Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention
About the Training Guide Touchstone is providing this Fraud, Waste and Abuse Prevention Training Guide as a resource for meeting Centers for Medicare & Medicaid Services (CMS) requirement that contracted entities provide fraud, waste and abuse prevention training to their employees who administer or deliver Medicare benefits or services. This training guide is designed for use by employees as well as first-tier, downstream and related entities that provide services or benefits in the Medicare Part C and Part D programs. For additional information, CMS issued the Medicare fraud, waste and abuse guidance that may be found at: http://www.cms.hhs.gov/prescriptiondrugcovcontra/downloads/pdbmanual_chapter9 _FWA.pdf As a first-tier, downstream or related entity that provides services or benefits in the Medicare Part C and Part D programs, you are responsible for recognizing behavior that may be considered fraud, waste or abuse. When such behavior is detected, it should not only be reported, but measures should also be put in place to confirm that such behavior does not occur in the future.
Introduction What is Medicare Fraud? In general, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person s own benefit or for the benefit of some other party. Some examples of fraud include, but are not limited to: Double billing Billing for more expensive services or procedures than were actually provided Doctor shopping for prescription drugs Eligibility fraud Short-filling prescriptions Prescription forging or altering An example of double billing is a pharmacist who deliberately charges both the patient and Medicare for the full cost of the same prescription and keeps the extra money. What is Medicare Waste? Waste is defined as using health care benefits or spending health care dollars without real need. An example of waste would be prescribing a medication for 30 days with a refill when it is not known if the medication will be needed. What is Medicare Abuse? Abuse describes the practice, either directly or indirectly results in unnecessary costs to the Medicare Program. Examples of Medicare abuse may include: Misusing codes on a claim Charging excessively for services or supplies Billing for services that were not medically necessary
Medicare Fraud and Abuse Laws The False Claims Act, Anti-Kickback Statute, Physician Self- Referral Law (Stark Law), Social Security Act, and the U.S. Criminal Code are used to address fraud and abuse. Federal False Claims Act (FCA) 31 U.S.C. Title 1347 The False Claims Act addresses any person or entity that does any of the following: Knowingly presents, or causes to be presented, to an employee of the United States government a false or fraudulent claim for payment or approval Knowingly makes, uses or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the government Conspires to defraud the government by getting a false or fraudulent claim allowed or paid. Civil penalties for violating the FCA may include fines and up to 3 times the amount of damages sustained by the Government as a result of the false claims. There is also a criminal FCA (18 U.S.C. Section 287.) Criminal penalties for submitting false claims An example may be a physician who submits claims to Medicare for medical services he or she knows were not provided. may include fines, imprisonment, or both. For more information on fraud, visit http://oig.hhs.gov/fraud. Anti-Kickback Statute Section 1128(b) of the Social Security Act (42 USC 1320a-7b (b)) The federal anti-kickback laws that apply to Medicare and Medicaid prohibit health care professionals, entities and vendors from knowingly offering, paying, soliciting or receiving remuneration of any kind to induce the referral of business under a federal program. Violators are subject to criminal sanctions including imprisonment, high fines, exclusion from Medicare and Medicaid, as well as civil penalties and possible prosecution. Examples include: Waiving copayments in certain instances Giving a physician a gift in exchange for an office visit payment
Physician Self-Referral Law (Stark Law) The Physician Self-Referral Law (Stark Law) (42 U.S.C. Section 1395nn) prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or an immediate 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. For more information, visit http://www.cms.gov/physicianselfreferral. Criminal Health Care Fraud Statute The Criminal Health Care Fraud Statute (18 U.S.C. Section 1347) prohibits knowingly and 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 of control of, any health care benefit programs.
Identifying Fraudulent Activities Health Plan Fraud Fraud committed by the health plan is defined as acts committed through deception, misrepresentation or concealment by the health plan s employees as directed by leadership of the health plan. Examples include: Failure to provide medically necessary services Marketing schemes Improper bid submissions Payments for excluded drugs Multiple billing Inappropriate formulary decisions Inappropriate enrollment/disenrollment False information Inaccurate data submission Fraud by Agents/Brokers Fraud committed by agents/brokers is defined as deception, misrepresentation or concealment by a licensed representative to obtain something of value for which he/she would not otherwise be entitled. Examples Include: Helping individuals fill out their enrollment information so they will be eligible for insurance. False advertising Fraud Due to Misrepresentation of Enrollment Information Fraud due to misrepresentation of enrollment information is defined as commission of an act of deception, misrepresentation, or concealment, or allowing it to be done by someone else, to obtain coverage for which one would not otherwise be entitled. Examples of eligibility fraud include: Individuals joining to form a nonexistent group for insurance purposes. Members not meeting the eligibility requirements Not disclosing medical conditions on an application
Claims Fraud Know how to recognize typical fraud techniques such as: Provider is not in the insured s geographic region Large bills incurred prior to term date or immediately after effective date Provider Fraud Provider fraud is defined as the devising of any scheme by any provider of health care or services to defraud for the purpose of personal or financial gain by means of false or fraudulent pretenses, representations promises. Examples of Provider Fraud can include: Billing for services not rendered Providing free services and billing the insurance company Nonqualified practitioners billing as qualified practitioners Billing for noncovered services using an incorrect code. Examples of Dental Fraud: Billing for dental services not rendered Providing excessive dental work that is not needed by the patient Falsifying the date of service to correspond with the member s coverage period Billing for non-covered services using an incorrect code Example of Pharmacy Fraud: Filling less than the prescribed quantity of a drug Billing for a brand when generic drugs are dispensed Forging or altering prescriptions Prescription drug switching Failure to offer negotiated prices Unlawful remuneration Inappropriate documentation of pricing information
Member Fraud Member fraud is defined as the commission of acts of deception, misrepresentation or concealment by any policyholder or group of policyholders in order to obtain something of value to which they would not otherwise be entitled. Examples of Member Fraud include: Alteration of bills Submission of false claims Doctor shopping Identity theft Improper coordination of benefits False disclosure with regard to continuation of benefits (COB)
Special Investigations Unit (SIU) Touchstone Health s Special Investigation Unit operated through the Compliance and Internal Audit Departments is responsible for the detection, prevention and reporting of Part C and D fraud, waste and abuse. All information received or discovered by the SIU will be treated as confidential and the results of the investigations will be discussed only with the persons having a legitimate reason to receive the information (e.g. state and federal authorities, and Touchstone s senior management. Touchstone cooperates with federal, state and local authorities in the investigation of potential fraud, waste and abuse when indicated. The SIU supports law enforcement agencies, CMS and the Medicare Drug Integrity Contractor (MEDIC) in the execution of any resulting corrective action that is taken as a result of the fraud, waste and abuse investigation. Referrals of Fraud Cases to Law Enforcement Authorities Touchstone is committed to aggressive investigation and referrals to possible prosecution of health care fraud by members, providers, agents, business entities, company employees and other individuals. Suspected fraud, waste and abuse for Medicare (Parts A, B, and C) are reported to CMS through the Department of Health and Human Services (HHS) Office of Inspector General (OIG.) Suspected Medicaid fraud, waste and abuse is reported to the Medicaid Program Integrity (MPI) administrator. Reporting of Violation by Health Care Professionals, Entities or Vendors If you become aware of possible violation of any federal or state rule, law, regulation or policy, or any violation of Touchstone s Compliance and Ethics Policy and Fraud, Waste and Abuse prevention training guide, immediately report it by calling the Report It Hotline at 1-877-778-5463 or www.touchstoneh.com/enroll/compliance/hotline. Username: Touchstoneh Password: Compliance13 See next page for additional contact information
You may also contact the following agencies: Touchstone Health Compliance Department One North Lexington Avenue 12 th Floor White Plains, NY 10601 Report It Hotline 1-877-778-5463 or www.touchstoneh.com/enroll/compliance/hotline. Username: Touchstoneh Password: Compliance13 Centers for Medicare and Medicaid Services (CMS) 1-800-633-4227 www.cms.hhs.gov U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) OIG s National Hotline: 1-800-447-8477 E-mail: HHSTips@oig.hhs.gov