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AHIP TRAINING Medicare Fraud, Waste,
and Abuse Training Exam
Medicare plan means - Answer A MA plan, MA-PD plan or PDP Subcontractor means - Answer **An individual or entity that provides services on behalf of a Medicare plan sponsor. This includes individuals and organizations with DIRECT relationship with the plan sponsor or individuals or organizations with INDIRECT relationship, such as an agent who has a contract with an agency or filed marketing organization that contract with a Medicare plan. FWA Training: A compliance program component - Answer **ALL Medicare plans are required to have robust programs to assure compliance by plan employees an subcontractors with all applicable laws, regulations and program guidance. **One required component of a compliance program is a FWA program to identify and address issues of compliance with FWA. **It is important to remember that ALL Medicare plan sponsor employees and subcontractors are responsible for complying with all relevant Medicare requirements, even if lack of compliance may not be viewed as FWA, FWA: Why participate in the training - Answer **Fraud, waste and abuse impacts everyone who receives or relies on healthcare in the US. **The purpose of this training is to help you detect, correct and prevent FWA and your help is needed. You are part of the solution! **As a subcontractor to or an employee of a Medicare plan, you are required to participate in FWA training.
FWA: Combating: A federal priority - Answer **Important priority for the Federal Government. **CMS, the Federal agency responsible for administering these programs, takes its role in leading anti- fraud efforts very seriously and has issued strict requirements for those involved in providing MA and Medicare Part D coverage. **The office of Inspector General, a sister agency to CMS within the US Department of Health and Human Services , is also actively involved in anti-fraud efforts. Steps by Medicare plans to Combat FWA - Answer --The establishment and operation of special investigation units (SIU) or other existing departments that perform an internal investigation function --The analysis of claims data --Collaboration with law enforcement agencies --Adherence to rules set forth by CMS regarding efforts to identify and prevent fraud, waste and abuse. CMS Anti-FWA requirements for Medicare plans - Answer --Actively seek to prevent fraud, waste and abuse --Detect and investigate suspected FWA --Implement corrective action when instances of FWA are uncovered --Have a system in place 24 hrs per day for employees and subcontractors to voluntarily, and confidentially report suspected FWA or misconduct related to the MA and Part D programs CMS FWA training requirements for a Sponsor's Employees - Answer **CMS requires Medicare plan sponsors to provide training in FWA to their employees involved in Medicare plan work. **This training must occur within 90 days of hire and annually thereafter. CMS FWA training requirements: Agents, Brokers and other Subcontractors - Answer **The FWA training must be received not only by Medicare plan sponsor employees but also by subcontractors and their employees who are under contract to provide health or administrative services. The EXCEPTIONS are limited to: ***accredited suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS) ***Healthcare providers who are enrolled in Medicare Part A/B
FWA Related to Agents and Brokers - Answer --An agent offers Medicare beneficiaries cash or other impermissible incentives to enroll in the Rx plan he represents. --An agent offers beneficiaries money for names, address and phone numbers of friends and acquaintances who are Medicare beneficiaries. --An agent forges a beneficiary's signature on an enrollment form. --An agent intentionally misrepresents a plan's costs or benefits for the purpose of attaining enrollment, or convincing someone to enroll. --An individual solicits MA enrollments and gather "initial premiums". She is not really an agent and disappears with the money. FWA Involving Medicare Plan Sponsors - Answer --The amt. MA plan enrollees must pay for certain services is greater than what the sponsor's literature implies. --An MA plan realizes it had been overpaid by the Medicare program but fails to report it to the CMS --An MA plan fails to disenroll an enrollee (and continues receiving payment for the enrollee) even though it knows the enrollee has permanently moved from the plan service area. Summarizing the Importance of FWA Detection, Correction, and Prevention - Answer **Most providers, supplies, pharmacists, and sale representatives who work with Medicare are honest and seek to do the right thing. But there are a few individuals and organizations that knowingly commit fraud, while others engage in practices that result in waste or abuse. **CMS and Medicare plan sponsors are committed to providing quality healthcare services to Medicare beneficiaries while reducing the costs of fraud, waste and abuse. These costs take the form of not only lost dollars, but also of a negative impact on the quality of life of Medicare beneficiaries. Fraud, waste, and abuse can inflict real physical and emotional harm. **This training has been designed to provide you with tools you need to participate in the ongoing efforts against fraud, waste and abuse. AUDIT - Answer **A methodical examination and review of data or processes with the purpose of verifying the data's accuracy or whether established processes are in place or are properly followed. Civil monetary penalties CMP's - Answer Penalties that may be imposed for a variety of conduct including Medicare FWA. Different amts. of penalties and assessments may be authorized based on the type of violation and can range as high as $50,000 per violation.
Example: Presenting a claim that a person knows or should know is for a service that was NOT provided as claimed or is false and fraudulent. Pharmacy benefits manager - Answer **A company that administers the prescription drug benefit program of a health plan or employer. **PBMs process and pay prescription drug claims and are often responsible for creating and updating formularies. **PBMs buy medications in large quantities from drug manufacturers and are therefore able to obtain and offer discounts. Special investigation unit - Answer **A unit of a health plan (often separate from the compliance office) dedicated to combating FWA. **It is frequently staffed by former law enforcement personnel, such as veterans of the FBI. **SIUs have traditionally focused their investigations on third-party claims submitted to health plans. **In the case of MA and Part D plans, however, the scope of SIU investigations is likely to include identification of suspected FWA committed by subcontractors involved in the delivery of the MA or PDP benefits. The Scope of Healthcare FWA - Answer **As a nation, we spend over $2.7 trillion on Healthcare every year, and it is estimated that tens of billions are lost each year to FWA. **One recent study estimated that fraud and abuse added as much as $98 billion to annual spending on Medicare and Medicaid. Combating FWA: A Health Plan Priority - Answer **Medicare plans also recognize the seriousness of FWA, which not only result in lost dollars but can jeopardize the quality of healthcare received by plan enrollees. **Health plans seek your help in combating FWA and this training is designed to help you recognize questionable activity and take steps to stop or prevent it. The Human Cost of FWA: An example - Answer **As mentioned, FWA is not only costly, it can have serious implications for the health of Medicare plan enrollees. **Member has card stolen and used by someone else for Rx's and other medical treatments; therefore member is unable to get her Rx's renewed. Member goes w/o her meds and has a minor stroke. Now her health records are not accurate.
**The can conduct internal and external audits, which may involve other steps such as randomly testing claims to verify delivery of billed services and products. Example of Collusion - Answer **Medicare fraud can involve several parties, including beneficiaries, providers, pharmacists, and organized crime. **Example: A physician write a series of Rx's, a Medicare beneficiary submits them to a pharmacy, and the beneficiary sells the prescribed drugs to a crime ring. The doctor and the beneficiary receive a cut from the crime ring. Defining Abuse: A Closer Look - Answer CMS provides this definition: "Abuse involves payment for items or services when there is no legal entitlement to that payment and the health care provider has not knowingly and/or intentionally misrepresented facts to obtain payment." Example of Provider Abuse - Answer Dr. Ben Jones commonly conducts tests that are viewed within the medical community as unnecessary. This is not fraud because Ben does not engage in deception for gain--he sincerely (although mistakenly) believes the tests to be necessary, and he bills only for tests that he actually performs. But it is abuse because he is receiving payments he is not legitimately entitled to because of his responsibility to provide only medically necessary services. An Example of Health Plan Employee abuse - Answer Maria Adams works for a Medicare plan. She uses the plan's email to send out information to enrollees of the plan promoting her husband's sports memorabilia business. (This activity would also be in violation of HIPPA privacy rules) Defining Waste: A Closer Look - Answer CMS provides this definition in its compliance guidance for Medicare plans: "WASTE is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources. Example of WASTE by Provider - Answer *Dr. Mindy Wang prescribes an expensive brand-name medication instead of a generic version that is proven (and widely known) to be just as effective. *This is WASTE, because it results in unnecessary healthcare expenditures. *But it is NOT FRAUD because Mindy sincerely (but mistakenly) believes the brand-name medication to be necessary, and she makes no false statements for gain. *It is NOT ABUSE because Mindy does not receive any payments she is not entitled to.
Example of WASTE by Brokerage Agency - Answer *A Medicare plan has agreed to reimburse ABC Agency for its printing costs related to promoting the plan. *the marketing agency does NOT shop around for a cost effective printer, but instead uses the most expensive printer in town because the agency owner is a friend of the owner of the printer. *The agency forwards all the printer bills to the Medicare plan for reimbursement. Example of WASTE by Health plan employee - Answer *Tom Miller is an employee of a Medicare plan. Tom routinely sends mail to enrollees via one-day-express using a private carrier whether or NOT the message is truly urgent. *Tom neglects to consider more reasonable alternatives such as two-day shipping or priority mail. Distinguishing FWA - Answer **It is often difficult to distinguish between abuse and FRAUD. This is because whether an action constitutes fraud or abuse depends on the specific facts and circumstances of the situation and the intent and prior knowledge of the individual committing the action. **It is also difficult to distinguish between waste and abuse because of their similarity and the dependence on the specific facts of an issue. **The good news is that you do NOT need to distinguish between FWA. **Report any activities that you suspect could be FWA. **Those who investigate the activity will determine which category it falls in. FWA Costs More than just Dollars - Answer **In closing this section, let's stress the point mentioned earlier: FWA can result not only in monetary losses to the healthcare system but also in harm to the health and wellbeing of patients. **A doctor bills Medicare (and falsifies medical records to support the billing) for services he never provide to Jane Chen. Jane later becomes ill and is admitted to the hospital. The doctors there rely on her medical records in making decisions about her condition and her treatment, but since these records are not accurate, the best medical outcome for Jane may NOT be achieved. **Agent Marco Martinez markets MA-PD plans by focusing solely on premiums--stressing low monthly costs w/o mentioning the potentially sizable cost sharing obligations that could be faced by a beneficiary. Maria Sanchez opts for a lower premium policy and later forgoes needed medical services because of her inability to pay the cost sharing involved in her policy. Legal Tools Against FWA (to Combat FWA) - Answer There are several legal tools that the government can employ in its fight against FWA, including the following statutes:
Example: Billco Pharmacy waives Medicare Part D copayments for certain drugs to encourage Part D enrollees to fill their Rx's there. - Answer The Federal Anti-Kickback Statute makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by the Federal Healthcare program, including Medicare. **Remuneration includes anything of value in cash or in kind. The anti-kickback regulations do provide safe harbors. If a payment arrangement fits within these safe harbors it is NOT treated as a violation of the law. **Penalties: Fines of up to $25,000, imprisonment up to 5 years, or both. Example of Physician Self-Referral Law (Stark Law) - Answer Dr. Frances Winters refers her patients needing routine blood tests to an outside independent laboratory that is owned by her husband. **Penalties for physicians who violate the Stark Law includes fines as well as exclusion from participation in ALL Federal healthcare programs, including Medicare. Civil Monetary Penalties - Answer The SS Act (which governs Medicare) authorizes civil monetary penalties when CMS or other federal authorities determine that an individual or entity has violated Medicare rules or regulations. **CMP's can be large--for instance, a health plan might be assessed $25,000 for each MA enrollee adversely impacted. Exclusion from Medicare Program - Answer **Violations of Medicare rules and regulations can also lead to exclusion from the Medicare program. **A healthcare provider's Medicare ID# and privilege of providing services to Medicare beneficiaries can be revoked. **Given the size and extent of the Medicare program, this can substantially limit a provider's future income and employment opportunities. **Also, an agent that is excluded from the Medicare program could NOT sell coverage under MA or Part D as well as any other federal healthcare programs. Exclusion from Medicare Program, continued OIG's LEIE (list of excluded individuals and entities. The general services administration database - Answer The office of the inspector general of the Dept. of health and human services HHS and General services administration GSA, maintain lists of individuals and entities banned from providing services to Medicare.
**Organizations sponsoring MSA or Medicare Part D plans, along with others working with Medicare, are required to review these lists when hiring or contracting and at least monthly thereafter to ensure no employees or subcontractors that assist in the administration or delivery of services to Medicare beneficiaries are on these lists. **The plan sponsor and/or its subcontractors must remove anyone appearing on either of these lists from supporting the sponsor's Medicare offerings. HIPAA - Answer *Severe penalties may be imposed on Medicare plans and their subcontractors for violating these requirements. **The health information technology for economic and clinical health (HITECH) HIPAA and HITECH changes to the law included: - Answer 1. Imposing penalties on business associates (subcontractors that use or dispose protected health information on behalf of a plan, including agents and brokers) for violating the law
- Imposing obligations to report to the HHS for Civil Rights security breaches. **Depending on culpability, a HIPPA violations may result in civil fines in EXCESS of $1,000,000. Individuals and entities that knowingly obtain and disclose individual health information in violation of HIPAA may be subject to criminal penalties including imprisonment and fines. Reporting FWA and other Compliance Issues Ways to report FWA: to the SIU or compliance dept. Telephone hotline Dedicated email address and Dedicated web portal. - Answer **You are expected to question and if appropriate report situations in which you suspect something improper, unethical or illegal is going on. **You have a duty to promptly report any suspected violations of the laws that you become aware of-- even if you were not involved in the activity, you may be subject to discipline if you knew about it and did not report it. **This can include, but NOT limited to, termination of your employment or contract. Recognizing Possible FWA - Answer 1. Make sure you are familiar with Medicare plan policies that explain the program requirements
- Be familiar with any guidance that identifies behavior that may be viewed as FWA
