FRAUD, WASTE & ABUSE WHAT YOU NEED TO KNOW STCHCN – 12/7/2015

Background The Deficit Reduction Act (DRA), passed by Congress and effective January 1, 2007, includes provision impacting all health care providers to create a plan to prevent, identify and report Fraud, Waste and Abuse of health care services.

Background Everyone is required to comply. This includes: –Medical Staff (MDs, NPs, CNMs, Pas) –Nursing Staff –Reception and Billing Staff –Administrative Staff –All contractors and vendors –All Members of the Board of Directors

What is Fraud, Waste or Abuse? Fraud must include: 1) Misrepresentation/concealment of a fact on a health care claim 2) Reasonable knowledge of the falsehood 3) Intent to harm others (payers) or gain benefit to self or organization 4) Action on that false claim 5) Financial damages

What is Fraud, Waste or Abuse? In general, FRAUD is defined as making false statements or representations of material facts to obtain some benefit or payment when none would otherwise exist, either for one’s personal gain or for the gain of a third party (like UPC).

What is Fraud, Waste or Abuse? Waste is the over-utilization of services, not caused by criminally negligent actions. It can be the misuse of resources, using too many resources or using too significant of a resource to address an issue.

What is Fraud, Waste or Abuse? Abuse describes practices that either directly or indirectly results in unnecessary, unneeded or excessive costs to the Medicare or Medicaid program. Abuse can be defined as providing patients with services or goods that are not medically necessary, do not meet professionally recognized standards or providing services/goods that are not fairly priced.

How could we commit FWA? Writing prescriptions that are not for the patient identified, unnecessary or not seen by us Billing for services that were not provided Misrepresenting services that were provided Billing at a HIGHER or LOWER level of service than what was provided Billing for non-covered services as “covered services”

What must employees do: Conduct all business in an open, honest and fair manner Always be ethical Consider regulatory compliance when doing your job Remember that the policy of UPC is not to ever engage in Fraud, Waste or Abuse and to report any pressure on you to engage in behavior you find suspect REPORT any potential incident

Reporting FWA Remember: EVERYONE has a responsibility to report! If you report, you are protected under the Whistleblower Provision –You cannot be retaliated against by a staff member, medical staff member or the organization –Whistleblowers who face persecution are protected by law and may win civil awards –“Whistleblowers” who knowingly file a false claim are subject to UPC’s disciplinary policies

Anti-Kickback Statute It is against the law for any health care provider to make a referral for services in return for a financial renumeration.

Reporting a Claim: Our Corporate Compliance Officer is: Lois Nease Human Resources/Compliance Director (716)