2013 Compliance, Fraud, Waste, and Abuse Training

1. 2013 Compliance, Fraud, Waste, and Abuse Training

2. Why Do We Have Compliance Training? • To improve services for American Behavioral members • To define expected conduct from providers, members and American Behavioral associates • To provide guidance that helps us make informed decisions concerning what is appropriate and right • To quickly identify and resolve compliance concerns • To assist us in abiding by the laws and regulations that govern our business • To help American Behavioral meet URAC accreditation standards • To avoid legal and financial penalties

3. The American Behavioral Compliance Mission • To direct our business in an ethical manner and in accordance with all regulations and accreditation standards • To foster open, honest and timely communication between American Behavioral and our providers • To integrate compliance as an essential part of daily operations • To promote the cooperative relationship between American Behavioral and our providers

4. The Ultimate Goal Developing controls and educating providers, members, and associates in order to reduce the amount of fraudulent, wasteful or abusive activities

5. The American Behavioral Code of Conduct • Be honest • Know the applicable American Behavioral guidelines, policies and procedures • Ask questions • Admit mistakes • Report concerns • Don’t be afraid to ask for help

6. Fraud, Waste and Abuse (FWA) • FWA is a nationwide problem that affects everyone either directly or indirectly • National estimates project that billions of dollars are lost due to fraud, waste and/or abuse, resulting in increased health care costs and increased cost for coverage • We have the responsibility to prevent, detect and eliminate FWA

7. Definition of Fraud Fraud is when a person intentionally misrepresents information, knowing that the misrepresentation could benefit himself/herself or some other person The most common kind of health care fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of payable benefits

8. Definition of Waste Performing functions in a manner requiring more resources than are necessary, e.g. using or billing for more supplies, technology or hours than are required

9. Definition of Abuse Refers to practices that may directly or indirectly cause financial loss to payers of insurance or health care benefits. Abuse often involves administering unnecessary services, improper billing or providing products or services that are not consistent with accepted practices

10. Examples of FWA • Fraud: Submitting false claims for health care services that were not provided or filing a claim for more complicated service than the service performed • Waste: Unnecessary spending or use of office supplies, technology, or resources • Abuse: Billing for services/supplies that are not medically necessary or providing care that is not consistent with accepted medical practices

11. Examples of Health Care Fraud and Abuse by a Provider • Billing for services that were not provided • Double billing: Duplicate submission of a claim for the same service • Misrepresenting the service provided • Up-coding: Charging for a more complex or expensive service that was actually provided • Billing for a covered service when the service actually provided was not covered

12. Examples of Health Care Fraud and Abuse by a Provider--Continued • Kickbacks: Receiving payments or other benefits for making a referral • Ordering excessive or inappropriate testing • Brief or intermediate-length visits coded as lengthy or comprehensive visits • Regularly waiving co-pays or co-insurance for patients, but filing with the insurance company for reimbursement

13. Examples of Health Care Fraud and Abuse by a Member/Client • Using a member ID card that does not belong to that person • Adding someone to a policy that is not eligible for coverage, e.g. a grandchild • Failing to remove someone from a policy when that person is no longer eligible, e.g. a former spouse

14. Examples of Health Care Fraud and Abuse by a Member/Client--Continued • Doctor shopping: Visiting several doctors to obtain multiple prescriptions/services • Providing false employer group and/or group membership information

15. Laws Regulating FWA • The Anti-Kickback Statute • The Anti-Kickback Statute is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business.1 Examples of prohibited activities include: • Waiving a co-pay or deductible for reasons other than real financial hardship (or allowable exceptions) • Accepting a payment that is different from fair market value as a means to obtain more business • Demanding or requesting a kickback (i.e. gifts, cash, write-offs, free supplies for referring patients to specific providers) 1http://www.healthlawyers.org/hlresources/Health%20Law%20Wiki/Anti-Kickback%20Statute.aspx

16. Laws Regulating FWA--Continued The Physician Self-Referral Law (Commonly Known as The Stark Law) Failure to comply with either The Anti-Kickback Statute or The Stark Lawcan result in fines, jail and/or exclusion from state health programs, Medicare or Medicaid The Stark 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.2 2 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf

17. The False Claims Act • The False Claims Act is a Federal law that prohibits a provider from knowingly submitting false, fictitious, or fraudulent claims to obtain payment from federal or state programs • Knowingly and/or willfully making a false statement about a claim is a federal felony.Penalties can include significant fines, jail time and/or exclusion from participation in federal and state programs.

18. Self-Disclosure of Criminal Activity • Felony convictions or other criminal activity (other than minor traffic violations) occurring prior to or during a provider’s contract with American Behavioral must be self-disclosed • The provider agrees to notify American Behavioral within seven (7) days of the loss, restriction or recommended adverse action against his or hospital privileges or license

19. Debarment, Exclusion, or Sanctions The Office of the Inspector General (OIG) and the General Services Administration (GSA) maintain a list of individual providers and entities that have been debarred or excluded from working with federal or state health programs. At the time of the initial credentialing or re-credentialing process, American Behavioral reviews and verifies that the individual or entity is not on that list The OIG also maintains a list of non-licensed individuals who have had sanctions levied against them preventing them from working with federal or state health programs. On a monthly basis, American Behavioral monitors this list to ensure that no American Behavioral associate has been sanctioned. As with other criminal activities, American Behavioral requires self-disclosure of any information related to debarment, exclusion or any activity that prevents a provider or American Behavioral associate from working directly or indirectly with Medicare, Medicaid or state health programs

20. Confidential Information • Compliance with HIPAA regulations is mandatory, and the confidentiality of records, documents and business practices must be maintained • Protected Health Information (PHI) and other member information must be appropriately safeguarded This information includes paper, electronic records and oral communication • PHI should only be shared if the disclosure is specifically allowed by HIPAA

21. Monitoring and Auditing • Everyone is obligated to monitor compliance activities and follow all policies and procedures • Any area of suspected non-compliance should be reported immediately • American Behavioral will review claims and other data submitted by each provider as an internal monitoring and auditing control • If compliance issues or concerns are identified during an audit, corrective actions are developed and implemented.

22. Prevention Tips Teaching American Behavioral Members to be Aware • Review each Explanation of Benefits to ensure the accuracy of the name of the provider, dates of service and types of services reported • Protect his or her insurance card and personal information at all times • Count his or her pills each time they pick up a prescription • Be wary of all advertisements that claim “free” treatments • Check providers’ credentials with the appropriate state licensing board. If a member is unsure of a provider’s credentials, tell them to ask American Behavioral • Members should report all suspected fraud and abuse to the Quality Department at American Behavioral 205-868-9633

23. Reporting a Potential Violation All reports will be investigated. Individuals expressing concerns or reporting violations in “good faith” can do so confidentially without fear of retribution or retaliation as required by law. “Good faith” means to tell the truth when reporting a concern or suspected violation. False reports, stretching the truth, or making statements made in retaliation against another person, or statements made for the sole purpose of getting someone in trouble will result in disciplinary actions.

24. Reporting a Potential Violation--Continued Report suspicious practices involving Medicare or other Federal programs to the Office of the Inspector General (OIG) Hotline. • Phone: 1-800-HHS-TIPS (1-800-447-8477) • Fax: 1-800-223-8164 • Email: HHSTips@oig.hhs.gov • Address: HHS Tips Hotline, P.O. Box 23489 Washington, DC 20026-3489

25. Getting Assistance When Reporting a Potential Violation Obtain assistance from a supervisor. If you suspect your immediate supervisor of FWA, you can contact the Quality Department (868-9633) or another trusted member of management. Take the route in which you feel most comfortable.

26. What to Do Once Suspected Fraud or Abuse is Reported To confirm that an allegation against a provider is substantiated: • Research the provider throughout all billings • Research pre-billing and post-billing reviews of the provider • Research submission and payment of claims • Query the provider history • Review contract or benefit language.

27. Potential Investigation/Corrective Actions • A pre-payment investigation may be warranted • Additional documentation may be requested from the provider before claims payment • Possible recovery of over-payments may be recommended. The decision to enact this recommendation would come from upper administration and/or corporate legal counsel • Mandatory retraining • Contract suspension and/or contract termination

28. Summary • Fraud: When a person misrepresents information, knowing that the misrepresentation could benefit himself/herself or some other person • Waste: Using more resources than necessary to complete a task • Abuse: When an associate, vendor, provider or contractor furnishes products or services that are inconsistent with accepted practices or that are clearly not reasonable or necessary

29. Summary--Continued Compliance: The material and policies in this training are mandatory. Ethical behavior can never be sacrificed in the pursuit of other objectives American Behavioral is committed to the highest standards of ethics and compliance. Everyone is responsible for their own conduct and behavior. If you are not sure about potential compliance or FWA issues, ask

30. Summary--Continued If you find yourself in a situation where you are unsure of what is right, ask yourself a few simple questions: • Am I being fair and honest? • Is this in the best interest of American Behavioral and the members we serve? • Are my actions legal? • Is this the right thing to do? • How will I feel about my actions afterwards? • Will my actions stand the test of time? • Would I feel good about my actions if I were to read about it in the newspaper or see it on the news?

31. Summary--Continued Fraud, waste, and abuse are serious problems. Report suspected fraud, waste, or abuse as soon as possible.

32. Summary--Continued Remember The Ultimate Goal: Developing controls and educating providers, members, and associates in order to reduce the amount of fraudulent, wasteful or abusive activities

33. Final Words