Manual Chapter 9 - The Part D Program to Control Fraud, Waste and Abuse The Role of the MEDIC Sponsor Corporate Responsibility Prescription Solutions by OptumRx Anti-Fraud Plan Prescription Solutions by OptumRx Pharmacy Manual Network Pharmacy Obligations 2
3 Who is CMS? The Centers for Medicare & Medicaid Services (CMS) is the government entity that has oversight of the Medicare Advantage (MA), Medicare Advantage Prescription Drug Plan (MAPD), Prescription Drug Plan (PDP), Retiree Drug Subsidy (RDS) and the Medicare Program overall Their Main office is in Baltimore, Maryland They have 10 Regional Offices Atlanta, Boston, Chicago, Dallas, Denver, Kansas City, New York, Philadelphia, San Francisco and Seattle Two satellite offices Los Angeles, CA and Miami, FL 3
4 CMS and Their Role in Part D: CMS is responsible for the following activities: Contractor Management Account Management MA, MAPD, PDP and RDS Sponsors and Downstream Entities Data Analysis and Performance Metrics (e.g., Prescription Drug Event (PDE) records) Audits Plan Sponsors Compliance plans Payment audits Compliance and Enforcement Intervention for non-compliance Education and corrective action plans Sanctions, penalties and terminations Program Integrity Medicare Drug Integrity Contractors (MEDICs) Chapter 9 of the Medicare Prescription Drug Benefit Manual Coordination of government and non-government partners 4
5 Important Federal Statutes for Medicare participants: False Claims Act: Prohibits persons from knowingly submitting false claims or making a false record or statement in order to secure payment by the federal government for the false or fraudulent claim. Federal Anti-Kickback Act: Prohibits the knowing and willful receipt or offer to pay any remuneration, directly or indirectly, covertly or overtly, in cash or in-kind, in return for referring or for inducing a referral. Referrals can be for arranging any item or service for which payment may be made in whole or in part under a federal health care program. Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA contains provisions and rules related to protecting the privacy and security of protected health information (PHI) as well as provisions related to the prevention of health care fraud and abuse. HIPAA Privacy The Privacy Rule outlines specific protections for the use and disclosure of PHI. It also grants rights specific to members. HIPAA Security The Security Rule outlines specific protections and safeguards for electronic PHI. If you become aware of a potential breach of protected information, you must comply with the security breach and disclosure provisions under HIPAA and, if applicable, with any business associate agreement. 5
6 Important Federal Statutes for Medicare participants: Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA contains provisions and rules related to protecting the privacy and security of protected health information (PHI) as well as provisions related to the prevention of health care fraud and abuse. Sample HIPAA Fraud, Waste, and Abuse Provisions The creation of the Fraud Abuse and Control Program for coordination of state and federal health care fraud investigation and enforcement activities. The expansion of the exclusion authority so that any health care fraud conviction, even if the fraud is not related to Medicare or Medicaid, results in mandatory exclusion from participation in the Medicare or Medicaid programs. The creation of a new series of federal crimes, together referred to as health care fraud, which make it a federal crime to defraud health care benefit programs any benefit program, not just Medicare or Medicaid. 6
7 Fraud, Waste and Abuse Defined: Fraud: Fraud is an intentional deception or misrepresentation made by an individual or entity that the person or entity knows to be false or does not believe to be true, knowing that the deception could result in some unauthorized benefit to himself or some other person. Waste: Waste generally means the over-utilization of services not caused by criminally negligent actions and often involves the misuses of resources. It is the needless, careless and cavalier expenditure of funds or the consumption of property that results from deficient practice, judgments, or controls in areas of responsibility and accountability. Abuse: Abuse generally refers to practices that while not generally considered fraudulent, and which do not involve knowing misrepresentation of facts, are inconsistent with accepted and sound medical, fiscal or business practice. These practices may directly or indirectly result in unnecessary costs to an insurance program, improper payment, or payment for services that fail to meet professional standards of care or are medically unnecessary. 7
8 Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Chapter 9 is one of a number of chapters in the CMS Medicare Prescription Drug Benefit Manual. Chapter 9 includes both interpretive rules and guidelines for Part D plan sponsors on how to implement the regulatory requirements to have in place a comprehensive fraud, and abuse plan to detect, correct, and prevent Fraud, Waste and Abuse as an element of their compliance plan. Even though sponsors are not law enforcement agencies, sponsors bear the ultimate responsibility for compliance and for detecting, preventing and correcting Fraud, Waste and Abuse. Prescription Solutions helps facilitate this responsibility by providing training and oversight of contracted Network Pharmacies. 8
9 Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: The core elements required of a sponsor compliance program are: Written policies and procedures Compliance officer and compliance committee Training and education Effective lines of communication Enforcement of standards through publicized guidelines Monitoring and auditing Corrective action procedures Comprehensive Fraud and Abuse plan (includes voluntary selfreporting of potential fraud and misconduct) 9
10 Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies: Examples of Fraud, Waste and Abuse perpetrated by marketers to watch for: Offering beneficiary cash payments as an inducement to enroll Unsolicited door-to-door marketing Enrollment of a beneficiary without their consent Stating that a marketing agent works for CMS, or the Social Security Administration (SSA) Misrepresentation of a product as Part D when it is Medigap, or non-medicare Enrolling beneficiary in an MAPD plan when they wanted a PDP Stating the marketer can enroll new beneficiary over the phone 10
11 Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies (continued): Examples of Fraud, Waste and Abuse perpetrated by prescribers to watch for: Illegal remuneration schemes prescriber is offered, paid, solicits or receives unlawful remuneration to induce or reward the prescriber to write prescriptions (kick backs) Prescription drug switching offers in cash or other benefit to prescribe one drug over another Script mills writing prescriptions for drugs that are not medically necessary, often in mass quantities, and often for individuals that are not his or her patients Theft of prescriber s Drug Enforcement Administration (DEA) number, Prescription pad, or e-prescribing authentication information and log-in 11
12 Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies: Examples of Fraud, Waste and Abuse perpetrated by pharmacies to watch for: Billing for brand and dispensing generic drugs Over-billing of quantity prescribed and inappropriate billing of compounds Over-billing of quantity in relation to days supply that exceeds prescribed amount False or fictitious claims submission Document fabrications and alterations Forged signature logs or insufficient proof of delivery Not processing returns to stock Use of dummy DEA s/national Provider Identifier (NPI) Inappropriate use of Dispense As Written (DAW) codes Billing of unauthorized refills Billing under expired prescriptions Prescription splitting to obtain multiple dispensing fees Pill shorting billing for more than dispensed Recycling medications black market repurchases for resale Not crediting for destroyed returns 12
13 Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies: Examples of Fraud, Waste and Abuse perpetrated by members to watch for: Over-utilization and drug seeking drug abuse (not limited to narcotics) Altered and forged prescriptions dates, strengths, quantities, refills, false claims Members initiating their own phone-in prescriptions Pharmacy hopping and doctor shopping review history of member Drug diversion and inappropriate use obtains drugs used by another non-covered party, or for resale on the black market Misrepresentation of status member misrepresents identity, eligibility, medical conditions to obtain benefits 13
14 Who is the MEDIC and what is their role in Part D? The Medicare Integrity Contractor: Purpose is to ensure the protection of the Medicare Trust Fund and Medicare beneficiaries. Responsible for the following activities: Answer the SAFERX Part D hotline Perform data analysis to detect Fraud, Waste and Abuse in Part D Investigation accusations of Fraud, Waste and Abuse in Part D Develop and refer cases to law enforcement Conduct audits Review compliance programs Cover pharmacies, prescribers, beneficiaries and marketing agents 14
15 Sponsor Role in Fraud, Waste, and Abuse Prevention: Monitoring and evaluating Medicare functions Auditing, monitoring and detecting Conducting investigations Performing data mining and analysis Voluntary self-reporting Maintaining a compliance plan that includes appropriate oversight of first-tier, related and down-stream entities (that would include Prescription Solutions and it s contracted Network Pharmacies) Promptly report any perceived or alleged instances of pharmacy, prescriber, or member fraud determined to warrant further investigations to the appropriate Compliance Officer or external regulatory agency 15
16 Prescription Solutions by OptumRx Anti-Fraud Plan: A system/process to monitor, detect and prevent Fraud, Waste and Abuse. Identifies an avenue to administer corrective action up to and including reclaim of the overpayments associated with Fraud, Waste and Abuse, and/or termination of the Agreement (including Network Pharmacy Agreements) if warranted. Prescription Solutions has a zero-tolerance policy on Fraud, Waste and Abuse. Includes explanations of: Examples of Fraud, Waste and Abuse perpetrated by pharmacies, prescribers and members Audit referral system Escalation oversight committee Education and training programs of staff and network Fraud prevention procedures that include but are not necessarily limited to: On-line edits Desk-top audits On-site audits 16
17 Prescription Solutions by OptumRx Pharmacy Manual: Distributed to all network pharmacies annually. Includes the following topics: Customer identification cards Claims processing Products offered Medicare product information and guidelines Terms and conditions: Compliance Fraud, Waste, and Abuse Pharmacy Audits Credentialing Involuntary disenrollment by plan or sponsor State Medicaid requirements 17
18 Network Pharmacy Obligations: Comply with contractual terms concerning compliance with Federal and state laws Report suspected Fraud, Waste or Abuse to Prescription Solutions Provide this training to all staff who work with Part D annually Maintain lists of personnel trained and the dates provided for audit purposes Attest to completion of training annually as requested by Prescription Solutions Address any questions to Prescription Solutions Maintain policies and procedures on Fraud, Waste and Abuse consistent with Federal and state laws 18
19 Contact Prescription Solutions with any questions at either of the following addresses: 19
Fraud, Waste and Abuse Prevention Training
Fraud, Waste and Abuse Prevention Training The Centers for Medicare & Medicaid Services (CMS) requires annual fraud, waste and abuse training for organizations providing health services to MA or Medicare
More informationFraud, Waste & Abuse. Training Course for UHCG Employees
Fraud, Waste & Abuse Training Course for UHCG Employees Overview The Centers for Medicare & Medicaid Services (CMS) require Medicare Advantage Organizations and Part D Plan Sponsors to provide annual fraud,
More information2010 Fraud, Waste, and Abuse Training Materials
2010 Fraud, Waste, and Abuse Training Materials UnitedHealthcare Medicare Plans Medicare Advantage AARP MedicareComplete Erickson Advantage Evercare Sierra Spectrum Sierra Village Health SM SecureHorizons
More information1 st Tier & Downstream Training Focus
Colorado Access Advantage (HMO) Medicare Advantage Part D Fraud, Waste and Abuse Compliance Training 2010 Introduction 2 The Centers for Medicare & Medicaid Services (CMS) requires annual fraud, waste
More informationMedicare Advantage and Part D Fraud, Waste and Abuse Compliance Training
Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training Overview This Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training for first-tier, downstream and related entities
More informationMedicare Advantage and Part D Fraud, Waste, and Abuse Training. October 2010
Medicare Advantage and Part D Fraud, Waste, and Abuse Training October 2010 Introduction 2008: United States spent $2.3 trillion on health care. Federal fiscal year 2010: Medicare expected to cover an
More informationFraud Waste and Abuse Training Requirement. To Whom It May Concern:
RE: Fraud Waste and Abuse Training Requirement To Whom It May Concern: This letter is to inform you about a new requirement being implemented by the CMS program (Centers for Medicare and Medicaid Services)
More informationCompliance and Program Integrity Melanie Bicigo, CHC, CEBS mlbicigo@uphp.com 906-225-7749
Compliance and Program Integrity Melanie Bicigo, CHC, CEBS mlbicigo@uphp.com 906-225-7749 Define compliance and compliance program requirements Communicate Upper Peninsula Health Plan (UPHP) compliance
More informationCMS Mandated Training for Providers, First Tier, Downstream and Related Entities
CMS Mandated Training for Providers, First Tier, Downstream and Related Entities I. INTRODUCTION It is the practice of Midwest Health Plan (MHP) to conduct its business with the highest degree of ethics
More information2012-2013 Compliance Expectations & Fraud, Waste and Abuse Training Materials for First Tier, Downstream and Related Entities
Cover area with cropped image. Do not overlap blue bar. Completely cover gray area. Cover area with cropped image. Do not overlap blue bar. Completely cover gray area. Cover area with cropped image. Do
More informationBlueCross BlueShield of Tennessee Senior Care Division and Volunteer State Health Plan
BlueCross BlueShield of Tennessee Senior Care Division and Volunteer State Health Plan Fraud Waste and Abuse Training for Providers, First Tier, Downstream and Related Entities Overview The Centers for
More informationFraud, Waste and Abuse Training for Medicare and Medicaid Providers
Fraud, Waste and Abuse Training for Medicare and Medicaid Providers For Use By: Licensed affiliates and subsidiaries of Magellan Health Services, Inc. Contents and Agenda Define Fraud, Waste, and Abuse
More informationFraud, Waste, and Abuse Training For Use By Care Wisconsin Providers Created: September 20, 2010 Reviewed/Revised: 8/18/2011
Fraud, Waste, and Abuse Training For Use By Care Wisconsin Providers Created: September 20, 2010 Reviewed/Revised: 8/18/2011 Definitions & Examples Why it Matters Prevention, Detection and Reporting Your
More informationMedicare Compliance and Fraud, Waste, and Abuse Training
Medicare Compliance and Fraud, Waste, and Abuse Training Objectives Recognize laws and concepts affecting compliance and fraud, waste, and abuse (FWA) Increase awareness of FWA Use identification techniques
More informationFraud, Waste, and Abuse
These training materials are divided into three topics to meet the responsibilities stated on the previous pages: Fraud, Waste, Compliance Program Standards of Conduct Although the information contained
More informationTouchstone Health Training Guide: Fraud, Waste and Abuse Prevention
Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention About the Training Guide Touchstone is providing this Fraud, Waste and Abuse Prevention Training Guide as a resource for meeting Centers
More informationDeveloped by the Centers for Medicare & Medicaid Services
Developed by the Centers for Medicare & Medicaid Services Every year millions of dollars are improperly spent because of fraud, waste, and abuse. It affects everyone. Including YOU. This training will
More informationMedicare Fraud, Waste and Abuse (FWA) Compliance Training. ICE Approved: 11/13/09
Medicare Fraud, Waste and Abuse (FWA) Compliance Training ICE Approved: 11/13/09 1 CMS Requirements The Centers for Medicare and Medicaid Services (CMS) requires annual fraud, waste, and abuse training
More informationMedicare Fraud, Waste, and Abuse Training for Healthcare Professionals 2010-2011
Medicare Fraud, Waste, and Abuse Training for Healthcare Professionals 2010-2011 Y0067_H2816_H6169_WEB_UAMC IA 11/22/2010 Last Updated: 11/22/2010 Medicare Requirements The Centers for Medicare and Medicaid
More informationTraining for providers
Fraud, waste and abuse awareness: Training for providers Introduction Annual requirement: The Centers for Medicare & Medicaid Services (CMS) requires annual fraud, waste and abuse (FWA) training for organizations
More informationMEDICAID AND MEDICARE (PARTS C&D) FRAUD, WASTE AND ABUSE TRAINING
MEDICAID AND MEDICARE (PARTS C&D) FRAUD, WASTE AND ABUSE TRAINING Why Do I Need Training/Where Do I Fit in? Why Do I Need Training? Every year millions of dollars are improperly spent because of fraud,
More informationMedicare Compliance Training and Fraud, Waste, and Abuse Training. Producer Training 2012-2013
Medicare Compliance Training and Fraud, Waste, and Abuse Training Producer Training 2012-2013 CMS, PHP and You Providence Health Plans (PHP) contracts with the Centers for Medicare & Medicaid Services
More informationFIRST TIER, DOWNSTREAM AND RELATED ENTITIES (FDR) ANNUAL TRAINING
FIRST TIER, DOWNSTREAM AND RELATED ENTITIES (FDR) ANNUAL TRAINING The Compliance Team appreciates your attention and cooperation during this CMS mandated annual training! DEFINITIONS ADVANTAGE utilizes
More informationOverview, Guidance & Training: Medicare Fraud, Waste & Abuse
Overview, Guidance & Training: Medicare Fraud, Waste & Abuse Learning Objectives 1. To become familiar with the new educational component of fraud, waste and abuse (FWA) training regulations that govern
More informationMedicare Compliance and Fraud, Waste and Abuse (FWA) Training
Medicare Compliance and Fraud, Waste and Abuse (FWA) Training and its Medical Partners 5/1/11 1 Overview & Objectives What: Compliance & Fraud Waste & Abuse (FWA) program requirements Things you need to
More informationPrime Staffing-Fraud, Waste and Abuse Prevention Training Guide Designed for First-tier, Downstream and Related Entities
Prime Staffing-Fraud, Waste and Abuse Prevention Training Guide Designed for First-tier, Downstream and Related Entities Prime Staffing is providing this Fraud, Waste and Abuse Prevention Training Guide
More informationFRAUD, WASTE & ABUSE. Training for First Tier, Downstream and Related Entities. Slide 1 of 24
FRAUD, WASTE & ABUSE Training for First Tier, Downstream and Related Entities Slide 1 of 24 Purpose of this Program On December 5, 2007, the Centers for Medicare and Medicaid Services ( CMS ) published
More informationMedicare Fraud, Waste, and Abuse Training for Pharmacies and Their Staff 2013/2014
Medicare Fraud, Waste, and Abuse Training for Pharmacies and Their Staff 2013/2014 Y0067_Pharmacy_FWA_Training_0913_IA 09/19/2013 1 Medicare Requirements The Centers for Medicare and Medicaid Services
More informationPreventing Fraud, Waste, and Abuse
2013 Compliance Training for Contractors and Vendors Module 2 Preventing Fraud, Waste, and Abuse For Internal Training Purposes Only 1 Learning Objectives After completing this training, learners will
More informationHow To Get A Medical License In Michigan
FRAUD, WASTE, & ABUSE Kimberly Parks NEIGHBORHOOD LEGAL SERVICES MICHIGAN ELDER LAW & ADVOCACY CENTER 12121 Hemingway Redford, Michigan 48239 (313) 937-8291 Why It s Important Fraud, Waste and Abuse drain
More informationProcedures. The following Privacy Notice is provided to all HealthPlus members:
HealthPlus Privacy Notice Policies and Procedures The following Privacy Notice is provided to all HealthPlus members: The HealthPlus Privacy Notice describes how personal and medical information about
More informationMEDICAID AND MEDICARE (PARTS C&D) FRAUD, WASTE AND ABUSE TRAINING
MEDICAID AND MEDICARE (PARTS C&D) FRAUD, WASTE AND ABUSE TRAINING Why Do I Need Training/Where Do I Fit in? Why Do I Need Training? Every year millions of dollars are improperly spent because of fraud,
More informationFraud Waste and Abuse Training First Tier, Downstream and Related Entities
Fraud Waste and Abuse Training First Tier, Downstream and Related Entities Revised: 04/2010 OVERVIEW Centene Corporation Purpose Bridgeway Compliance Program Definitions of Fraud Waste & Abuse Laws and
More informationCODE OF CONDUCT. Providers, Suppliers and Contractors
CODE OF CONDUCT Providers, Suppliers and Contractors Table of Contents Code of Conduct... Honesty and integrity... Quality and Service... Responsibilities of Providers, Suppliers and Contractors... Compliance
More informationStandards of. Conduct. Important Phone Number for Reporting Violations
Standards of Conduct It is the policy of Security Health Plan that all its business be conducted honestly, ethically, and with integrity. Security Health Plan s relationships with members, hospitals, clinics,
More informationMedicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training
Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training Developed by the Centers for Medicare & Medicaid Services Issued: February, 2013 Important Notice This training module
More informationFraud, Waste and Abuse Training for Pharmacies
Fraud, Waste and Abuse Training for Pharmacies What You ll Learn Definitions of fraud, waste and abuse Examples of each Relevant statutes Your responsibilities Fraud, Waste and Abuse Accounts for billions
More informationMODULE II: MEDICARE & MEDICAID FRAUD, WASTE, AND ABUSE TRAINING
MODULE II: MEDICARE & MEDICAID FRAUD, WASTE, AND ABUSE TRAINING 2 0 1 4 Introduction The Medicare and Medicaid programs are governed by statutes, regulations, and policies PacificSource must have an effective
More informationFraud Waste & A buse
5 Fraud Waste & Abuse Fraud, Waste and Abuse Detecting and preventing fraud, waste and abuse Harvard Pilgrim is committed to detecting, mitigating and preventing fraud, waste and abuse. Providers are also
More information2012-2013 MEDICARE COMPLIANCE TRAINING EMPLOYEES & FDR S. 2012 Revised
2012-2013 MEDICARE COMPLIANCE TRAINING EMPLOYEES & FDR S 2012 Revised 1 Introduction CMS Requirements As of January 1, 2011, Federal Regulations require that Medicare Advantage Organizations (MAOs) and
More information2015 Fraud, Waste & Abuse Prevention
Quality Independent Physicians, LLC Awareness Training 2015 Fraud, Waste & Abuse Prevention Fraud, Waste and Abuse (FWA) Training Objectives After completing this training you should be able to: Recognize
More informationMedicare Compliance and Fraud, Waste and Abuse (FWA) Training 5/1/11
Medicare Compliance and Fraud, Waste and Abuse (FWA) Training 5/1/11 1 Overview & Objectives What: Compliance & Fraud Waste & Abuse (FWA) program requirements Things you need to be aware of and implement
More informationMedicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training. Important Notice
Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training Developed by the Centers for Medicare & Medicaid Services Issued: February, 2013 Important Notice This training module
More informationSUBJECT: FRAUD AND ABUSE POLICY: CP 6018
SUBJECT: FRAUD AND ABUSE POLICY: Department of Origin: Compliance & Audit Responsible Position: Vice President of Compliance and Audit Date(s) of Review and Revision: 07/10; 04/11; 11/11; 02/12; 6/12;
More informationMEDICARE DRUG INTEGRITY CONTRACTORS IDENTIFICATION
Department of Health and Human Services OFFICE OF INSPECTOR GENERAL MEDICARE DRUG INTEGRITY CONTRACTORS IDENTIFICATION OF POTENTIAL PART D FRAUD AND ABUSE Daniel R. Levinson Inspector General October 2009
More informationDiscrepancies are claims that appear to have unusual or potentially abusive, wasteful or fraudulent elements (e.g., quantity, days supply).
Purpose: Provide guidelines for pharmacies for audits and appeals of pharmacy audit findings resulting from MedImpact auditor data review and claims selection for identification of potential fraud, waste
More informationFEHB Program Carrier Letter
FEHB Program Carrier Letter All Carriers U.S. Office of Personnel Management Healthcare and Insurance Letter No. 2014-29 Date: December 19, 2014 Fee-for-service [ 25 ] Experience-rated HMO [ 25 ] Community-rated
More informationPrevention of Fraud, Waste and Abuse Training
Prevention of Fraud, Waste and Abuse Training For Group Health Contracted Providers FWA Department l Office of Compliance and Ethics 1 Outline Purpose Deemed Compliant Group Health Compliance Program Fraud,
More informationSECTION 18 1 FRAUD, WASTE AND ABUSE
SECTION 18 1 FRAUD, WASTE AND ABUSE Annual FW&A Training Required for Providers and Office Staff 1 Examples of Fraud, Waste and Abuse 2 Fraud, Waste and Abuse Program Policy 3 Suspected Non-Compliance
More informationFraud, Waste and Abuse CareMore s Program for Prevention, Detection and Response C A R E M O R E M E D I C A L E N T E R P R I S E S
Fraud, Waste and Abuse CareMore s Program for Prevention, Detection and Response 1 C A R E M O R E M E D I C A L E N T E R P R I S E S Key Program Objectives 2 This course will cover FWA in the Medicare
More informationMedicare Advantage and Part D Fraud, Waste, and Abuse Training. Committed to Integrity
Medicare Advantage and Part D Fraud, Waste, and Abuse Training Committed to Integrity Dear Provider: CHP Introductory Statement The Centers for Medicare & Medicaid Services (CMS) has mandated that all
More informationSection 10. Compliance
Section 10. Compliance Fraud, Waste, and Abuse Introduction Molina Healthcare of [state] maintains a comprehensive Fraud, Waste, and Abuse program. The program is held accountable for the special investigative
More informationFraud, Waste & Abuse Prevention Awareness Training
Fraud, Waste & Abuse Prevention Awareness Training Last Updated: July 30, 2013 What is Fraud, Waste and Abuse (FWA) Upon completion of this training you should be able to: Recognize and understand the
More informationFraud, Waste & Abuse. UPMC Health Plan Quality Audit, Fraud, Waste & Abuse Department
Fraud, Waste & Abuse UPMC Health Plan Quality Audit, Fraud, Waste & Abuse Department Definitions of Fraud, Waste & Abuse FRAUD: An intentional deception or misrepresentation made by a person or entity,
More informationPharmacies Medicare Part D Training Obligations and Medicare Training Resources
Pharmacies Medicare Part D raining Obligations and Medicare raining Resources Your obligation - MS regulations require that all pharmacies contracted with Medicare Part D Plan Sponsors, such as the Medco
More information2013 Medicare. Part D Fraud, Training. First Tier, Downstream and Related Entities
2013 Medicare Advantage and Part D Fraud, Waste and Abuse Waste, Training First Tier, Downstream and Related Entities February, 2013 Training Objectives 1 Why is Fraud, Waste, and Abuse (FWA) Training
More informationFraud Waste and Abuse Training First Tier, Downstream and Related Entities. ONECare by Care1st Health Plan Arizona, Inc. (HMO) Revised: 10/2009
Fraud Waste and Abuse Training First Tier, Downstream and Related Entities ONECare by Care1st Health Plan Arizona, Inc. (HMO) Revised: 10/2009 Overview Purpose Care1st/ ONECare Compliance Program Definitions
More informationThe following presentation was based on the
Fraud Waste and Abuse Presentation The following presentation was based on the Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training developed by the Centers for Medicare
More informationFraud, Waste and Abuse Training. Protecting the Health Care Investment. Section Three
Fraud, Waste and Abuse Training Protecting the Health Care Investment Section Three Section 1.2: Purpose According to the National Health Care Anti-Fraud Association, the United States spends more than
More informationFraud, Waste and Abuse Training
Fraud, Waste and Abuse Training 1 Why Do I Need Training? Every year millions of dollars are improperly spent because of fraud, waste and abuse. It affects everyone, Including YOU. This training will help
More informationMedicare Part D Compliance Fraud, Waste & Abuse. Training for Network Pharmacies 2011/2012
Medicare Part D Compliance Fraud, Waste & Abuse Training for Network Pharmacies 2011/2012 Table of Contents Introduction... 3 Section One: Medicare and the Medicare Part D Compliance Program... 6 Medicare
More informationMedicare Compliance, Fraud, Waste and Abuse Training for Medicare Part D- Contracted Pharmacies
Medicare Compliance, Fraud, Waste and Abuse Training for Medicare Part D- Contracted Pharmacies 2008 Medco Health Solutions, Inc. All rights reserved. Training Introduction In this training, you ll learn
More informationCompliance Program Guide for Contractors. Integrity Program
Compliance Program Guide for Contractors Integrity Program Prepared by: Compliance Officer Version 2.2 December 2013 1 Table of Contents Integrity Program Overview... 2 Standards of Conduct... 3 Reporting
More informationProgram Integrity (PI) for Network Providers
Program Integrity (PI) for Network Providers Purpose of Program Integrity Quality providers o Improved outcomes for consumers o Reduced oversight for provider o Confidence in network for LME-MCOs Financial
More informationFraud Prevention Training Requirements For Medicare Advantage Plans
MEDICARE ADVANTAGE (Part C) PRESCRIPTION DRUG (Part D) FRAUD, WASTE, and ABUSE EDUCATION AND TRAINING 1 INTRODUCTION CMS has mandated that Medicare Advantage Organizations (MAOs) and Prescription Drug
More informationMedicare Fraud, Waste, and Abuse Training for Healthcare Professionals 2013/2014
Medicare Fraud, Waste, and Abuse Training for Healthcare Professionals 2013/2014 Y0067_SIU_HC_Prof_WEB_UAM_0913_IA 09/19/2013 1 Medicare Requirements The Centers for Medicare and Medicaid Services ( CMS
More informationFlorida Health Care Plans Fraud, Waste & Abuse and Compliance Training
Florida Health Care Plans Fraud, Waste & Abuse and Compliance Training 2014 Version INTRODUCTION The United States spends more than $2 trillion on health care every year. The National Health Care Anti-Fraud
More informationCompliance. In general, compliance means conforming to a rule, such as a specification, policy, standard or law.
COMPLIANCE TRAINING Compliance In general, compliance means conforming to a rule, such as a specification, policy, standard or law. Regulatory compliance describes the goal that corporations or public
More informationFalse Claims / Federal Deficit Reduction Act Notice Help Stop Healthcare Fraud, Waste and Abuse: Report to the Firelands Corporate Compliance Officer
1111 Hayes Avenue Sandusky, OH 44870 www.firelands.com False Claims / Federal Deficit Reduction Act Notice Help Stop Healthcare Fraud, Waste and Abuse: Report to the Firelands Corporate Compliance Officer
More informationPreferred IPA Medicare Fraud, Waste, and Abuse Training General Compliance Training HIPAA Compliance Training 2014-2015
Preferred IPA Medicare Fraud, Waste, and Abuse Training General Compliance Training HIPAA Compliance Training 2014-2015 This training program consists of three parts: 1. Medicare Parts C & D Fraud, Waste,
More informationTable of Contents. 2 P a g e
Table of Contents Introduction... 3 Important Contact Information... 3 Pharmacy Rights... 3 Claims Adjudication... 3 Reversals... 4 Required Data Fields... 4 Identification cards... 4 Required Identification
More informationCompliance Program Code of Conduct
Compliance Program Code of Conduct INTRODUCTION All personnel must not only act in compliance with all applicable legal rules and regulations, but also strive to avoid even the appearance of impropriety.
More informationPrinciples of Business Ethics Compliance and Fraud Prevention Guide
Principles of Business Ethics Compliance and Fraud Prevention Guide Military Healthcare Services Dear Health Care Professionals, Entities and Vendors: Our industry s attention has increased its focus on
More informationFraud, Waste and Abuse Page 1 of 9
Page 1 of 9 Overview It is the policy of MVP Health Care, Inc. and its affiliates (collectively referred to as MVP ) to comply with all applicable federal and state laws regarding fraud, waste and abuse.
More informationMedicare 101. Presented by Area Agency on Aging 1-A
Medicare 101 Presented by Area Agency on Aging 1-A What is Medicare? n Federal Health Insurance for: n People 65 years of age or older n Some persons with disabilities, after a 24 month waiting period
More informationCOMPLIANCE AND OVERSIGHT MONITORING
COMPLIANCE AND OVERSIGHT MONITORING The contract between HCA and Molina Healthcare defines a number of performance requirements that must be satisfied by Molina Healthcare subcontracted Providers to provide
More informationNOYES HEALTH ADMINISTRATION POLICY/PROCEDURE
NOYES HEALTH ADMINISTRATION POLICY/PROCEDURE SUBJECT: DETECTION AND PREVENTION OF POLICY: 200.161 FRAUD, WASTE, AND ABUSE EFFECTIVE DATE: June, 2012 ISSUED BY: Administration TJC REF: None PAGE: 1 OF 5
More informationCORPORATE COMPLIANCE POLICY AND PROCEDURE
Title: Fraud Waste and Abuse Laws in Health Care Policy # 1011 Sponsor: Corporate Compliance Approved by: Carleen Dunne, Director, Corporate Compliance and Privacy Officer Issued: Page: 1 of 7 June 25,
More informationProgram Integrity Fraud, Waste, and Abuse Training
Program Integrity Fraud, Waste, and Abuse Training March 2015 Jim K. Hampton, Director Fraud Operations & SIU Health Care Fraud is a crime that has a significant effect on the private and public health
More informationCompliance Training for Medicare Programs Version 1.0 2/22/2013
Compliance Training for Medicare Programs Version 1.0 2/22/2013 Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. 1 The Compliance Program Setting standards
More informationSCAN Health Plan Policy and Procedure Number: CRP-0067, False Claims Act & Deficit Reduction Act 2005
Health Plan Policy and Procedure Number: CRP-0067, False Claims Act & Deficit Reduction Act 2005 Approver Approval Stage Date Chris Zorn Approval Event (Authoring) 12/09/2013 Nancy Monk Approval Event
More informationProvider Training Series The Search for Compliance Annual Mandatory Training for all Providers
Provider Training Series The Search for Compliance Annual Mandatory Training for all Providers Melissa Hooks, Director of Program Integrity Annual Training for All Providers Compliance with Medicaid Detection
More informationCombating Medicare Parts C and D Fraud, Waste, and Abuse
Combating Medicare Parts C and D Fraud, Waste, and Abuse Why Do I Need Training? Every year billions of dollars are improperly spent because of FWA. It affects everyone including you. This training will
More informationCompliance, Code of Conduct & Ethics Program Cantex Continuing Care Network. Contents
Compliance, Code of Conduct & Ethics Program Cantex Continuing Care Network Contents Compliance, Code of Conduct & Ethics Program 1 What is the CCCN Code of Conduct? 2 Operating Philosophies 2 Employee
More informationPHI Air Medical, L.L.C. Compliance Plan
Page No. 1 of 13 Introduction: The PHI Air Medical, L.L.C. is to be used by employees, contractors and vendors to get a high level understanding of the key regulatory requirements relating to our participation
More informationMinimum Performance and Service Criteria for Medicare Part D
Minimum Performance and Service Criteria for Medicare Part D 1. Terms and Conditions. In addition to the other terms and conditions of the Pharmacy Participation Agreement ( Agreement ), the following
More informationAppleCare. 2013 General Compliance Training
AppleCare 2013 General Compliance Training Goals After completing this course, you will understand: The Principles of Ethics and Integrity and the Compliance Plan How to report a suspected or detected
More informationFraud, Waste and Abuse: Compliance Program. Section 4: National Provider Network Handbook
Fraud, Waste and Abuse: Compliance Program Section 4: National Provider Network Handbook December 2015 2 Our Philosophy Magellan takes provider fraud, waste and abuse We engage in considerable efforts
More informationHow To Get A Medical Bill Of Health From A Member Of A Health Care Provider
Neighborhood requires compliance with all laws applicable to the organization s business, including insistence on compliance with all applicable federal and state laws dealing with false claims and false
More informationStandards of Conduct for First Tier, Downstream, and Related Entities (FDR)
Standards of Conduct for First Tier, Downstream, and Related Entities (FDR) The Health Plan 52160 National Road East St. Clairsville, Ohio 43950-9365 740.695.7902, 1.888.847.7902 TDD: 740.695.7919, 1.800.622.3925
More informationDo You Know Where the Drugs Are Going? Partners in Integrity
Do You Know Where the Drugs Are Going? Partners in Integrity Objectives At the conclusion of this presentation, participants will be able to: Identify common types of drug diversion activities. List at
More informationDo You Know Where the Drugs Are Going?
Do You Know Where the Drugs Are Going? Presentation Objectives At the conclusion of this presentation, participants will be able to: Identify common types of drug diversion activities. List at least four
More informationCORPORATE COMPLIANCE POLICY AND PROCEDURE
Title: Fraud Waste and Abuse Laws in Health Care Policy # 1011 Sponsor: Corporate Approved by: Carleen Dunne, Director, Corporate and Privacy Officer Issued: Page: 1 of 7 June 25, 2007 Last Reviewed/Updated
More informationThe United States spends more than $1 trillion each year on healthcare
Managed Care Fraud and Abuse Compliance Guidelines I. Introduction The United States spends more than $1 trillion each year on healthcare representing approximately 15 percent of the gross national product.
More informationOffice of Inspector General (OIG) Compliance Recommendations for Medicare Part D
Office of Inspector General (OIG) Compliance Recommendations for Medicare Part D Presented by Rachael A. Ream 216.513.1314 rream@hallrender.com Conflict of Interest Statement My hsuband received a $100
More informationTM Nightingale. Home Healthcare. Fraud & Abuse: Prevention, Detection, & Reporting
Fraud & Abuse: Prevention, Detection, & Reporting What Is Fraud? Fraud is defined as making false statements or representations of facts to obtain benefit or payment for which none would otherwise exist.
More informationOverview of Gateway Health Plan Medicare Assured HMO SNP
Overview of Gateway Health Plan Medicare Assured HMO SNP Training Objectives To provide training on Gateway Health Plan Medicare Assured. To provide training on Gateway s Medicare Compliance Program. To
More informationSUBJECT: BUSINESS ETHICS AND REGULATORY COMPLIANCE PROGRAM & PLAN (BERCPP)
Effective Date: 6/17/2008; 1/3/2007; 6/2/2004, BOD #04-028 Revised Date: 9/5/2012 Review Date: 9/13/2012 North Sound Mental Health Administration Section 2000-Compliance: Business Ethics and Regulatory
More informationHPC Healthcare, Inc. Administrative/Operational Policy and Procedure Manual
Operational and Procedure Manual 1 of 7 Subject: Corporate Compliance Plan Originating Department Quality & Compliance Effective Date 1/99 Administrative Approval Review/Revision Date(s) 6/00, 11/99, 2/02,
More informationFWA Program. Program Description. Issued by: Regulatory Compliance Department
FWA Program Program Description Issued by: Regulatory Compliance Department July 2016 2016 FWA Program Description Page 1 of 16 Table of Contents Introduction Introduction..3 Definitions 4 Examples..6
More information