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 Plan (PDP) Sponsors provide fraud, waste and abuse training for all entities they partner with to provide benefits or services, not just to direct employees within their organizations. Training must be completed annually. To meet this requirement, Indiana University Health Plans (IU Health Plans) is providing this training module. You can also access it at www.iuhealthplansmedicare.org. This training will cover the following topics: Laws and regulations related to MA and Part D fraud, waste and abuse (i.e. False Claims Act, Anti Kickback statute, HIPAA, etc.) Obligation to create policies and procedures to address fraud, waste and abuse Recognizing, reporting, and preventing suspected fraud, waste and abuse Protections from those who report suspectedfraud, waste andabuseabuse 2
OBJECTIVES Describe the CMS Fraud, Waste and Abuse training requirements for first tier, downstreamandrelated and related entities Prevent fraud, waste, and abuse in the administration of federal and state health programs Provide information for providers and employees to detect and fight fraud, waste, and abuse Provide information on protection for employees to encourage reporting of issues 3
DEFINITIONS Part C Medicare Advantage Plans (MA) provide all of a person s Part A and B coverage offered by private entities and may include prescription drug coverage (Part D) Part D Plans voluntary prescription p drug coverage available to everyone with Medicare person can buy a stand alone plan, or belong to an MA plan that offers this coverage (MA PD) 4
DEFINITIONS cont d Medicare Advantage Organization Apublic or private entity organized and licensed by astateasariskbearing entity (with the exception of provider sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements. Part D Sponsors A PDP Sponsor, MA organization offering a MA PD plan, a PACE* plan including qualified prescription drug coverage, and a Cost Plan offering qualified prescription drug coverage. This includes employer and union sponsored plans. *PACE is the Program of All Inclusive Care for the Elderly 5
DEFINING Fraud Waste Abuse 6
Defining Fraud, Waste, and Abuse Health Care Fraud Intentionally, or knowingly and willfully attempting to execute a scheme to falsely obtain money from any health care benefit program. Specific to Medicare this would include billing Medicare for services that were never provided or received. 7
Defining Fraud, Waste, and Abuse Waste In the health care setting, this occurs when there is over utilization of services, or other practices that result in unnecessary costs. This spending can be eliminated without reducing the quality of care. 8
Defining Fraud, Waste, and Abuse Abuse Improper behaviors or billing practices that create unnecessary costs. The state of mind is what separates fraud from abuse. The result is still an unauthorized benefit. 9
RECOGNIZING Fraud Waste Abuse 10
Recognizing Fraud, Waste and Abuse Examples MA Organizations and Part D Sponsors Failing to provide medically necessary services Offering beneficiaries cash to induce them to enroll in certain programs Discriminating against beneficiaries because of illness category Inappropriate formulary decisions based on costs rather than clinical appropriateness 11
Recognizing Fraud, Waste and Abuse Examples Pharmacies Billing for brand named drugs when generics are dispensed Billing for non covered prescriptions as covered Prescription splitting Dispensing expired prescriptions Manipulating True Out of Pocket costs (TROOP) 12
Recognizing Fraud, Waste and Abuse Examples Providers Illegal payment schemes Prescription Drug Switching (i.e. offering the prescriber a benefit to prescribe certain medications over others) Falsifying information Unnecessary treatment Billing for services not rendered Double billing Upcoding Unbundling Altering claim forms 13
Recognizing Fraud, Waste and Abuse Examples Pharmacy Benefit Managers (PBM s) Prescription drug switching Unlawful payment for steering a beneficiary toward a certain plan, drug or formulary placement Inappropriate formulary decisions Drug splitting and/or shorting Failure to offer negotiated prices 14
Recognizing Fraud, Waste and Abuse Examples Beneficiaries Use of another person s Medicare card to get medical care, supplies, or equipment Providing false statements on an enrollment application Using a false address to obtain coverage when your primary address is out of the service area 15
PREVENTING Fraud Waste Abuse 16
CMS Control of Fraudulent Activities: Close coordination with contractors, providers and law enforcement agencies Strict Medicare Program compliance requirements that protect stakeholders Applying fair and firm enforcement policies Using data analysis and medical review to detect violations early Educating physicians, providers, suppliers, andbeneficiaries 17
PREVENTION TIPS Monitor Exclusion Lists: Check the Office of Inspector General (OIG) and General Services Administration (GSA) lists for all new employees and at least annually thereafter to ensure that employees and other entities that assist in the administration or delivery of services to Medicare beneficiaries are not included on such lists. OIG List of Excluded Individuals/Entities (LEIE): http://exclusions.oig.hhs.gov/search.html p// g / General Services Administration (GSA) database of excluded individuals/entities: http://epls.arnet.gov/ 18
PREVENTION TIPS cont'd Communicate with staff and colleagues Open communication in exit interviews i to uncover compliance issues Take action, report Have a compliance program Carefully monitor claims for accuracy Perform medical record reviews Conduct regular internal audits Implement written policies and procedures Conduct effective training and education Enforce standards through well published disciplinary guidelines Corrective Action 19
PREVENTION TIPS cont'd For Beneficiaries: Report suspected instances of fraud Review payment notices for errors (make sure Medicare was not billed for services, supplies or equipment not received) Do not contact a physician to request a service you do not need Be cautious of providers who claim they have been endorsed by the Federal government or by Mdi Medicare 20
RELEVANT LAWS 21
Deficit Reduction Act of 2005 A provision of the Deficit Reduction Act of 2005 (DRA) requires entities that receive at least $5 million in payments py from a federal or state health plan, including Medicare or Medicaid, to establish written policies describing: federal and state false fl claims statutes; federal and state whistleblower protections; and the entity s policy for preventing and detecting fraud, waste, and abuse in federal and state health care programs. 22
Federal False Claims Statutes Federal False Claims Act, 31 U.S.C. 3729 Program Fraud Civil Remedies Act 31 U.S.C. 3801 Qui Tam Whistleblower Provisions, 31 USC U.S.C. 3730 23
Federal False Claims Act Imposes liability on any person who: knowingly files a false or fraudulent claim for repayment or approval knowingly makes oruses a false record or statement to obtain payment on a false or fraudulent claim; knowingly makes or uses a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money to the government; or conspires to defraud a federal program. 24
Federal False Claims Act cont d Knowingly is defined to mean that a person has actual knowledge of the information in the claim; acts in deliberate ignorance ofthetruth truth orfalsity ofthe information in the claim; or acts in reckless disregard ofthe truthorfalsity oftheinformation in the claim. 25
Federal False Claims Act cont d Potential liability under the FCA includes penalties ranging from $5,500 to $11,000 per claim. In addition, the health plan can be required to pay three times the amount of damages sustained by the U.S. government. The OIG may also seek to exclude the health plan from participation in federal health care programs. 26
Program Fraud Civil Remedies Act The Program Fraud Civil Remedies Act is a federal statute that provides additional penalties for improper claims and improper statements, including $5,000per false claim plus twotimes the amount of the claim. A person violates the Act if they know, or have reason to know, they are submitting a claim that is: false, fictitious, or fraudulent; includes or is supported by written statements that are false, fictitious, or fraudulent; includes or is supported by a written statement that omits a material fact which makes the statement false as a result; or for payment for property or services not provided as claimed. 27
Whistleblower Protection To encourage individuals to come forward and report misconduct involving false claims, the Federal False Claims Act includesa qui tam or whistleblower provision. This provision allows a person with actual knowledge of allegedly false claims li to the government to file a lawsuit on bhlf behalf of the U.S. government. 28
Whistleblower Protection cont d The whistleblower must file his or her lawsuit on behalf of the government in federal district court. The lawsuit will be kept confidential while the government reviews and investigates the allegations contained in the lawsuit and decides how to proceed. If the government decides to intervene, the prosecution of the lawsuit will be directed by the U.S. Department of Justice. If the government decides not to intervene, the whistleblower can continue with the lawsuit on his or her own. 29
Whistleblower Protection cont d Whistleblowers are protected from retaliation by their employers. They may not be discharged, demoted, suspended, threatened, harassed or discriminated against in the terms and conditions of employment because of lawful actions taken by the employee in connection with an action under the FCA. 30
Whistleblower Protection cont d If the lawsuit is successful, the whistleblower may receive an award of up to 30% of the amount recovered. The whistleblower may also be entitled to expenses including attorneys fees and costs of bringing the lawsuit. Also, additional relief may be awarded, including employment reinstatement, back pay, and any other compensation arising from retaliatory conduct against a whistleblower for filing an action under the False Claims Act. 31
Fraud Enforcement and Recovery Act of 2009 expands the scope of potential FCA liability by eliminating the presentment requirement 32
Patient Protection and Affordable Care Act (2010 Changes to FCA) Changes to the Public Disclosure Bar Original Source Requirement Overpayments Statutory Anti Kickback Liability 33
Indiana False Claims Statutes Indiana False Claims Act, I.C. 5 11 5.5 2 Indiana State Whistleblower Provision, I.C. 22 5 3 3 34
Indiana False Claims Act The Indiana False Claims Act imposes liability on any person who knowingly orintentionally: presents a false claim to the state for payment or approval; makes or uses a false record or statement to obtain payment or approval of a false claim from the state; with the intent to defraud the state, delivers less money or property to the state than the amount recorded or authorizes issuance of a receipt without knowing the information is true; or makes or uses a false record or statement to avoid an obligation to pay or transmit property to the state. 35
Indiana False Claims Act cont d A violation of this provision carries a penalty of $5,000 for each such improper claim. In addition, the health plan can be required to pay three times the amount of damages sustained by the state. 36
Indiana Whistleblower Provision An employee of a private employer that is under public contract may report in writing the existence of: a violation of federal law or regulation; a violation of a state law or rule; a violation of an ordinance of a political subdivision; or the misuse or public resources. 37
Indiana Whistleblower Provision cont d For having made a report, the employee may not suffer retaliation including dismissal, denial of salary increases or benefits, transfer or reassignment, denial of promotion, or demotion. If the lawsuit is successful, the whistleblower may receive an award of up to 30% of the amount recovered. The whistleblower may also be entitled to expenses including attorneys fees and costs of bringing the lawsuit. 38
Anti Kickback Laws Federal Law 1) Prohibits knowingly and willfully committing fraud 2) Prohibition on offering, paying, soliciting, or receiving any renumeration 3) Prohibition on providing inducements or rewards in connection with patient referrals Penalties 1) Mandatory exclusion from programs 2) Criminal penalties (prison, $25,000 fine) 3) Civil penalties, possible exclusion Exceptions 1) Safe Harbors (bona fide personal services contract, t proper rebate bt program) 39
REPORTING Fraud Waste Abuse 40
Reporting Fraud, Waste and Abuse Office of the Inspector General Telephone: 1 800 HHS TIPS (1 800 447 8477) TTY: 1 800 377 4950 Email: HHSTips@oig.hhs.gov gov Centers for Medicare & Medicaid Services (CMS) Tl Telephone: 1 800 MEDICARE (1 800 633 4227) 41
IU Health Plans Reporting Procedures IU Health Plans is committed to complying with all laws governing its operations. IU Health Plans has anonymous and non retaliatory procedures for the reporting of concerns regarding improper conduct. 42
IU Health Plans Reporting Procedures cont d IUHealthPlansemployees,representatives,membersorotherparties can report potential violations of the organization s compliance policies orof federal or state health care program requirements throughthe Indiana University Health Trustline at 1 888 trust36 (1 800 878 7836) Please be aware that although this is anonymous reporting, you must leave information that is specific enough to follow up with investigation. 43
IU Health Plans Reporting Procedures cont d Matters can also be reported directly to the IU Health Plans Compliance Director at 317 963 9773. Matters reported through the Compliance Line, Compliance Director, Compliance Committee or other communication sources will be documented and investigated promptly to determine their truthfulness and significance. 44
IU Health Plans Reporting Procedures cont d IU Health Plans will periodically include information on prescription drug fraud, waste and abuse in its newsletters and other membership information packages. Further, to screen enrollee complaints, IU Health Plans will provide a timely hearing and resolve grievances between enrollees and IU health Plans, its employees, or representatives. 45
FOR ADDITIONAL INFORMATION: 1. Fraud, Waste and Abuse Training Clarification, Kimberly Brandt, Director, Program Integrity Group, CMS, Office of Financial Management, August 21, 2009. 2. Medicare Fraud, Medicare Fraud Prevention and Detection Tips, http://www.medicare.gov/fraudabuse/tips.asp, April 17, 2009. 3. Internal/External Strategies for Managing Risk and Dealing with Government Enforcement Agencies, Medicare Marketing Summit, Marci Handler, Epstein, Becker, & Green, March 16, 2009. 4. Medicare Advantage Prescription Drug Fraud, Waste and Abuse Training, HealthCare Administrative Solutions, Inc. (HCAS), September 9, 2009. RESOURCES: 1. Office of Inspector General http://hhs.gov/fraud/safeharborregulations.asp. 2. Prescription Drug Benefit Manual, Chapter 9, Part D Program to Control Fraud, Waste and Abuse http://www.cms.hhs.gov/prescriptiondrugcovcontra/downloads/pdbmanualchapter9fwa.pdf. 3. Code of Federal Regulations www.gpoaccess.gov/fr/index.html. 4. http://www.taf.org/fca stats DoJ 2008.pdf Comprehensive information regarding FCA statistics can also be found at http://www.taf.org/statistics.htm, including information on recoveries in individual cases 5. http://www.healthcare.gov/law/introduction/index.html 46
Thank You! 47