Overview, Guidance & Training: Medicare Fraud, Waste & Abuse

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1 Overview, Guidance & Training: Medicare Fraud, Waste & Abuse

2 Learning Objectives 1. To become familiar with the new educational component of fraud, waste and abuse (FWA) training regulations that govern Medicare Part D Plan Sponsors, (and or Medicare Advantage). 2. To understand the relevant laws and recognize and detect examples of potential fraud, waste and abuse. 3. To be familiar with reporting, preventing and correcting fraud, waste and abuse. 4. To describe instances specific to pharmacy surrounding Medicare FWA. 5. To familiarize yourself with specific FWA resources.

3 Fraud, Waste and Abuse Training Program Relevant Laws Documentation Requirements Examples of Potential FWA Reporting and Preventing FWA

4 What is the purpose of the fraud, waste, and abuse requirement? Background: Medicare is currently the nation s largest federally funded health insurance program, (est. annual price tag of $440 billion [12/2008]). Due to its sheer size and complexity, the government considers fraud and abuse a major concern, which is why it is included Medicare Modernization Act. The overall purpose behind the requirement is to protect the federal government and Medicare beneficiaries from fraudulent, abusive, and wasteful practices, situations or schemes through the delivery of the prescription drug benefit by ensuring that plan sponsors and their downstream entities (pharmacies) have received appropriate training to detect, correct, and prevent fraud, waste, and abuse.

5 Who will need to receive fraud, waste, and abuse training? It is CMS' intent that ANYONE who participates in the provision of the Part D benefit, either through interaction with the Medicare patient OR with the medications dispensed to Medicare beneficiaries, If this criteria is met, Then these individuals should receive fraud, waste, and abuse training.

6 When is the compliance deadline for employees to receive fraud, waste, and abuse training? 1. The training requirement became effective January 1,. 2. Mandatory training (e.g., of pharmacy / applicable staff) must begin January 1,, and must be completed within the year; Dec. 31,. 3. FWA training must be provided on an annual basis.

7 Source: Federal Register Part V Department of Health and Human Services, 42 CFR 422 and 423 [CMS-4124-FC]. Revised Regulations December 5, 2007, the Centers for Medicare & Medicaid Services (CMS) issued final rules in the Federal Register for 42 CFR Parts 422 and 423 of the Medicare Advantage Program and Prescription Drug Benefit Program, respectively. Specifically, Plan sponsors Must: 1. Maintain appropriate oversight and attest it will implement a compliance plan that includes effective training and education between the compliance officer, organization employees, contractors, agents and directors; 2. Establish training and communication requirements for their first tier, downstream and related entities in which there is a contractual relationship; 3. Obtain training logs and copies of attestations from their first tier, downstream and related entities to comply with this requirement.

8 Definitions Fraud Federal health care fraud generally involves a person or entity s intentional use of false statements or fraudulent schemes (such as kickbacks) to obtain payment for, or to cause another to obtain payment for items or services payable under a Federal health care program. Waste Use or expend carelessly, extravagantly, or to no purpose. Abuse In general, program abuse, which may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicare Program. Some examples of abuse: Charging in excess for services or supplies; Providing medically unnecessary services; or Providing services that do not meet professionally recognized standards. Note: Abuse cannot be differentiated categorically from fraud as the distinction between fraud and abuse generally depends on: 1. prior knowledge, 2. intent, 3. specific facts, 4. circumstances, 5. available evidence Source: Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals Ninth Edition: July 2007; CMS Medicare Fraud and Abuse.

9 Definitions Health Care Fraud- Knowingly & willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. Health Care Abuse- Involves payments for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse may, directly or indirectly result in unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care or services that are medically unnecessary.

10 Centers for Medicare and Medicaid Services Prescription Drug Benefit Manual Chapter 9 Part D program to Control Fraud, Waste and Abuse CMS has issued a fraud, waste and abuse guidance for the Medicare Part D drug benefit. This 70-page guidance, (i.e., Prescription Drug Benefit Manual, Chapter 9 Part D program to Control Fraud, Waste and Abuse, [ Chapter 9 ]), includes interpretive rules and guidance for Part D plan sponsors as they implement mandatory fraud waste and abuse compliance programs.

11 Chapter 9: Pharmacy provisions 1. Application To Pharmacies. a) This statement found in Chapter 9: i. plan sponsors may be held liable for violations by providers and other downstream entities is referenced. See 40. b) Pharmacies, pharmacists, and other clinical staff / clinicians are included in the definitions of providers and downstream entities.

12 MP-D Plan Sponsors & Contracts MP-D plan sponsors are permitted to contract with four entities: 1. First Tier any party that agrees to provide administrative or healthcare services and enters into a written agreement. (Usually these are Pharmacy Benefit managers [PBMs]). 2. Downstream any party that enters into a written agreement below First tier and a plan sponsor, (E.g., PBM contracting with Pharmacies). 3. Related Entity is an entity related to a plan sponsor by ownership and performs management functions and or provides services under contract to Medicare enrollees; (e.g., Plan sponsor owns it s own PBM). 4. Contractors any person or entity that contracts with CMS to provide any service or task related to the Medicare Program.

13 Chapter 9: Pharmacy provisions 1. Requirements vs. Recommendations. a) Recommendations are reflected by the use of the term should, whereas statutory or regulatory program requirements are reflected by the use of the term shall or must. See 20. Comment: It is important to note that a plan sponsor can turn a CMS recommendation into a mandatory requirement by adding a mandatory provision to network contracts that pharmacies participate in. 2. Exclusions Lists -.. Plan sponsors should review the HHS OIG and GSA exclusion lists at least once a year, and have processes in place to prevent the payment of claims for services provided by excluded providers

14 Chapter 9: Exclusions Lists a) Section of the guidance provides two examples of policies that should be adopted: 1) The Sponsor should obtain certifications from first tier entities, downstream entities, and related entities that these entities will review the OIG and GSA exclusions lists upon initially hiring and annually thereafter to ensure that any employee or manager responsible for administering or delivering Part D benefits is not excluded from Federal health care programs. The Sponsor should likewise obtain certifications that if an employee of the first tier entity, downstream entity, or related entity responsible for the administration of delivery of any Part D benefits is on such lists, that employee will immediately be removed from any work related directly or indirectly to all Federal health care programs and the entity will take appropriate Corrective actions.

15 Chapter 9: Exclusions Lists (cont). a.2). The Sponsor should adopt Policies that ensure and document the review of the DHHS OIG and General Services Administration (GSA) exclusion lists for all new employees and at least once a year thereafter to ensure that its employees, board members, officers, and first tier entities, downstream entities, or related entities that assist in the administration or delivery or Part D benefits are not included on such lists. If the Sponsor s employees, board members, officers, managers or first tier entities, downstream entities, or related entities are on such lists, the Sponsor s policies shall require the immediate removal of such employees, board members, or first tier entities, downstream entities, or related entities from any work related directly or indirectly on all Federal health care programs and take appropriate corrective actions.

16 Chapter 9: Pharmacy provisions - Conflict Of Interest 3. Sponsors should adopt several conflict of interest policies. a) Recommendation: a sponsor should obtain certifications from first tier entities, downstream entities, and related entities that these entities will require its managers, officers and directors responsible for the administration or delivery of Part D benefits to sign a conflict of interest statement, attestation, or certification at the time of hire and annually thereafter certifying that the manager, officer or director is free from any conflict of interest in administering or delivering Part D benefits. ( ).

17 4. Training And Education Chapter 9: Pharmacy provisions a) Plan sponsors must provide effective training and education for its employees, subcontractors, agents and directors who are involved in the Part D benefit.all persons involved with the Sponsor s administration or delivery of the Part D benefit should receive general compliance training. i. To the extent that it is feasible and reasonable, first tier entity, downstream entity, and related entity staff should be permitted to attend the Sponsor s training or agree to conduct their own Part D compliance training in accordance with the guidance provided below. ii. General compliance training: Sponsors should also consider requiring that any first tier entities, downstream entities, and related entities with any Part D responsibilities on behalf of the Sponsor to have their own training, or where there are sufficient organizational similarities, the Sponsor may choose to make its training programs available to these entities. Section

18 Chapter 9: Pharmacy provisions -Audits By Plan Sponsors Pharmacies that submit claims data to CMS must certify the accuracy, completeness, and truthfulness of that data Plan sponsors are responsible for exercising oversight of Part D data generated or submitted by [pharmacies] to ensure the accuracy of that data so that the Sponsor receives accurate payments. 5. Chapter 9 provides that plan sponsors must have a plan in place to monitor and audit pharmacies and other downstream entities. a) Section of the guidance suggests that pharmacies *may* be able to perform their own audits in lieu of audits by plan sponsors: In the event that first tier entities, downstream entities, and related entities perform their own audits related to the prescription drug benefit, Sponsors should seek written assurances from these entities that they have an adequate audit work plan in place. Sponsors should regularly receive these audit results with respect to their enrollees, and likewise seek assurances that corrective actions are taken by the entity when appropriate. Sections & 40.2.

19 Chapter 9: Pharmacy provisions Sponsor Audits, (cont)., b) Chapter 9 provides examples of Policies and Procedures that CMS believes sponsors should have in place: a) One is a process to identify overpayments and underpayments at any level within the Sponsor s network and properly report and repay, where applicable, such overpayments and, b) a process to identify improper services at any level within its network and properly report and repay, where applicable, and overpayments. and, c) The guidance also lists several types of reports that plan sponsors should receive from pharmacies, such as payment reports and drug utilization reports and

20 Chapter 9: Pharmacy provisions - Audits By Government 7. CMS or its designees (e.g., MEDICS [Medicare Drug Integrity Contractor]) may audit plan sponsors or their subcontractors. a) During these audits, CMS may inspect and audit any pertinent contracts, books, documents, papers, and records b) CMS audits may review any information needed to determine compliance with the Part D contract and the Part D regulation, such as copies of prescriptions, invoices, pharmacy licenses, claims records, signature logs, purchase records, contracts, rebate and discount agreements, as well as, interviews of staff

21 Chapter 9: Pharmacy provisions - Edits 8. Edits : Plan sponsors should have systems capability to establish an edit on a given provider and use that edit to automatically deny a claim or suspend payment on a claim when appropriate. CMS lists several examples of recommended edits: a) Controls on early refills; b) Limits on the number of days before a refill is permitted; c) Edits to prevent payment for statutorily excluded drugs; d) Limits on the number of times a prescription can be refilled; e) Brand name versus generic drug use; f) Excessive claims for controlled substances; g) Step therapy edits;

22 Chapter 9: Pharmacy provisions - Investigations and Remedies For Violations 9. Plan sponsors must conduct a timely, reasonable inquiry into any conduct where evidence suggests there has been misconduct related to payment or delivery of prescription drug items or services under the Part D contract. If misconduct is identified it should be reported to a MEDIC. Reporting of potential fraud that occurs at pharmacies and other downstream entities is especially encouraged. a) Sponsors must take corrective action when any misconduct is identified. corrective actions for misconduct committed by a Sponsor s first tier entity, downstream entity, or related entity the elements of the corrective action should be detailed in a written agreement with the entity that includes ramifications should the subcontractor fail to satisfactorily implement the Corrective action. See ; ; ;

23 Chapter 9: Pharmacy provisions - Examples of Pharmacy Fraud Section : Categories of listed by CMS are: Inappropriate billing practices Prescription drug shorting Bait and switch pricing Prescription forging or altering Dispensing expired or adulterated prescription drugs Prescription refill errors Illegal remuneration schemes TrOOP manipulation Failure to offer negotiated prices Pharmacies need to review the processes surrounding these functions as this has been noted by CMS as areas of interest for potential fraud.

24 Requirements According to federal regulations, plan sponsors are ultimately responsible for oversight and monitoring of education and training of first tier, downstream and related entities. How can YOU comply with the FWA education and training requirements? Three Options: 1. Provide your own training in accordance with CFR (b)(4)(vi)(c) or (b)(4)(vi)(c) Effective training and education between the compliance officer and organization employees, contractors, agents, and directors. See Resources for websites that have FWA information. 2. Take training from another MA and/or Part D Plan Sponsor, or other organization. 3. Complete training provided by plan sponsor. Your organization must maintain internal training logs, and submit the required attestation within the designated timeframe to plan sponsors upon request. Source:Federal Register, Part V Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR 422 and 423.

25 Documentation Requirements (cont). 1. Your organization is required to complete an attestation statement which must be signed by an authorized representative. 2. Upon request, your organization may be required to submit copies of training logs demonstrating that your employees received fraud, waste and abuse training. 3. If your organization has contracted with other entities to provide health and/or administrative services on behalf of eligible Part D beneficiaries, you will need to ensure that FWA training has been completed for eligible parties providing services. In addition and or if applicable, those entities will also need to provide your organization with copies of their training logs.

26 Attestation Pursuant to the final rule issued in the Federal Register for 42CFR Parts 422 and 423 of the Medicare Program December 5, 2007, Medicare Advantage and Part D sponsor is ultimately responsible for compliance plan oversight, including monitoring training and education, and complying will all statutory and regulatory requirements. Attestation As a first tier, downstream or related entity attests that it has conducted appropriate education and training to identify, correct and prevent potential fraud, waste and abuse, per the final rule issued in the Federal Register for 42 CFR Parts 422 and 423 of the Medicare Program. Please select the method of education and training that your organization chose to comply with the final rule requirement. [ ] Conducted our own education and training per CFR (b)(4)(vi)(c) or (b)(4)(vi)(c). [ ] Took training and education provided by a Medicare Advantage and/or Part D sponsor, or other organization. [ ] Took training and education provided by Plan Sponsor. Signature attests that your organization has completed appropriate education and training to identify, correct and prevent potential fraud, waste and abuse, and your organization will furnish upon request to eligible parties training logs to validate that training was completed. In addition, your organization will obtain attestations from other entities that provide health, prescription and/or administrative services on behalf of contracted Medicare Advantage and/or Part D beneficiaries, and upon request obtain training logs to verify that fraud, waste and abuse training was completed by those entities, as applicable. (Signature) Name: (Date) Title: Please return this completed attestation to:

27 Training Log Employee Name - (print) Employee Signature Name of Training Date of Training Manager s Initials

28 Relevant laws The False Claims Act prohibits knowingly presenting (or causing to be presented) to the federal government a false or fraudulent claim for payment or approval. When submitting claims data to CMS for payment, the claims data must be believed to be certifiably true and accurate. The False Claims Act is enforced against any individual/entity that knowingly submits (or causes another individual/entity to submit) a false claim for payment to the Federal government. Source:42 U.S.C. 1320a-7b. Prescription Drug Benefit Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse (Rev.2, );

29 Laws, (cont.), Section 1128B9b) of the Social Security Act (42 U.S.C. 1320a-7b(b)) provides criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward business payable (or reimbursable) under the Medicare or other Federal health care programs. For example, recent kickback cases have involved unlawful referral payments in form of free office space, free equipment, free drugs or supplies, inflated or sham consulting contracts, and travel and entertainment to physicians by hospitals, pharmaceutical companies and laboratories. In addition to applicable criminal sanctions, an individual or entity may be excluded from participation in the Medicare and other Federal health care programs and subject to civil monetary penalties. For purposes of the anti-kickback statute, remuneration includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind. Source:42 U.S.C. 1320a-7b. Prescription Drug Benefit Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse (Rev.2, ); and Testimony of Lewis Morris, Chief Counsel to the Inspector General U.S. Department of Health and Human Services (April 6, 2006).

30 General Examples of Fraud Incorrect reporting of diagnoses or procedures to maximize payments. Billing for services not furnished and/or supplies not provided; this includes billing Medicare for appointments that the patient failed to keep. Billing that appears to be a deliberate application for duplicate payment for the same services or supplies, billing both Medicare and the beneficiary for the same service or billing both Medicare and another insurer in attempt to get paid twice. Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount. Billing based on gang visits such as a physician visiting a nursing home and billing for 20 nursing home visits without furnishing any specific service to individual patients. Misrepresentations of dates and descriptions or services furnished or the identity of the beneficiary or the individual who furnished the services. Billing non-covered or non-chargeable service as covered items. Using another individual s Medicare Health Insurance card to obtain medical care.

31 Examples of Abuse Charging in excess for services or supplies. Providing medically unnecessary service. Providing services that do not meet professionally recognized standards. Billing Medicare based on a higher Fee Schedule than is used for patients not on Medicare. Submitting bills to Medicare that are the responsibility of other insurers under the MSP provisions. Violating the participating physician, provider, or supplier agreement with Medicare or Medicaid. Breaches in the assignment agreement. Violating the Maximum Allowable Actual Charge Limits or the limitation amount when applicable. Note: Abuse may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicare Program.

32 Examples specific to Pharmacy Phantom Billing Billing for services not performed. Double Billing charging for the same service, medication more than once. Improper cost reports submitting false cost reports to seek higher Medicare reimbursement than what s supported. Routinely waving co pays. Inappropriate billing practices. Prescription drug shorting. Bait and switch pricing. Prescription forging or altering. Dispensing expired or adulterated prescription drugs. Prescription refill errors. Illegal remuneration schemes. TrOOP manipulation. Failure to offer negotiated prices

33 Examples of potential FWA committed by: Pharmacy Benefit Manager (PBM) level: Unlawful Remuneration: PBM receives unlawful remuneration (reward, compensation, etc.) in order to steer a beneficiary toward a certain plan, drug, or formulary item. Includes unlawful remuneration from vendors beyond switching fees. Failure to Offer Negotiated Prices: Occurs when a PBM does not offer a beneficiary the negotiated price of a Part D drug. Pharmacy level: Bait and Switch Pricing: Bait and switch pricing occurs when a beneficiary is led to believe that a drug will cost one price, but at the point of sale the beneficiary is charged a higher amount. Prescription Drug Shorting: Pharmacist provides less than the prescribed quantity and intentionally does not inform the patient or make arrangements to provide the balance but bills for the fully-prescribed amount. Prescription Forging or Altering: Where existing prescriptions are altered, by an individual without the prescriber s permission to increase quantity or number of refills. Source: Prescription Drug Benefit Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse (Rev.2, ).

34 Source:Prescription Drug Benefit Manual, Chapter 9 Part D Program to Control Fraud, Waste and Abuse (Rev.2, ). Potential FWA (cont). Provider A psychiatrist billing Medicare, Medicaid and TriCare, and private insurers for psychiatric services that were provided by his nurses rather than himself / herself. Illegal Remuneration Schemes: Provider is offered, or paid, or solicits, or receives unlawful remuneration to induce or reward the prescriber to write prescriptions for drugs, products or services Script Mills: Provider writes prescriptions for drugs that are not medically necessary, often in mass quantities, and often for patients that are not theirs. These scripts are usually written, but not always, for controlled drugs for sale on the black market, and might include improper payments to the provider. Theft of Provider s DEA Number or Prescription Pad: Prescription pads and/or DEA numbers stolen and illegally used to write prescriptions for controlled substances or other medications often sold on the black market. Double billing resulting in duplicate payment. Billing for non covered services as if covered.

35 Compliance Plan: Required eight components 1. *Written Policies and Procedures, Standards of Conduct; 2. *Compliance Officer & Compliance Committee; 3. *Training & Education; 4. *Effective lines of communication; 5. *Enforcement of Standards through well publicized disciplinary guidelines; 6. *Monitoring & Auditing; 7. *Corrective Action Procedures; 8. Comprehensive Fraud & Abuse Plans that include procedures to voluntarily self report potential fraud or misconduct. *Source: The Office of Inspector General, seven fundamental elements of an effective compliance program

36 Anti-kickback Statute- prohibits offering, soliciting, paying, or receiving reimbursement for referrals for services that are paid in whole or in part by the Medicare Program. In addition, the statute prohibits offering, soliciting, paying, or receiving reimbursement in return for purchasing, leasing, ordering, arranging for, or recommending the purchase, lease, or order of any goods, facility, item, or service for which payment may be made in whole or part by the Medicare Program. Fines / Statues Civil Monetary Penalty (CMP) - a punitive fine imposed by civil court on an entity that has profited from illegal or unethical activity.

37 Fines / Statues Physician Self-Referral ( Stark ) Statute-prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or a member of his or her family) has an ownership / investment interest or with which he or she has a compensation arrangement, unless an exception applies.

38 Reporting Beneficiaries and physicians, suppliers, and other providers can and should report instances of suspected or potential fraud to Medicare. CMS and other agencies have a responsibility to perform the following tasks: Identify cases of suspected fraud. Investigate suspected fraud cases thoroughly and in a timely manner. Take immediate action to ensure that Medicare Trust Fund dollars are not inappropriately paid out and that any payments made in error are recouped.

39 Prevention / Detection There are a number of programs and tools which state and federal authorities can use in their efforts to discover and prevent fraud and abuse. 1. Medical Review (MR) identifies and addresses these billing errors through data analysis. 2. The Probe Review is a review process which validates claim errors through examination of past claims. 3. The Medicare Incentive Reward Program (IRP) encourages the reporting of fraud by offering a financial incentive for notifying authorities about illegal activities. 4. National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are issued to encourage providers and suppliers to code claims correctly.

40 The Medicare Incentive Reward Program (IRP) The Medicare IRP pays an incentive reward to individuals who provide information on Medicare fraud and abuse or other sanctionable activities. The Medicare Program will make a monetary reward for information that leads to a minimum recovery of $100 of Medicare funds from individuals and entities determined by CMS to have committed sanctionable offenses.

41 Medical Review The goal of the medical review program is to reduce payment error by identifying and addressing billing errors concerning coverage and coding made by providers. To achieve the goal of the MR program, contractors proactively identify potential billing errors concerning coverage and coding made by providers through analysis of data such as profiling of providers, services, and/or beneficiary utilization and evaluation of other information such as complaints, enrollment and/or cost report data.

42 The Probe Review The probe review is used to validate claim errors. Providers are notified when probe reviews are conducted and asked to provide medical documentation for the claim(s) in question. Once the results of the probe review are determined, providers are notified of those results. Probe reviews can either: Examine claims per provider for provider specific problems. Examine approximately 100 claims from multiple providers widespread, larger problems such as a spike in billing for a specific procedure.

43 Medical Record Documentation Providers can provide medical record documentation that assists the MR process by ensuring that: Documentation is provided, when requested, for every service selected for MR; Documentation demonstrates that the patient s condition warrants the type and amount of services furnished; Documentation is legible; Each service is coded correctly.

44 Data Analysis Data Analysis is an integrated, on-going component of MR and benefit integrity (BI) activities and involves collecting and analyzing data. The three basic components of data analysis are: 1. Collecting data; 2. Identifying potential errors; and 3. Ongoing monitoring and modification of data analysis components.

45 Frequently Asked Questions, (FAQs) Will pharmacies be required to show proof that applicable staff have received FWA training during a pharmacy audit? Yes, this is definitely part of the pharmacy auditing process. However, since the training requirement did not begin until Jan. 1, and must be completed by December 31,, it is unlikely that a pharmacy audit would include requests for training documentation. NCPA 2008.

46 FAQs (cont.), What are the basic elements of a fraud, waste, and abuse program? CMS requires plan sponsors to have a comprehensive fraud, waste, and abuse program, however specifics of these programs are left to the discretion of each sponsor. This is why pharmacies may see some variation from plan to plan. Each plan s requirements must contain one or more of the following elements however: Written Policies and Procedures - Some (not all) plans are requiring pharmacies to have written policies and procedures that address fraud, waste, and abuse as part of an overall compliance plan. These policies typically must be shared with all new employees and reviewed annually by all pharmacy staff. Staff Training - All pharmacies will need to document that pharmacy staff members have gone through annual fraud, waste, and abuse training beginning in. Exclusion Lists - Though this is not an official part of the fraud, waste, and abuse requirement, it is a previous requirement of the Part D program for pharmacies to check two federally maintained databases to ensure their employees are not listed on these federal exclusion lists. https://www.epls.gov/

47 FAQs What Constitutes Fraud? Fraud occurs when an individual intentionally deceives or misrepresents the truth, knowing that it could result in some unauthorized benefit to himself or herself or some individual. The violator may be: a physician, nurse, pharmacist or other practitioner; a hospital or other institutional provider; a clinical laboratory or other supplier; an employee of any provider; a beneficiary; a Medicare Contractor employee; or any individual in a position to file a claim for Medicare benefits

48 FAQs: FWA Resources 1. Department of Health and Human Services Office of Inspector General a) 2. Centers for Medicare & Medicaid Services a) b) 3. Social Security Administration a)

49 FAQs: Questions, Reports or Complaints about Fraud and Abuse? To ask questions or to report suspected fraudulent or abusive activities, providers are encouraged to contact their Medicare Contractor or to call HHS/OIG directly at HHS-TIPS ( ). TTY/TDD users should call In cases where providers employees submit complaints, such cases should be forwarded to OIG immediately. The amount of the reward will not exceed 10% of the overpayment recovered in case or $1000, whichever is less. Collected fines and penalties are not included as part of the recovered money for purposes of calculating the reward amount.

50 Sunset over Lake Gaston, Va.

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