Fraud, Waste, and Abuse (FWA) Training Program

Transcription

1 Fraud, Waste, and Abuse (FWA) Training Program for First Tier, Downstream, and Related Entities by MTM - Corporate UPDATED 4/19/2011

2 Why is MTM providing this training, what you should take away from this training and why it is so important? MTM is providing this training for many reasons: The Centers for Medicare and Medicaid Services (CMS) has handed down new rules regarding Fraud, Waste and Abuse (FWA) that must be followed by not only MTM, but also MTM First Tier, Downstream and Related Entities (transportation providers, drivers and office staff). Not only does CMS require this training, MTM Clients do as well. We all have a responsibility to help make sure FWA does not happen and to report it if we suspect it is happening, without fear of reprisal. This training will give you the basic information necessary to understand what FWA actually is and what your obligations are if you suspect FWA is taking place. By knowing the basics of FWA and what to do if we suspect it is happening, not only are we in compliance with CMS and MTM Client requirements; we are helping reduce the potential for future FWA to take place. By being on the look-out for FWA, we are all taking care of Federal monies that are given to the Medicaid and Medicare programs for people that rely on Medicaid and Medicare to get their medical treatments.

3 What should you learn by taking part in this training? By the end of this slide-show and training, the short quiz you will be asked to take will show that you will have more knowledge about: Definitions for Fraud, Waste and Abuse (FWA) Why MTM is doing this FWA training Applicable Federal laws dealing with FWA What the obligations are for everyone involved Examples of member FWA What MTM can do to get resolution in a situation where member FWA is suspected Examples of First Tier, Downstream and Related Entities FWA What MTM can do to get resolution in a situation where FWA is suspected by the First Tier, Downstream and Related Entity Who is responsible for identifying FWA Who is responsible for monitoring and auditing FWA at MTM How to prevent FWA Methods for reporting FWA Protection for whistle blowers

4 Definitions of Fraud, Waste, and Abuse Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal and State law. Waste: Over-utilization of services, or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid/Medicare program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes Covered Member practices that result in unnecessary cost to the Medicare/Medicaid program.

5 Why is MTM conducting First Tier, Downstream, and Related Entities Fraud, Waste, and Abuse (FWA) training? MTM does business with both Medicare and Medicaid Clients. These Clients are required by the Centers for Medicare and Medicaid Services (CMS) to conduct FWA training with the Clients first tier, downstream, and related entities (in short, their sub-contractors, like MTM). With MTM Clients being regulated to train their first tier, downstream, and related entities, MTM must do the same with MTM first tier, downstream, and related entities (transportation providers, drivers, and office staff). In effect, because MTM Clients are being regulated by CMS, so too is MTM and any MTM subcontractors. Documentation of the annual FWA training (for MTM staff and MTM first tier, downstream, and related entities) must be maintained and must be available to CMS and/or MTM Clients whenever requested.

6 What should be included in the Fraud, Waste and Abuse (FWA) training? 1. Applicable laws and regulations (federal & state specific). 2. The obligations of first tier, downstream, and related entities to have appropriate policies and procedures in place that address FWA. 3. The types of FWA that may occur with Covered Members. 4. Possible resolutions to Covered Member FWA. 5. The types of FWA that may occur in first tier, downstream, and related entities. 6. Possible resolutions to first tier, downstream, and related entity FWA. 7. The process for reporting suspected FWA in first tier, downstream, and related entities. 8. The protections for employees of first tier, downstream, and related entities who report suspected FWA.

7 Laws and Regulations Related to Fraud, Waste and Abuse (FWA) Suspected violations of the False Claims Act; 31 U.S.C of the False Claims Act Suspected violations of the Stark Law Suspected violations of the AntiKickback Statute Suspected marketing violations, including inducements Any act identified in any act defined in 18 U.S.C. Chapter 47, especially 1001 and 1035 Health Insurance Portability and Accountability Act (HIPAA) Any/all state specific laws and regulations that address Medicaid and Medicare Fraud, Waste and Abuse (FWA).

8 Obligations of the First Tier, Downstream, and Related Entities 1. Shall have policies and procedures in place regarding FWA. 2. Shall comply with all policies and procedures that are developed and amended from time to time by MTM that are relative to FWA. 3. Shall acknowledge that payments made to them consist of federal and state money and they can/will be held civilly and/or criminally liable in the event of nonperformance, misrepresentation, FWA of services rendered to MTM and its Clients. 4. Shall immediately refer all information regarding suspected or confirmed FWA by MTM riders to MTM.

9 Types of Covered Member Fraud, Waste and Abuse (FWA) 1. Changing, forging, or altering any of the following: Prescriptions Medical Records Referral Forms 2. Lending of an insurance card to another person 3. Using transportation services for non-medical services 4. Misrepresentation of eligibility status 5. Identity theft 6. Resale of medications to others 7. Medication stockpiling 8. Doctor shopping

10 Resolution Options to Covered Member Fraud, Waste, and Abuse (FWA) 1. Adding a note to the Covered Member s permanent file, instructing Customer Service Staff on setting future trips. 2. Adding the Covered Member s name to a list a frequent abusers so all of the Covered Member s trip requests will be monitored and case managed in an effort to prevent future FWA. 3. Reporting the issue to the designated State or County Medicaid office or to the MTM Client.

11 Types of Fraud, Waste, and Abuse (FWA) that can occur in First Tier, Downstream, and Related Entities 1. Falsifying credentials 2. Billing for services not rendered 3. Inappropriate billing 4. Double billing, upcoding and unbundling 5. Collusion among providers Providers agreeing on minimum fees they will charge and accept 6. Falsifying information that has been submitted through a prior authorization or other formulary oversight mechanism in order to justify coverage

12 Resolution Options to First Tier, Downstream and Related Entities (transportation providers, drivers and office staff) Provider Fraud, Waste and Abuse (FWA) 1. Recovering trip cost 2. Providing Transportation Provider Education 3. Making a recommendation for an audit of the transportation provider s trip records 4. Establishing a Corrective Action Plan (CAP) 5. Disciplinary action against the First Tier, Downstream, and Related Entities 6. Dismissal from the MTM network of the First Tier, Downstream, and Related Entities

13 Who is responsible for identifying Fraud, Waste, and Abuse (FWA)? 1. All MTM employees and Board of Directors 2. All MTM First Tier, Downstream, and Related Entities (transportation providers, drivers, office staff, etc.)

14 Who is responsible for monitoring and auditing Fraud, Waste, and Abuse (FWA) at MTM? 1. All reported incidents of FWA are reported to the Quality Management Department. 2. A Compliance Auditor investigates each reported incident of FWA. 3. The Compliance Auditor notes the results of the investigation into the Covered Member s file. 4. Any FWA reported against a first tier, downstream, and related entity is handled in the same manner. 5. MTM reports all incidents of FWA to its Clients on a monthly basis.

15 Prevention of Fraud, Waste, and Abuse (FWA) 1. Preventing FWA before it happens is critical. 2. First Tier, Downstream, and Related Entities (transportation providers, drivers, and office staff), as it relates to MTM riders only, should report any incidents they suspect of being FWA to MTM s Quality Management Department as soon as possible. 3. MTM staff should be diligent and watch carefully for signs of FWA: Deny a trip if it seems suspect Push the trip request up the internal chain of command to a Team Lead Contact the Client (insurance company) and get their guidance Report the suspicious activity to the Quality Management Department for investigation

16 What methods are there for reporting Fraud, Waste and Abuse (FWA)? 1. Contact the Quality Management Department at MTM: Try to include the following information: Subject (s) of FWA. Subject (s) identification information. Description of FWA. Any other important information.

17 What protections are in place for individuals of First Tier, Downstream, and Related Entities who report suspected Fraud, Waste, and Abuse (FWA)? 1. Whistle blowers are offered certain protections against retaliation under the False Claims Act. 2. Employees who are discharged, demoted, harassed, or otherwise confront discrimination in furtherance of such an action or as a consequence of whistle blowing activity are entitled to all relief necessary to make the employee whole.

18 Conclusion highlights to Fraud, Waste and Abuse (FWA) training You have been given more knowledge about what FWA really is and why it is important to be on the look-out for cases of suspected FWA. You now have the tools necessary to feel confident in reporting any suspected FWA, without fear of reprisal. You understand why MTM is requiring this training. You know that everyone is responsible for reporting FWA. You know that preventing FWA is critical stop it before it happens or gets out of hand. You know that you are protected by Federal laws if you report FWA.