FIRST TIER, DOWNSTREAM AND RELATED ENTITIES (FDR) ANNUAL TRAINING

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1 FIRST TIER, DOWNSTREAM AND RELATED ENTITIES (FDR) ANNUAL TRAINING The Compliance Team appreciates your attention and cooperation during this CMS mandated annual training!

2 DEFINITIONS ADVANTAGE utilizes the Centers for Medicare and Medicaid Services (CMS) current definitions to define First Tier, Downstream, and Related Entities (FDRs): First Tier Entity is 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 healthcare services to a Medicare eligible individual under the Medicare Advantage program or Part D program. Downstream Entity is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit or Part D benefit, below the level of the arrangement between a Medicare Advantage Organization 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.

3 DEFINITIONS Related Entity means any entity that is related to a Medicare Advantage Organization or Part D sponsor by common ownership or control and: Performs some of the Medicare Advantage Organization or Part D plan Sponsor s management functions under contract or delegation; Furnishes services to Medicare enrollees under an oral or written agreement; or Leases real property or sells materials to the Medicare Advantage Organization or Part D plan Sponsor at a cost of more than $2,500 during a contract period.

4 STANDARDS OF CONDUCT ADVANTAGE Health Solutions, Inc. (ADVANTAGE) is committed to complying with all applicable state and federal laws. ADVANTAGE s Code of Business Conduct and Ethics (Code) is part of our Corporate Compliance Program. The Code memorializes ADVANTAGE s commitment to ethical and lawful conduct and is designed to guide us in upholding our high standards of fair and ethical practices.

5 STANDARDS OF CONDUCT The Code is intended to serve as implementation of the Corporate Compliance Program, describe compliance expectations of the workforce, and provide guidance on dealing with potential compliance issues. Refer to: ADVANTAGE s Code of Conduct

6 STANDARDS OF CONDUCT This Code of Business Conduct and Ethics (Code) memorializes ADVANTAGE Health Solutions, Inc. s commitment to ethical and lawful conduct and is designed to guide us in upholding our high standards of fair and ethical practices. Read this Code thoroughly and make sure you understand it. We are all responsible for complying with the standards of behavior described in this Code. In any case where we believe illegal or unethical conduct may have occurred, we must report it without fear of retaliation. Each of us is invited to contact any of the resources listed in this Code to ask questions about the ethical nature of any action that may arise.

7 DOCUMENT RETENTION Medicare Advantage plans and their contracted providers must retain medical records, financial records and source reports for a period of ten (10) years, (42 C.F.R (b)(4)(vi)(G)).

8 Prevention & Detection of FRAUD, WASTE & ABUSE (FWA)

9 FRAUD, WASTE AND ABUSE (FWA) As a contractor with the Center for Medicare and Medicaid Services (CMS) and the State of Indiana, ADVANTAGE is required to provide annual fraud, waste and abuse training

10 FRAUD, WASTE AND ABUSE DEFINED Fraud an intentional act of deception, misrepresentation, or concealment in order to gain something of value 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.

11 DIFFERENCES BETWEEN FRAUD, WASTE AND ABUSE Primary difference is intent and knowledge. Fraud requires the person to have an intent to obtain payment/benefit and the knowledge that their actions are wrong. Waste and Abuse may involve obtaining improper payment/benefit but does not require the same intent and knowledge.

12 FRAUD PENALTIES Individuals/Providers shall be fined, imprisoned or both. If the fraud results in death, the individual may be imprisoned for any term of years, life or both.

13 FRAUD, WASTE, AND ABUSE PROGRAM The ADVANTAGE Compliance Fraud, Waste and Abuse Program is an enterprise-wide program designed to detect and prevent fraud, waste and abuse for all lines of business and corporate activities. This Program monitors compliance by ADVANTAGE s staff, contractors and first tier downstream entities. Following this training, you will be asked to review the FWA Program and attest to your understanding.

14 FRAUD, WASTE, AND ABUSE The FWA Program emphasizes monitoring and auditing activities, as well as the importance of timely and open communication Any suspected or substantiated incidents of FWA situations, whether or not the situation is described within the FWA Program, should be reported to any of the following: ADVANTAGE s Compliance Toll Free Helpline at The Compliance department will launch a confidential investigation within the required federal timeframes.

15 CONSEQUENCES OF COMMITTING FWA The following are potential penalties. The consequence depends on the violation. Civil money penalties. Criminal conviction/fines. Civil prosecution. Imprisonment. Loss of license. Exclusion from federal health care programs.

16 OIG EXCLUSION LIST Sponsors must review the DHHS OIG List of Excluded Individuals and Entities (LEIE list) prior to the hiring or contracting of any new employee, temporary employee, volunteer, consultant, governing body member or FDR and monthly thereafter to ensure that none of these persons or entities are excluded or become excluded from participation in federal programs,(42 CFR (b)(4)(vi)(F), (a)(8)).

17 OIG EXCLUSION LIST The Office of the Inspector General for the U.S. Department of Health & Human Services has the authority to exclude individuals or entities from federally funded health care programs. Reason for exclusion include health-care related fraud, patient abuse/neglect and unlawful manufacture or distribution of controlled substances. Hiring an individual or entity on the exclusion list may be subject to civil monetary penalties. No federal health care program payment may be made for any item/service furnished, ordered or prescribed by an individual or entity on the exclusion list.

18 EXAMPLES OF FWA Charging in excess for services or supplies Providing medically unnecessary services Billing for items or services that should not be paid for by Medicare or Medicaid (or other payer) Billing for services that were never rendered Billing for services at a higher rate than is actually justified Misrepresenting services resulting in unnecessary cost, improper payments to providers or overpayments

19 EXAMPLES OF RISKS To Individuals Unnecessary procedures may cause injury or death Falsely billed procedures create an erroneous record of the patient s medical history Diluted or substituted drugs may render treatment ineffective or harmful exposure Unnecessary drug treatment contributes to abuse and addiction

20 FRAUD SCHEMES Providers Failing to provide medically necessary services Altering claim forms, records, medical documentation Limiting access to needed services, such as withholding referral to appropriate provider Offering beneficiaries case payment as inducement Participating in illegal remuneration schemes

21 FRAUD SCHEMES Providers (cont.) Prescribing medications for reasons other than clinical needs Theft of DEA number, prescription pad, e- prescribing login Falsifying information in order to justify coverage Soliciting, offering, or receiving kickback, bribe or rebate Billing for services not rendered

22 FRAUD SCHEMES Pharmacies Billing for brand when generic was dispensed Billing non-covered prescriptions as covered items Billing for prescription never picked up by patient Splitting prescriptions to force additional copays and fees Engaging in unlawful remuneration, such as steerage for $$$ Dispensing expired drugs Altering prescriptions Manipulating the TrOOP (Part D)

23 FRAUD SCHEMES Beneficiaries and Members Sharing or stealing ID card Falsifying identity, eligibility, or medical condition in order to illegally receive drug or service Forging or altering prescriptions Doctor shopping in order to obtain multiple prescriptions for narcotics or other drugs

24 NON-RETRIBUTION/NON RETALIATION We are all encouraged to raise issues and concerns, and each of us may do so without fear of retaliation or disciplinary action. ADVANTAGE maintains a strict non-retaliation policy to protect employees who report problems and concerns in good faith from retaliation, retribution or harassment. No Board Director, executive, manager, supervisor or employee is permitted to engage in retaliation, retribution or any form of harassment against an employee for reporting a compliance related concern, (42 C.F.R (b)(4)(vi)(A)(7)).

25 RELEVANT LAWS The False Claims Act The Anti-Kickback Statue The Beneficiary Inducement Statute Self-Referral Prohibition Statue (Stark Law) The Whistleblower Protection Act

26 FALSE CLAIMS ACT The False Claims Act: (31 U.S.C , also called the "Lincoln Law") is an American federal law that imposes liability on persons and companies (typically federal contractors) who defraud governmental programs. The law includes a "qui tam" provision that allows people who are not affiliated with the government to file actions on behalf of the government (informally called "whistleblowing"). Persons filing under the Act stand to receive a portion (usually about percent) of any recovered damages. Claims under the law have typically involved health care, military, or other government spending programs.

27 FALSE CLAIMS ACT PROHIBITS Presenting false claim for payment or approval. Making or using false record/statement in support of false claim. Conspiring to violate the False Claims Act. Falsely certifying the type/amount of property to be used by the government. Certifying the receipt of property without knowing if it is true. Buying property from unauthorized government officer. Knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay the government.

28 FALSE CLAIMS ACT DAMAGES & PENALTIES Damages may be tripled. Penalty between $5,000 and $10,000 for each claim.

29 THE ANTI-KICKBACK STATUTE The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. 1320a-7b (the "Antikickback Statute"), provides for criminal penalties for certain acts impacting Medicare and state health care (e.g., Medicaid) reimbursable services. Enforcement actions have resulted in principals being liable for the acts of their agents. Of primary concern is the section of the statute which prohibits the offer or receipt of certain remuneration in return for referrals for or recommending purchase of supplies and services reimbursable under government health care programs.

30 THE ANTI-KICKBACK STATUTE PROHIBITS Knowingly and willfully soliciting, receiving, offering or paying remuneration (including any kickback, bribe or rebate) for referrals for services.

31 THE ANTI-KICKBACK STATUTE PENALTIES Fine up to $25,000. Imprisonment up to five years. Both a fine up to $25,000 and imprisonment up to five years.

32 THE BENEFICIARY INDUCEMENT STATUTE Prohibits offering a remuneration that a person knows, or should know, is likely to influence a beneficiary to select a particular provider, practitioner, or supplier Examples: Waiver of coinsurance or deductible amounts Transfer of items or services for free

33 THE SELF-REFERRAL PROHIBITION STATUTE (STARK LAW) Physician self-referral (Stark Law) is the practice of a physician referring a patient to a medical facility in which the physician has a financial interest, be it ownership, investment, or a structured compensation arrangement. This self referral has been classified as instances of conflict of interest within organizations.

34 STARK LAW PROHIBITS Physician from making referral to certain designated health services to an entity in which the physician (or member of his/her family) has an ownership/investment interest or with which he/she has a compensation arrangement (exceptions apply)

35 STARK LAW DAMAGES AND PENALTIES Claims tainted by an arrangement that does not comply with Stark Law are not payable. Up to $15,000 for each service provided. Up to $100,000 fine for entering into an arrangement or scheme.

36 WHISTLEBLOWER PROTECTION ACT Whistleblower Protection Act: A United States federal law that protects federal whistleblowers who work for the government or a company deal with Government Funding and report agency misconduct. A Covered Entity violates the Whistleblower Protection Act if its authorities take (or threaten to take) retaliatory personnel action against any employee or applicant because of disclosure of information by that employee or applicant regarding non-compliant or fraudulent activities.

37 WHISTLEBLOWER PROTECTION Whistleblower An employee, former employee, or a member of an organization who reports misconduct to people or entities that have the power to take corrective action. Whistleblowers are protected against retaliation if they report misconduct in good faith Can report fraud anonymously Sue an organization for submitting false claims on behalf of the government and collect a portion of any settlement that may result

38 WHISTLEBLOWER PROTECTION ACT Whistleblowers may file complaints that they believe reasonably evidences a violation of a law, rule or regulation; gross mismanagement; gross waste of funds; an abuse of authority; or a substantial and specific danger to public health or safety.

39 REPORTING DISCLOSURES Criminal penalties for HIPAA violations are directly applicable to covered entities, including the following: Health plans, health care clearinghouses, health care providers who transmit claims in electronic form, and Medicare prescription drug card sponsors. Corporate criminal liability principles apply for the following: Individuals such as directors, employees, or officers of the covered entity, where the covered entity is not an individual. Even if an individual is not directly liable under HIPAA, they can be charged with conspiracy or aiding and abetting.

40 REPORTING DISCLOSURES In the event of an inappropriate disclosure of PHI, the following steps should be taken: Immediately report to both your supervisor and the Compliance Department. Failure to report puts both YOU and ADVANTAGE at risk of fines and penalties. Take corrective action immediately. If further unnecessary disclosures are probable, take action to stop them before they occur.

41 REPORTING SUSPECTED INCIDENTS Report suspected incidents anonymously to an external Compliance Helpline number, This line is answered 24 hours/day, 7 days/week by an independent, outside entity.

42 CONSEQUENCES Administrative Sanctions Revocation of payments, licenses or contracts Exclusion List Civil and Criminal Penalties Up to $25K for each beneficiary adversely affected Corporate Integrity Program Conviction under False Claims Act, $$$ per false claim Prison sentence of 20+ years, if patient suffers bodily injury

43 GOVERNMENT RESOURCES Dept of Health and Human Services Office of Inspector General Centers for Medicare and Medicaid Svcs (CMS) Profs/ CMS Information about the Physician Self Referral Law CMS Prescription Drug Benefit Manual Medicare Learning Network (MLN) Fraud & Abuse Job Aid

44 TRAINING SUMMARY The Compliance Department, as well as ADVANTAGE as an organization, cannot stress enough the importance of reporting HIPAA and FWA violations. The financial and criminal repercussions are strict and highly enforced by CMS and the State, and will certainly be carried out. It is the duty and responsibility of every workforce member to report all suspected and actual violations and incidents to the compliance department, legal council, or one of the below listed government funded resources, in accordance with company policies and procedures.

45 NEXT STEPS Please attest that you read and understand the 2014 Annual Compliance Training by submitting an electronic signature and completing the comprehension quiz. If you have any questions, please contact Peggy Gillam Stephie Guptill Jan Teal THANK YOU