FRAUD, WASTE, & ABUSE (FWA) 2012

Slides:



Advertisements
Similar presentations
The Deficit Reduction Act, Deficit Reduction Act of 2005 In the Deficit Reduction Act of 2005 (DRA) Congress, for the first time, has mandated healthcare.
Advertisements

Our Goals Today To help you feel comfortable with asking questions.
Health Care Fraud and Abuse Integrated Delivery System (IDS) Prepared by Marion County CAPS for use with IDS Providers.
Hill Country CMHMR Center FRAUD & ABUSE Training August 2008.
Fraud, Waste, and Abuse (FWA) Training Program for First Tier, Downstream, and Related Entities UPDATED 4/19/2011.
Hill Country MHDD Centers COMPLIANCE & ETHICS
1 Fraud & Abuse: Prevention, Detection and Reporting Staff Training on BCN’s Fraud & Abuse Compliance Program Presented to BCN Staff Work Site: ______________________.
Corporate Compliance Instructor Notes:
MARKETPLACE FRAUD How the Assistance Network can Prevent, Detect, and Report suspected fraud.
RMG:Red Flags Rule 1 Regal Medical Group Red Flags Rule Identify Theft Training.
BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association How the Deficit Reduction Act of 2005 Impacts BlueCare Tennessee.
CarePoint Health Plans
2010 Region II Conference Corporate Compliance Panel June 3, 2010
Medicare Parts C and D Fraud, Waste, and Abuse Compliance Training
AppleCare Medical Group
Regulatory Control of Providers Financial Relationships Civil False Claims The Act.
Fraud, Waste & Abuse DEFICIT REDUCTION ACT OF 2005 Presented by: MARCH Vision Care, 2013.
AMG Compliance Training
FRAUD, WASTE & ABUSE TRAINING
Pennsylvania Child Protective Services Law: Module 4: Reporting and the Role of the Child Welfare Professional Transfer of Learning The Pennsylvania Child.
DIVISION OF HEALTH SCIENCES OFFICE OF INSTITUTIONAL INTEGRITY Protecting Yourself and Your Practice.
Program Integrity. The Cost of Fraud, Waste, and Abuse Between July 2012 and January 2013, the North Carolina Division of Medical Assistance collected.
False Claims Act and Whistleblower Protections False Claims Act and Whistleblower Protections Genetic Disease Screening Program Employee Education and.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved. 1 McGraw-Hill Chapter 5 HIPAA Enforcement HIPAA for Allied Health Careers.
Medicare Advantage & Part D Compliance Training 2009.
Copyright© 2011 WeComply, Inc. All rights reserved. 9/6/2015 Whistleblowing.
© 2010 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.
Copyright © 2005 Thomson Delmar Learning. ALL RIGHTS RESERVED.1 This product was funded by a grant awarded under the President’s Community-Based Job Training.
COMPLIANCE PROGRAM. Agenda  Initial Scenarios  Review of General Compliance Information  Review UCP’s Compliance Program  Questions and Discussion.
Blue Cross of Idaho Medicare Advantage Provider Fraud, Waste and Abuse Training Fall 2009.
Fraud and Abuse in Dentistry. Definition Fraud is the intentional perversion of truth in order to induce another to part with something of value, or surrender.
Deficit Reduction Act of 2005 Signed into law February 8, 2006.
SMJ Life Health Annuities/Secure Benefits Alliance 2012.
“Health Care Fraud” 18USC, Ch. 63, Sec Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice— 1. To defraud any.
Welcome….!!! CORPORATE COMPLIANCE PROGRAM Presented by The Office of Corporate Integrity 1.
Anytime you see the information button, click on it for more information Click on the home button if you need to return to this instruction page At the.
Welcome General Compliance Training.  To inform you who to contact to ask questions  To let you know that you are responsible to disclose  To share.
Flowers Hospital General Compliance Training-Students 2013.
Prepared by: The Office of Corporate Compliance & HIPAA Administration
VIVA Health Provider Compliance and Fraud, Waste and Abuse (FWA) Training.
jasa.org Board of Directors Presentation & Training February 24 th, 2016 Corporate Compliance Program.
Fraud, Waste and Abuse Training Presentation.  What is Independent Care (iCare) Health Plan?
© 2016 McGraw-Hill Education. All rights reserved. Ch 8 Privacy, Security and Fraud.
Ann Williams Investigator Eastern District of Texas.
FRAUD, WASTE & ABUSE WHAT YOU NEED TO KNOW STCHCN – 12/7/2015.
We are dedicated to A Healthy Georgia.
Tips to Prevent Medicare Fraud
Chief Compliance Officer
What is HIPAA? HIPAA stands for “Health Insurance Portability & Accountability Act” It was an Act of Congress passed into law in HEALTH INSURANCE.
Fraud Waste and Abuse Company Training.
RISK MANAGEMENT IN THE TREATMENT OF OPIOID DEPENDENCE
Medicare parts c and D Fraud, Waste, and Abuse Training
2005 Deficit Reduction Act: Fraud, Waste & Abuse, and Compliance Training 9/21/2018.
Compliance Program 2018.
Code of Conduct/ Fraud, Waste & Abuse
What Every Employee Should Know About Compliance.
LifeBridge Health Sinai Hospital Orientation.
“Health Care Fraud” 18USC, Ch. 63, Sec. 1347
Northern Michigan Regional Entity Region 2
Division of Health Sciences Office of Institutional Integrity
UMMC ANNUAL COMPLIANCE TRAINING 2009
Component 1: Introduction to Health Care and Public Health in the U.S.
Legislative Hearing December 17, 2018 OIG FFAID OVERVIEW
COMPLIANCE PROGRAM.
Fraud & Abuse Prevention
Compliance and Fraud, Waste and Abuse (FWA) Training
Annual Compliance Training
Fraud, Waste & Abuse (FWA) Education Related to Sales Activities
Corporate Compliance Board Training 2018
Office of the Inspector General
Presentation transcript:

FRAUD, WASTE, & ABUSE (FWA) 2012

OBJECTIVES After reviewing this training and successful passing of the quiz, you will be able to: Understand Fraud, Waste, and Abuse (FWA) training requirements What laws regulate Fraud, Waste, and Abuse Describe steps taken to prevent and combat FWA Refer suspected FWA to your Special Investigations Unit

INTRODUCTION With over a million health care providers and over six billion benefit transactions going on every year, health care fraud is on the rise. Health care fraud is now a top priority for the US Department of Justice – second only to terrorism and violent crimes. In 2009, $2.5 trillion was spent on health care in America. The National Health Care Anti-Fraud Association (NHCAA) estimates that 3% of health care expenditures, or $75 billion dollars, are fraudulent.

EMPLOYEE RESPONSIBILITIES It is essential that all employees of Optima Health understand what fraud and abuse is, how to detect it and how to assist members, providers, and other customers who may be reporting suspicious activities. Optima Health has measures in place to prevent, detect and investigate all forms of insurance fraud, including fraud involving employees or agents; fraud resulting from misrepresentations in the application, renewal or rating of insurance policies and claims fraud. Employees of Optima Health are all responsible for the detection and prevention of fraud, waste, and abuse. Each employee should become familiar with these types of improprieties and be alert for any irregularities.

8 FWA DEFINITIONS FRAUD – An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. WASTE – Is overutilization of services, or other practices that result in unnecessary costs. Generally not considered caused by criminally negligent actions but rather misuse of resources. ABUSE – An individual’s activities that are inconsistent with sound fiscal, business, or medical practices that result in an unnecessary cost, reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care.

FWA EXAMPLES Unnecessary treatments Billing for services not rendered and/or supplies not provided Double billing Eligibility fraud Misrepresentation of services Coding schemes: Unbundling Upcoding Altering claim forms Altering medical record documentation Limiting access to needed services Soliciting, offering or receiving a kickback, bribe or rebate Misrepresentation of medical conditions Failure to report third party billing

FRAUD, Waste & Abuse Laws False Claims Act (FCA) Stark Law Anti-Kickback Statute Deficit Reduction Act The False Claims Whistleblower Employee Protection Act The Exclusion Statute

FalSE CLAIMS ACT (FCA) The False Claims Act (FCA), 31 U.S.C. 3729-3733 states that a person who knowingly submits a false or fraudulent claim to Medicare, Medicaid or other federal healthcare program is liable to the federal government for three times the amount of the federal government’s damages plus penalties of $5,000 to $11,000 per false or fraudulent claim.

Stark Law Stark Law, Social Security Act, 1877 deals with referrals for the provisions of health care services. If a physician or an immediate family member has a financial relationship with an entity, the physician may not refer to the entity for health services where compensation may be made. This is to prevent physicians from making a financial gain and/or overutilization of services.

Anti-Kickback Statute Anti-Kickback Statute, 41 U.S.C, states that it is a criminal offense to knowingly and willfully offer, pay, solicit or receive any compensation for any item or service that is reimbursable by any federal health care program. Penalties include exclusion from federal health care programs, criminal penalties, jail, and civil penalties.

Deficit Reduction Act (DRA) DRA, Public Law No. 109-171 , requires compliance for continued participation in the Medicare and Medicaid programs. The law requires: the development of policies and education relating to false claims, whistleblower protections and procedures for detecting and preventing fraud, waste, and abuse.

False Claims whistleblower Protection Act Whistleblower Protection Act, 31 U.S.C. 3730 (h) states that a company is prohibited from discharging, demoting, suspending, threatening, harassing, or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer. The FCA also includes the “qui tam” provision, which allows persons to sue those who defraud the government. Persons would be eligible to receive a percentage of recoveries from the defendant. The Whistleblower Act protects a person when they file a qui tam claim.

EXCLUSION STATUTE The Office of Inspector General (OIG) is required by law 42 U.S.C. §1320a-7, to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud Patient Abuse or Neglect Felony convictions Excluded providers may not bill directly for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or a group practice.

Special Investigations Unit (SIU) The Special Investigations Unit is dedicated to detecting, investigating and preventing all forms of suspicious activities related to possible health insurance fraud and abuse, including any reasonable belief that insurance fraud will be, is being, or has been committed. The SIU: Reviews and investigates allegations of Fraud and Abuse Takes Corrective Actions for any supported allegations Reports misconduct to all appropriate agencies Provides Staff Training per the Deficit Reduction Act

How Does the SIU Combat Fraud, Waste, & Abuse? The SIU identifies potential fraud through: Prepayment claims reviews Retrospective claims reviews Service Calls/Inquiries from Members, Vendors and/or Providers Data Analysis Hotline Calls Compliance E-mails

Employee FWA ReportING Reports to the Optima Health Compliance Hotline may be made without fear of intimidation, coercion, threats, retaliation or discrimination. Employees may contact their immediate supervisor, or call the Compliance Hotline to file a complaint. The Hotline is available 24 hours a day. The Hotline number is 1-866-826-5277 or 757-687-6326. All hotline calls may remain anonymous. Employees may report suspicious claims activity to the Special Investigations Unit via Internal Service Form, or direct contact with the unit. Employees may also report via the SIU Compliance e-mail at any time. The Compliance e-mail is Compliancealert@sentara.com.

This is the end of the 3rd Module of the 2012 Optima Health Compliance Course. Please begin Quiz #3. Thank you!