1. Fraud & Abuse Prevention
The GCBH Program for Assuring Compliance with State and Federal Laws Regarding the Use of Funding for Healthcare Services
Updated July 2016

2. Welcome
The State Mental Health Division requires each Behavioral Health Organization (BHO) receiving Medicaid funding to maintain appropriate oversight and develop a compliance plan that includes measures to detect, prevent and correct fraud, waste and abuse.
Establish fraud, waste and abuse training and effective lines of communication between the BHO and its downstream and related entities.
This presentation is the first of three parts of the required training.

3. Instructions
During the second part of the training process, you will read the GCBH Fraud, Waste, and Abuse Prevention Program Plan (Policy No. CO201). The last slide of this presentation will tell you how to access it.
The third part of the training process is the completion of an attestation indicating you have read and understood the course and GCBH Fraud, Waste, and Abuse Prevention Program Plan. You will print this off, sign and submit to your Manager.
Let’s Begin!

4. Why Focus on Fraud, Waste and Abuse?
The United States spends more than 2 trillion on health care every year.*
The Federal General Accounting Office estimates that in 2014 Medicare alone paid out 60 billion dollars for fraudulent claims…and that is likely an underestimate.
One Harvard expert estimated that of the 600 billion dollars paid out by Medicare, up to 30% may go to fraudulent claims**
*Statement by Daniel R. Levinson, Inspector General, Office of the Inspector General, U.S. Department of Health and Human Services; before the Senate Special Committee on Aging, United States, on combating Fraud, Waste, and abuse in Medicare and Medicaid (May 06,2009).
* * Malcolm Sparrow, 2016

5. GCBH Approaches to the Issue
Greater Columbia has a Compliance Plan that is used to guide our interventions against Fraud, Waste and Abuse.
The Plan is patterned after the Federal government’s “Seven Essential Elements” that we should employ.
The following slides describe our plan…

6. What is a Compliance Plan?
A compliance plan is a series of internal controls and measures to ensure the plan sponsor follows applicable laws and regulations that govern Federal programs, like Medicare and Medicaid
The adoption and implementation of a compliance program significantly reduces the risk of fraud, abuse and waste in the health care setting, while providing quality of services and care to patients.
Organizations contracting directly or indirectly with the federal government are obligated to:
Report fraud, waste and abuse;
Demonstrate their commitment to eliminating fraud, waste and abuse; and
Implement internal policies and procedures to identify and combat health care fraud.

7. What is a Compliance Plan? (cont’d)
An effective Compliance Plan includes 7 core elements:
Written Standards of Conduct: Development and distribution of written Standards of Conduct and Policies and Procedure that promote the Plan Sponsor’s commitment to compliance and that address specific areas of potential fraud, waste and abuse.
Designation of a Compliance Officer: Designation of an individual and a committee charged with the responsibility and authority of operating and monitoring the compliance program.
Compliance Training: Development and implementation of regular, effective education and training, such as this training.
Internal Monitoring and Auditing: Use of risk evaluation techniques and audits to monitor compliance and assist in the reduction of identified problem areas.

8. What is a Compliance Plan? (cont’d)
Disciplinary Mechanisms: Policies to consistently enforce standards and address dealing with individuals or entities that are excluded from participating in CMS programs.
Effective Lines of Communication: Between the compliance officer and the organization’s employee’s, managers and directors and members of the compliance committee, as well as first tier, downstream and related entities.
Procedures for Responding to Detected Offenses and Corrective Action: Policies to respond to and initiate corrective action to prevent similar offenses including a timely, reasonable inquiry.

9. What Is “Fraud”?
“Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to self or another person.”
Fraud is INTENTIONAL.
The intent of fraud is UNLAWFUL BENEFIT for self or others.
In other words, fraud happens when…
you become aware that you have acted deceitfully in a way that could benefit you or others,
and you don’t correct your error,
whether or not the benefit actually occurs!

10. What is “Abuse”?
“Practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that don’t meet professionally recognized standards for health care.”
A practice may be substandard without constituting “abuse.”
“Abuse” is a substandard practice that drives up Medicaid costs because it isn’t sound, or because it is not medically necessary, or because it doesn’t meet recognized professional standards.

11. Definitions (cont’d)
Waste: Waste is the extravagant, careless or needless expenditure of healthcare benefits or services that results from deficient practices or decisions.
Example of waste:
Over-utilization of services
Misuse of resources

12. Some Examples of Fraud, Waste & Abuse
Billing for services that weren’t provided
Billing multiple insurers for the same services
Billing Medicaid for services that should have been paid for by another source of funding
Providing services the client doesn’t need
Providing and/or billing for a service that is more complex than the diagnosis justifies (i.e., upcoding)
Submitting separate bills for services that should have been billed together, under one billing code (i.e., unbundling)
Embezzlement and theft
Falsifying personal or agency credentials
Over-utilization of services
Misuse of resources
...And there are others

13. FRAUD & ABUSE TYPES
There are several other common ways fraud and abuse can occur. Examples include:
False claims
Kickbacks
Identity theft
Identity swapping
Marketing schemes
Duplicate billing

14. FWA LAWS THE FALSE CLAIMS ACT
The False Claims Act makes it illegal to:
Knowingly present, or cause to be presented, to an officer or employee of the United States Government a false or fraudulent claim for payment or approval.
Knowingly making, using, or causing to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government
Conspiring to defraud the Government by getting a fraudulent claim allowed or paid
Has actual knowledge of the information
Acts in deliberate ignorance of the truth or falsity of the information
Acts in reckless disregard of the truth or falsity of the information; no proof of specific intent to defraud is required

15. FWA LAWS THE FALSE CLAIMS ACT
The False Claims Act imposes two sorts of liability:
The submitter of the false claim/statement is liable for a civil penalty, regardless of whether the submission of a claim actually causes the Government any damages and even if the claim is rejected
The submitter of the claim is liable for damages that the government sustains because of the submission of the false claim
Under the False Claims Act, those who knowingly submit or cause another person to submit false claims for payment by the government are liable for three times the Government’s damages plus civil penalties of $5,000 to $10,000 per false claim

16. FWA LAWS ANTI-KICKBACK STATUTE
The Anti-kickback Statute makes it a criminal offense to knowingly and willfully solicit, receive, offer or pay remuneration (including any kickback, bribe or rebate) in return for:
Referrals for the furnishing or arranging of any items or service reimbursable by a Federal Health Care Program
Purchasing, leasing, ordering or arranging for any items or service reimbursable by a Federal Health Care Program
Remuneration is defined as the transfer of anything of value, directly for indirectly, overtly or covertly in cash or in kind.
If an arrangement satisfies certain regulatory safe harbors, it is not treated as an offense under the statute.
Criminal penalties for violating the anti-kickback statute may include fines, imprisonment, or both.

17. PHYSICIAN SELF-REFERRAL LAW STARK LAW
The Physician Self-Referral Law 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.
Penalties for Stark Law violations include fines and exclusion from participation in all Federal Health Care Programs.

18. Preventing Potential FWA
How can you prevent potential fraud, waste and abuse?
Understand your organization’s FWA policies and procedures, including standards of conduct and reporting potential FWA
Know your organization’s compliance hotline
Conduct effective training and education
Enforce standards of conduct
Develop effective lines of communication between compliance officer and employees
Conduct internal monitoring and auditing, including detection through medical review and data analysis
Maintain confidentiality of protected health information (PHI)

19. GCBH’s Responsibility for Prevention
Establish ethical processes, and monitor their performance.
Establish policies and procedures that help employees avoid committing fraud or abuse.
Screen employees and subcontractors, and exclude them from providing GCBH-funded services if:
They have been convicted of a criminal offense related to health care.
The Federal Government has found them ineligible to receive federal funds.
Take disciplinary action whenever necessary.

20. Legal Actions
A provider, supplier or health care organization that has been convicted of fraud may receive a significant fine, prison sentence or be temporarily or permanently excluded from the Medicaid program or other Federal health care programs, and in some states, lose their license. Failure to comply with fraud and abuse laws may result in:
Investigations referred to the Office of Inspector General (OIG)
Civil monetary penalties that can result in up to $10,000 per violation and exclusion from the Medicare program
Denial or revocation of a Medicaid Provider Number
Suspension of payment

21. What is your responsibility?
First, the obvious….
DO NOT ENGAGE IN BEHAVIORS THAT COULD BE CONSIDERED FRAUDULENT, WASTEFUL OR ABUSIVE!
Second, SPEAK UP.
If you suspect that fraud or abuse has occurred, you must report it.
You may report in several ways, which are listed in the Fraud & Abuse Prevention Program Plan.
You may report anonymously.
Report your concerns to the Compliance Team

22. And Who Is That? Jaime Gier is the GCBH Chief Compliance Officer
She reports directly to the GCBH Executive Director.
She is supported by a Compliance Team as she investigates every report of alleged fraud or abuse.
Members of the team include:
The IT Director
The Quality Director
The Medical Director
A Quality specialist
The Contracts Manager
They report their findings to the Compliance Committee:
Representatives from GCBH Board of Directors
Representatives from Network Providers
Members of GCBH senior management

23. How do you submit a concern or question to the GCBH Chief Compliance Officer?
A report is made in any of the following ways:
In person, to the CCO (Jaime Gier);
By faxing the CCO at (509) ;
By calling, on an anonymous basis if so desired, the CCO at (509) or (800)
By mailing a written concern to:
Corporate Compliance Officer, Jamie Gier
Greater Columbia Behavioral Health
101 N. Edison Street
Kennewick, WA
A dedicated and confidential compliance line for Fraud, Waste and Abuse (FWA):

24. More About Reporting
Any person associated with GCBH may report a concern, or request information, about fraud and abuse.
This includes consumers, employees, subcontractors and others.
If a person provides his/her name when reporting, there is no guarantee of anonymity.
The CCO will try to protect a person’s identity if s/he requests that, but may choose to disclose it if that seems necessary.
A person who provides his/her name when reporting suspected fraud or abuse is entitled to know whether an investigation has occurred.
A person who reports in good faith is covered under Whistle Blower protection

25. What is “WHISTLEBLOWER PROTECTION”
The whistleblower provision protects employees who assist the federal government in investigation and prosecution of violations of False Claims Act. The provision prevents retaliation against employees assisting in the investigation and prosecution. If any retaliation does occur, the employee has a right to obtain legal counsel to defend the actions.
A whistleblower is someone such as an employee who reports suspected misconduct that would be considered an action against company policy or federal laws or regulations.

26. Zero Tolerance for Anything Shady
Disciplinary action will be taken:
Against any person whose conduct appears to have been intentionally or willfully indifferent to, or in reckless disregard of, state and federal laws;
When someone makes a report with the intent to harm another; and
When someone retaliates in any manner against another person who reported a concern in good faith.
GCBH is obligated to penalize malicious reporting,
and to protect those who report legitimate concerns.

27. FWA RESOURCES RESOURCES
Centers for Medicare and Medicaid Services (CMS)
Medicare Learning Network (MLN)
OIG and fraud
Office of Inspector General (OIG) list of excluded individuals
Health Care Fraud Prevention & Enforcement Action Team (HEAT)
More information on Anti-Kickback Statute
More information on Stark Law
Federal Register Citations 42 CFR , , CFR and
Health Insurance Portability and Accountability Act (HIPAA)
National Health Care Anti-Fraud Association
Part D Prescription Drug Benefit Manual
LINK

28. Attestation of Training
I have reviewed the GCBH Fraud, Waste, and Abuse training materials and Policy and understand the information.
Signature:_____________________
Print Name:______________________
Date:__________________________
Please print out this form for your manager to keep in your records for auditing purposes. You should also keep a copy for your own records.

29. CONGRATULATIONS! You have completed Part 1 of the training process.
Please review the Policy CO201 - Fraud, Waste, and Abuse as part of completing this training.
If you wish, you may view this presentation again by clicking on the arrow below.
NOTE: You may find the policy on our web site by looking for Policies near the bottom
of our web site, or using the term “GCBH Policies” or “GCBH CO201” with Bing or Google.
End
Presentation