Blue Cross of Idaho

1. Blue Cross of Idaho Medicare Advantage Provider Fraud, Waste and Abuse Training Fall 2009

2. Training Objectives • Recognize laws and concepts affecting fraud, waste and abuse (FWA) • Increase awareness of FWA • Use identification techniques in the work environment • Report Medicare FWA concerns

3. Background (continued) • In December 2007, the Centers for Medicare & Medicaid Services (CMS) published new Medicare Advantage (MA) and Part D regulations that became effective January 1, 2009. • These regulations require MA and Part D Plan Sponsors—such as Blue Cross of Idaho —to apply their training requirements and “effective lines of communication” to those entities we partner with “to provide services in the MA and Part D programs.” Those entities include providers who have contracted with Blue Cross of Idaho to provide services to our MA members. • Federal Register, pp. 68700-68741, December 5, 2007

4. Definitions Fraud: The intentional use of deception for unlawful gain or unjust advantage. Waste and abuse: Incidents or practices that are inconsistent with sound fiscal, business, or medical practices and result in unnecessary costs to the Medicare program. This includes costs for services that are not medically necessary or that fail to meet professionally recognized standards.

5. Federal and state authorities • Many federal government agencies play a part in the oversight of federal health care programs including: • The Office of Inspector General (OIG) – An agency of the Department of Health and Human Services (HHS) whose mission is to protect the integrity of the HHS programs, as well as the health and welfare of the beneficiaries of those programs. • Department of Justice • Centers for Medicare & Medicaid Services (CMS) – the agency that administers the Medicare program, which provides health insurance for more than 43 million elderly and disabled Americans. CMS is part of HHS. • Office of the State Attorney General

6. Federal False Claims Act (FCA) • The FCA (31 U.S.C. §§3729-3733) establishes liability under a number of circumstances. Some examples include any person or entity who: • knowingly presents or causes a false claim to be presented to the federal government for payment or approval; • knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; • knowingly conceals and/or improperly avoids or decreases an obligation to pay or transmit money or property to the federal government; • conspires to commit a violation of the liability sections of the Act.

7. FCA Penalties • Penalties of the FCA include: • Civil penalties between $5,000 –$11,000 plus three times the total damages per claim; • Possible exclusion from Medicare and Medicaid; • Possible criminal prosecution.

8. Examples of FCA Violations • Two examples of provider activity that may constitute a FCA violation are: • Billing for services that were not rendered. • Upcoding—billing for a service that was not rendered simply because the coding generates more income than the correct billing for the service that was actually rendered.

9. Anti-Kickback Statute (AKS) • The AKS 42 U.S.C. §§1320a-7b) provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward the referral of business payable or reimbursable under the Medicare or other federal health care programs. • The individual or entity may be excluded from participation in Medicare or other federal health care programs.

10. Beneficiary Inducement Law • The Beneficiary Inducement Law: • Prohibits offering a remuneration that a person knows, or should know, is likely to influence a beneficiary to select a particular provider, practitioner, or supplier; • Creates liability of civil monetary penalties of up to $10,000 for each wrongful act.

11. Examples of AKS Violations Two examples of provider activity that may constitute violations of the AKS are: • Taking money from pharmaceutical representatives in exchange for promising to prescribe that company’s drugs over others. • Only referring Medicare patients to one physical therapy practice, in exchange for receiving money from that practice for such referrals.

12. Exclusion Lists • OIG has the authority to exclude individuals or organizations from participating in Medicare, Medicaid, and other federal programs. • Exclusion reasons include:–conviction of fraud or abuse; • –default on federal student loans; • –controlled-substance violations; • –licensing board actions.

13. Exclusion List Screening • OIG: http://exclusions.oig.hhs.gov/search.aspx • GSA: https://www.epls.gov/ • No payment will be made by any federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. • Individuals must be checked at the time of hire and annually thereafter. No excluded individual or entity may provide goods or services reimbursed by a federal health care program.

14. Record Retention • Providers must maintain service, prescription, claim, and billing records for ten years. • Records are subject to CMS or contractor audit.

15. Examples of Potential Provider FWA • 1. A physician prescribes medications for his mother, a Part D member, and fills the prescriptions for his own use. • 2. A Durable Medical Equipment (DME) provider submits false claims to an MA plan for payment of DME supplies that were never provided to a plan member. • 3. A physician submits claims to an MA plan for services that were not rendered, or rendered in an incomplete manner.

16. Examples of Potential Plan Sponsor FWA • 1. A Part D plan sponsor participates in marketing schemes such as offering beneficiaries a cash payment as an inducement to enroll in Part D, enrolling beneficiaries without their consent, and using unlicensed agents. • 2. A MA plan fails to provide medically necessary MA services required by law while continuing to report claims experience to CMS for those services. • 3. A Part D plan sponsor denies Part D members their right to appeal plan denials

17. Examples of Potential Beneficiary FWA • 1. After obtaining the drugs through his Part D coverage by falsely reporting loss and by feigning illness to obtain the drugs from multiple providers, the beneficiary sells the drugs on the street. • 2. A beneficiary utilizes false identification to enroll in an MA plan. • 3. A Part D member submits false pharmaceutical drug receipts to his Part D plan for payment.

18. FWA Prevention • The federal government strongly encourages providers to develop and implement voluntary compliance programs, as effective tools in detecting and preventing fraud, waste, and abuse perpetrated against the federal government’s health care programs. • Elements of a compliance plan include: • Written policies and procedures; • Compliance Officer and Compliance Committee; • Effective training and education; • Effective lines of communication; • Internal monitoring and auditing; • Well-publicized disciplinary guidelines; • Corrective actions, when needed; and • Comprehensive FWA program.

19. Reporting FWA Concerns Blue Cross of Idaho Medicare Advantage Compliance Officer Jane Lindsay (208) 387-6949 Fraud and Abuse Hotline 800-682-9095 CMS 1-800-MEDICARE HHS OIG 1-800-447-8477 HHSTips@oig.hhs.gov All reports are kept confidential and callers may remain anonymous.

20. Conclusion Thank you for completing the MA Compliance Training Session for Medicare Advantage Providers at Blue Cross of Idaho. If you have any questions regarding this presentation, please contact the Blue Cross of Idaho Medicare Advantage Officer or your provider representative.