Fraud, Waste and Abuse Network Pharmacy Training 2011
Table of Contents Centers for Medicare & Medicaid Services (CMS) Role Important Federal Statutes for Medicare Participants Fraud, Waste and Abuse Defined Medicare Prescription Drug Benefit Manual Chapter 9 - The Part D Program to Control Fraud, Waste and Abuse The Role of the MEDIC Sponsor Corporate Responsibility Prescription Solutions by OptumRx Anti-Fraud Plan Prescription Solutions by OptumRx Pharmacy Manual Network Pharmacy Obligations 2
Who is CMS? The Centers for Medicare & Medicaid Services (CMS) is the government entity that has oversight of the Medicare Advantage (MA), Medicare Advantage Prescription Drug Plan (MAPD), Prescription Drug Plan (PDP), Retiree Drug Subsidy (RDS) and the Medicare Program overall Their Main office is in Baltimore, Maryland They have 10 Regional Offices Atlanta, Boston, Chicago, Dallas, Denver, Kansas City, New York, Philadelphia, San Francisco and Seattle Two satellite offices Los Angeles, CA and Miami, FL 3
CMS and Their Role in Part D: CMS is responsible for the following activities: Contractor Management Account Management MA, MAPD, PDP and RDS Sponsors and Downstream Entities Data Analysis and Performance Metrics (e.g., Prescription Drug Event (PDE) records) Audits Plan Sponsors Compliance plans Payment audits Compliance and Enforcement Intervention for non-compliance Education and corrective action plans Sanctions, penalties and terminations Program Integrity Medicare Drug Integrity Contractors (MEDICs) Chapter 9 of the Medicare Prescription Drug Benefit Manual Coordination of government and non-government partners 4
Important Federal Statutes for Medicare participants: False Claims Act: Prohibits persons from knowingly submitting false claims or making a false record or statement in order to secure payment by the federal government for the false or fraudulent claim. Federal Anti-Kickback Act: Prohibits the knowing and willful receipt or offer to pay any remuneration, directly or indirectly, covertly or overtly, in cash or in-kind, in return for referring or for inducing a referral. Referrals can be for arranging any item or service for which payment may be made in whole or in part under a federal health care program. Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA contains provisions and rules related to protecting the privacy and security of protected health information (PHI) as well as provisions related to the prevention of health care fraud and abuse. HIPAA Privacy The Privacy Rule outlines specific protections for the use and disclosure of PHI. It also grants rights specific to members. HIPAA Security The Security Rule outlines specific protections and safeguards for electronic PHI. If you become aware of a potential breach of protected information, you must comply with the security breach and disclosure provisions under HIPAA and, if applicable, with any business associate agreement. 5
Important Federal Statutes for Medicare participants: Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA contains provisions and rules related to protecting the privacy and security of protected health information (PHI) as well as provisions related to the prevention of health care fraud and abuse. Sample HIPAA Fraud, Waste, and Abuse Provisions The creation of the Fraud Abuse and Control Program for coordination of state and federal health care fraud investigation and enforcement activities. The expansion of the exclusion authority so that any health care fraud conviction, even if the fraud is not related to Medicare or Medicaid, results in mandatory exclusion from participation in the Medicare or Medicaid programs. The creation of a new series of federal crimes, together referred to as health care fraud, which make it a federal crime to defraud health care benefit programs any benefit program, not just Medicare or Medicaid. 6
Fraud, Waste and Abuse Defined: Fraud: Fraud is an intentional deception or misrepresentation made by an individual or entity that the person or entity knows to be false or does not believe to be true, knowing that the deception could result in some unauthorized benefit to himself or some other person. Waste: Waste generally means the over-utilization of services not caused by criminally negligent actions and often involves the misuses of resources. It is the needless, careless and cavalier expenditure of funds or the consumption of property that results from deficient practice, judgments, or controls in areas of responsibility and accountability. Abuse: Abuse generally refers to practices that while not generally considered fraudulent, and which do not involve knowing misrepresentation of facts, are inconsistent with accepted and sound medical, fiscal or business practice. These practices may directly or indirectly result in unnecessary costs to an insurance program, improper payment, or payment for services that fail to meet professional standards of care or are medically unnecessary. 7
Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Chapter 9 is one of a number of chapters in the CMS Medicare Prescription Drug Benefit Manual. Chapter 9 includes both interpretive rules and guidelines for Part D plan sponsors on how to implement the regulatory requirements to have in place a comprehensive fraud, and abuse plan to detect, correct, and prevent Fraud, Waste and Abuse as an element of their compliance plan. Even though sponsors are not law enforcement agencies, sponsors bear the ultimate responsibility for compliance and for detecting, preventing and correcting Fraud, Waste and Abuse. Prescription Solutions helps facilitate this responsibility by providing training and oversight of contracted Network Pharmacies. 8
Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: The core elements required of a sponsor compliance program are: Written policies and procedures Compliance officer and compliance committee Training and education Effective lines of communication Enforcement of standards through publicized guidelines Monitoring and auditing Corrective action procedures Comprehensive Fraud and Abuse plan (includes voluntary selfreporting of potential fraud and misconduct) 9
Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies: Examples of Fraud, Waste and Abuse perpetrated by marketers to watch for: Offering beneficiary cash payments as an inducement to enroll Unsolicited door-to-door marketing Enrollment of a beneficiary without their consent Stating that a marketing agent works for CMS, or the Social Security Administration (SSA) Misrepresentation of a product as Part D when it is Medigap, or non-medicare Enrolling beneficiary in an MAPD plan when they wanted a PDP Stating the marketer can enroll new beneficiary over the phone 10
Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies (continued): Examples of Fraud, Waste and Abuse perpetrated by prescribers to watch for: Illegal remuneration schemes prescriber is offered, paid, solicits or receives unlawful remuneration to induce or reward the prescriber to write prescriptions (kick backs) Prescription drug switching offers in cash or other benefit to prescribe one drug over another Script mills writing prescriptions for drugs that are not medically necessary, often in mass quantities, and often for individuals that are not his or her patients Theft of prescriber s Drug Enforcement Administration (DEA) number, Prescription pad, or e-prescribing authentication information and log-in 11
Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies: Examples of Fraud, Waste and Abuse perpetrated by pharmacies to watch for: Billing for brand and dispensing generic drugs Over-billing of quantity prescribed and inappropriate billing of compounds Over-billing of quantity in relation to days supply that exceeds prescribed amount False or fictitious claims submission Document fabrications and alterations Forged signature logs or insufficient proof of delivery Not processing returns to stock Use of dummy DEA s/national Provider Identifier (NPI) Inappropriate use of Dispense As Written (DAW) codes Billing of unauthorized refills Billing under expired prescriptions Prescription splitting to obtain multiple dispensing fees Pill shorting billing for more than dispensed Recycling medications black market repurchases for resale Not crediting for destroyed returns 12
Medicare Prescription Drug Benefit Manual Chapter 9, The Part D Program to Control Fraud, Waste, and Abuse: Examples of potential Fraud, Waste and Abuse schemes perpetrated by marketing agents, prescribers, and pharmacies: Examples of Fraud, Waste and Abuse perpetrated by members to watch for: Over-utilization and drug seeking drug abuse (not limited to narcotics) Altered and forged prescriptions dates, strengths, quantities, refills, false claims Members initiating their own phone-in prescriptions Pharmacy hopping and doctor shopping review history of member Drug diversion and inappropriate use obtains drugs used by another non-covered party, or for resale on the black market Misrepresentation of status member misrepresents identity, eligibility, medical conditions to obtain benefits 13
Who is the MEDIC and what is their role in Part D? The Medicare Integrity Contractor: Purpose is to ensure the protection of the Medicare Trust Fund and Medicare beneficiaries. Responsible for the following activities: Answer the 1-877-7SAFERX Part D hotline Perform data analysis to detect Fraud, Waste and Abuse in Part D Investigation accusations of Fraud, Waste and Abuse in Part D Develop and refer cases to law enforcement Conduct audits Review compliance programs Cover pharmacies, prescribers, beneficiaries and marketing agents 14
Sponsor Role in Fraud, Waste, and Abuse Prevention: Monitoring and evaluating Medicare functions Auditing, monitoring and detecting Conducting investigations Performing data mining and analysis Voluntary self-reporting Maintaining a compliance plan that includes appropriate oversight of first-tier, related and down-stream entities (that would include Prescription Solutions and it s contracted Network Pharmacies) Promptly report any perceived or alleged instances of pharmacy, prescriber, or member fraud determined to warrant further investigations to the appropriate Compliance Officer or external regulatory agency 15
Prescription Solutions by OptumRx Anti-Fraud Plan: A system/process to monitor, detect and prevent Fraud, Waste and Abuse. Identifies an avenue to administer corrective action up to and including reclaim of the overpayments associated with Fraud, Waste and Abuse, and/or termination of the Agreement (including Network Pharmacy Agreements) if warranted. Prescription Solutions has a zero-tolerance policy on Fraud, Waste and Abuse. Includes explanations of: Examples of Fraud, Waste and Abuse perpetrated by pharmacies, prescribers and members Audit referral system Escalation oversight committee Education and training programs of staff and network Fraud prevention procedures that include but are not necessarily limited to: On-line edits Desk-top audits On-site audits 16
Prescription Solutions by OptumRx Pharmacy Manual: Distributed to all network pharmacies annually. Includes the following topics: Customer identification cards Claims processing Products offered Medicare product information and guidelines Terms and conditions: Compliance Fraud, Waste, and Abuse Pharmacy Audits Credentialing Involuntary disenrollment by plan or sponsor State Medicaid requirements 17
Network Pharmacy Obligations: Comply with contractual terms concerning compliance with Federal and state laws Report suspected Fraud, Waste or Abuse to Prescription Solutions Provide this training to all staff who work with Part D annually Maintain lists of personnel trained and the dates provided for audit purposes Attest to completion of training annually as requested by Prescription Solutions Address any questions to Prescription Solutions Maintain policies and procedures on Fraud, Waste and Abuse consistent with Federal and state laws 18
Contact Prescription Solutions with any questions at either of the following email addresses: Pharmacycontracts@prescriptionsolutions.com Network@prescriptionsolutions.com 19