Fraud, Waste & Abuse

1. Fraud, Waste & Abuse TRAINING COURSE As of May 2014 Click here to enter the course. Provided by Health Care Service Corporation & its subsidiaries

2. FRAUD WASTE & ABUSE WHY? is this training so important The Bottom Line

3. FRAUD WASTE & ABUSE Who Am I In the Big Picture WHO?

4. FRAUD WASTE & ABUSE WHAT? can I do to stop fraud, waste & abuse The Action Steps

5. FRAUD WASTE & ABUSE What do I need to know about the LAW? Know the Law

6. FRAUD WASTE & ABUSE Start here Return to this page by clicking the Home icon Who Am I In the Big Picture? The Bottom Line The Action Steps Know the Law

7. THE BOTTOM LINE The Bottom Line Who Am I In the Big Picture? The Action Steps Know the Law Why is this training so important? WHY? Back / Forward Home

8. CMS requires training for New & Existing Employees who Work on a government contract

9. Written Policies, Procedures and Standards of Conduct Compliance Officer, Compliance Committee and High Level Oversight Effective Training and Education Effective Lines of Communication Well Publicized Disciplinary Standards Effective System for Routine Monitoring and Identification of Compliance Risks Procedures and System for Prompt Response to Compliance Issues 7 CMS Core Requirements

10. Written Policies, Procedures and Standards of Conduct Compliance Officer, Compliance Committee and High Level Oversight Effective Training and Education Effective Lines of Communication Well Publicized Disciplinary Standards Effective System for Routine Monitoring and Identification of Compliance Risks Procedures and System for Prompt Response to Compliance Issues Click here to view Chapter 9 Clickhereto view the Federal Sentencing Guidelines Clickhereto view HCSC’s Compliance Program 7 CMS Core Requirements

11. Ms. B. Skloss Click on the magnifying glass

12. Ms. B. Skloss Every patient has the same diagnosis

13. Ms. B. Skloss Every patient has the same diagnosis Billing for more than 24 hours/day

14. Ms. B. Skloss Every patient has the same diagnosis Billing for more than 24 hours/day Billing for Individual, Group & Family Therapy for most clients

15. Ms. B. Skloss Every patient has the same diagnosis Billing for more than 24 hours/day Billing for Individual, Group & Family Therapy for most clients Billing for in-person visits when speaking with them on the phone

16. Ms. B. Skloss Every patient has the same diagnosis Billing for more than 24 hours/day Billing for 7 days/week even on holidays Billing for Individual, Group & Family Therapy for most clients Billing for in-person visits when speaking with them on the phone

17. Ms. B. Skloss HCSC

18. Ms. B. Skloss Explanation of Benefits FRAUD

19. WHO AM I IN THE BIG PICTURE?

20. Know and abide by terms of government contract 1 Stay true to your company’s code 2 Click here to view HCSC’s Code of Conduct. Save this page to your favorites. 3 Cooperate fully and truthfully with government agencies RESPONSIBILITIES

21. I have been hired within the past 90 days. This is my annual training. I work directly or indirectly on a government program, such as Medicare or Medicaid. INDIRECTLY DIRECTLY ON GOVERNMENT PROGRAM

22. Report improper payment to government officials 4 Violations regarding gifts to government employees can result in serious consequences Comply with the laws that impact government programs 5 RESPONSIBILITIES

23. 6 Avoid conflicts of interest GOOD FOR MY COMPANY GOOD FOR ME RESPONSIBILITIES

24. How do I report fraud, waste and abuse? Recognize and report fraud, waste & abuse 7 RESPONSIBILITIES

25. Corporate Integrity Compliance Program HCSC/HISC/GHS

26. TOM LUBBEN HCSC’s Chief Compliance & Privacy Officer Corporate Integrity Compliance Program HCSC/HISC/GHS

27. TOM LUBBEN HCSC’s Chief Compliance & Privacy Officer Corporate Integrity Compliance Program HCSC/HISC/GHS Government Programs Compliance

28. KIM GREEN HCSC’s Government Programs Compliance Officer, Medicare Compliance Officer Government Programs Compliance Specific policies Oversees compliance Government contracts

29. Monitor & Audit FDR RESPONSIBILITIES First Tier Down-stream • Monitor and audit themselves & downstream • Implement policies & procedures • Comply with the law • Set high ethical standards • Report suspected FWA to the Plan Sponsor Downstream

30. First Tier Down-stream Downstream

31. HCSC

32. THE ACTION STEPS Detect Report Correct Prevent

33. Abuse Waste Fraud Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice— (1) To defraud any health care benefit program or (2) To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program US Code Title 18, Section 1347 Detect

34. Fraud Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice— (1) To defraud any health care benefit program or (2) To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program US Code Title 18, Section 1347 False information is intentionally submitted to the government to get money or a benefit Detect

35. Fraud $43,904 FRAUD FRAUD HCSC Detect

36. Law Litmus Test Click the box next to the correct answer. Which of the following laws prohibits knowingly submitting or causing someone else to submit a claim for payment with government funds using false information or making false statements in order to get a claim paid or approved by the government? Anti-Kickback Statute NO, but we’ll talk about this later. Stark Statute NO, but we’ll talk about this later. False Claims Act HIPAA NO, but we’ll talk about this later.

37. PENALTIES That’s right! There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud. There can also be a liability for submitting a claim from a subcontractor to a contractor, even if there is no intent for the submitter to be paid directly or indirectly by the government. It is the most used law for prosecuting fraud. Ms. Skloss was found guilty of Theft related to the false claims filed with both the Texas Medicaid Program and BCBSTX. Damages may be triple the amount of the claim and the government may impose a civil penalty of $5,500 - $11,000 for each false claim. It may also carry heavy criminal penalties. If convicted, depending upon the circumstances, the individual may be fined and/or imprisoned for a number of years up to and including life. There may be additional penalties required due to state governments based on the state False Claims Acts. It’s important to note that the False Claims Act applies if the person knew or even should have known that the claim was false.

38. Abuse Waste Fraud IntentionalNot intentional UNNECESSARY COSTS Detect

39. Abuse Waste • Overutilization of services • Generally not considered to be criminally negligent • Misuse of resources • Request for payment • No legal entitlement • Not knowingly misrepresented facts Detect

40. Which prescription is suspicious? NO, not this one. Detect

41. CORRECT! It appears that the date on this prescription has been altered. Detect

42. PRESCRIPTIONS & MEDICINE FRAUD CLUES • Many identical prescriptions in a short time • Prescription does not match the beneficiary’s medical history • Generics are being provided when prescription requires a brand • Drugs are expired. Detect

43. Which scenario is suspicious? This is a simple case of tonsillitis. You’ll be out of the hospital today. All of that for tonsillitis? I’m going to run a series of 12 tests: an MRI, blood work, CAT Scan… Detect NO, not this one.

44. CORRECT! All of that for tonsillitis? I’m going to run a series of 12 tests: an MRI, blood work, CAT Scan… Does the treatment match the diagnosis? Detect

45. PHYSICIAN FRAUD CLUES • Bills for services not provided • Prescriptions for a higher quantity than medically necessary for the condition Detect

46. Read the sales scenarios below. Which one is suspicious? These are the services you can expect if you sign up for Medicare. I’ve also provided a list of doctors in your area who accept Medicare. If you sign up for Medicare today and make Dr. Popper your primary physician, you’ll get a $100 gift card. Detect NO, not this one.

47. CORRECT! If you sign up for Medicare today and make Dr. Popper your primary physician, you’ll get a $100 gift card. Offering monetary rewards to sign up for a government health plan Detect

48. Law Litmus Test Click the box next to the correct answer. Which of the following prohibits willfully receiving or offering a bribe or rebate for referrals for services that are paid under a federal health care program? Stark Statute NO, but we’ll talk about this later. HIPAA NO, but we’ll talk about this later. Exclusion NO, but we’ll talk about this later. Anti-Kickback Statute

49. PENALTIES THAT’S RIGHT! These 9 cardiologists paid the government over $3.2 million to settle their case for entering into the kickback scheme with the hospital. Two of them also plead guilty to criminal embezzlement charges involving the same conduct. Fines up to $25,000, imprisonment up to 5 years or both. If the sales rep offering a $100 gift card for beneficiaries to join the plan with Dr. Popper is receiving money from the doctor in return for referring patients to him, he is violating the Anti-Kickback Statute. Sales agents must always be honest and truthful in presenting products as outlined in the benefit guides, without adding anything to it. This law applies to more than sales people. The real live case below involves providers. $100 Nine cardiologists and a local hospital entered into a kickback agreement, under which the cardiologists received payment from the hospital (even though they did not perform services for the hospital) in exchange for referring their patients to the hospital for surgery.

50. Detect