Fraud, Waste and Abuse Training for Pharmacies

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1 Fraud, Waste and Abuse Training for Pharmacies

2 What You ll Learn Definitions of fraud, waste and abuse Examples of each Relevant statutes Your responsibilities

3 Fraud, Waste and Abuse Accounts for billions of dollars lost Who pays? Patients Working people Honest providers

4 Why FWA Training? Centers for Medicare & Medicaid Services (CMS) Mandates it! Initial training by December 31, 2009 Attestation due January 1, 2010 Annual training Pharmacy must maintain records

5 What Is Health Care Fraud? Title 18 U.S. Code, Section 1347 Keys words Intent, knowledge and willingness False or fraudulent pretenses Delivery of payment for health care benefits Unauthorized benefit to the perpetrator or some other person

6 Examples of Health Care Fraud Billing for nonexistent prescriptions Billing for brand when generics are dispensed Billing for non-covered items as covered Billing for prescriptions never picked up Inappropriate use of dispense as written ( DAW )) codes

7 What Is Health Care Waste? Practices resulting in unnecessary cost: Overuse, underuse and misuse of care Non-value value-added added services Medication errors Prescription refill errors

8 What Is Health Care Abuse? Unnecessary, inappropriate care Care doesn t meet professionally recognized standards Provider conduct inconsistent with acceptable business and/or pharmacy practices resulting in greater reimbursement

9 Examples of Health Care Abuse Dispensing quantities inconsistent with prescription requirements Dispensing incorrect size or quantity of medication Billing with incorrect National Drug Code (NDC) numbers Waste/abuse may become fraud

10 Who Can Commit Health Providers and staff Care Fraud? Beneficiaries Health insurance employees Pharmacy personnel Vendors Scammers

11 Examples of Provider Fraud Upcoding Duplicate billing Ghost beneficiaries Misrepresenting services Unbundling services Phantom billing Billing for free services

12 How Can Health Care Fraud Happen in Pharmacies? People trust their pharmacists Patients rely on pharmacists to interpret prescriptions Elderly patients or those with disabilities are especially vulnerable Patients may be intimidated by health care system Reluctance to question pharmacist for fear of negative impact

13 Examples of Beneficiary Fraud Identity swapping Identity theft Doctor shopping Resale, inappropriate use or diversion of prescription drugs Forging or altering bills, receipts or prescriptions

14 Laws and Regulations The False Claims Act The Anti-Kickback Statute Physician Self-Referral Statute Health Insurance Portability and Accountability Act of 1996

15 Federal False Claims Act Legal tool to counteract fraudulently billing government Allows private citizens to sue on behalf of the government, i.e., whistleblowing May receive 15 percent to 25 percent of recovery

16 False Claims Act Penalties Three times the amount of damages Civil penalties of $5,500 to $11,000 per false claim One false claim of $100 can result in penalty 114 times original claim

17 How Penalties Can Add Up One false claim for $100 what the government was billed (e.g., one prescription) Triple the damages that s $300 Add the maximum penalty of $11,000 $100 + $300 + $11,000 dollars = $11,400 Staying out of trouble with the government priceless

18 Anti-Kickback Statute Prohibits knowingly or willingly Inducing or rewarding referrals of business payable under a federal health program Falsely applying for benefits or payments Concealing or failing to disclose knowledge

19 Anti-Kickback Statute Penalties Felony conviction Imprisonment up to five years and/or Up to $25,000 fine Possible exclusion from federal health care programs

20 Stark Penalties Denial of payment Refund of amounts up to $15,000 for each improper referral/claim submitted Civil monetary penalties up to $100,000 per occurrence

21 HIPAA Health Insurance Portability and Accountability Act Obtain or disclose individually identifiable health information Specific knowledge of a violation is not required to be penalized

22 HIPAA Violation Penalties HIPAA Civil Penalties $100/violation up to $25,000/year HIPAA Criminal Penalties $50,000/up to 1 year in prison $100,000 fine/up to 5 years for false pretenses $250,000/up to 10 years with intent to sell

23 Beneficiary Inducements Remuneration that the Medicare or Medicaid beneficiary knows or should know is likely to influence his/her selection Remuneration includes Cash Waivers of copayments/deductibles Transfer of items or services for free or other than fair market value Non-cash items, gifts or services

24 Beneficiary Inducement Penalties Fines up to $10,000 per violation, plus Three times damages incurred by the government Potential exclusion from participation in government programs Civil monetary penalties may apply

25 Office of Inspector General/General Services Administration Exclusion/Debarment Protects government from doing business with those who pose a business risk to the government Prevents companies/individuals from participating in government programs

26 OIG Exclusions From Government Programs Payment ban applies to all methods of federal program reimbursement, including: Itemized claims Cost reports Fee schedules Prospective payment system

27 OIG Exclusions (continued) Items/services furnished or ordered by an excluded provider Items/services furnished to a hospital inpatient or outpatient based on an excluded provider s orders Administrative and management services not directly related to patient care but necessary to provision of care and items.

28 OIG Exclusions (continued) Services reimbursed through prospective payment or bundled physician group Processing of claims submitted to a Medicare fiscal intermediary Services by an excluded administrator, billing agent, accountant, claims processor or utilization reviewer Items or equipment sold by an excluded manufacturer or supplier and used to treat or care for beneficiaries

29 OIG/GSA Exclusion/Debarment Hiring prohibition Civil monetary penalty $10,000/claim submitted for services/items furnished during exclusion Knew or should have known person excluded Affirmative duty to check employees exclusion status Web site list: hhs.gov/oig

30 Your Responsibilities Know/follow applicable laws, regulations, policies, procedures Report known/suspected violations Do annual compliance/specialized Medicare compliance training Establish and adhere to your Code of Conduct Do not retaliate against whistleblowers

31 Reporting Potential FWA Excellus BlueCross BlueShield Special Investigations Department 165 Court St. Rochester, NY Hotline Numbers: Buffalo 1 (877) Rochester 1 (800) Central New York 1 (800) Utica 1 (800) address: flora.allen@excellus.com

32 Fraud & Abuse Resources Medicare Fraud & Abuse brochure Medicare.gov FLRx.com

33 Link to Attestation When all employees of your organization involved with the Medicare Part D Program have completed a FWA training program, please click here to access the attestation for your organization.

34 Thank you for participating in our training program. Please click the X in the upper right corner to close this application.