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• At the end of the training, take the quiz. Once you pass the quiz the answers will be submitted automatically-no need to do anything further.

A couple of things to note as you proceed through the class:

Marion County Health Department Presents: Fraud, Waste and Abuse Refresher

• If a screen does not proceed on its own you may need to click the next button located at the bottom of your screen

Hi June, I wanted to talk to you about our Fraud, Waste and Abuse policy

Oh good! I’ve been hearing about it and wanted to know more…

It is required by federal law that we have refreshers each year

You’re right Paul

What exactly do we mean by Fraud?

Fraud is…

The intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to oneself or someone else…NOT GOOD!

Let’s take a closer look at what is and isn’t Fraud

Examples of Fraud1. Billing for No Shows2. Misrepresenting a diagnosis in

order to justify the services3. Misrepresenting who, what, or

where the services occurred4. Duplicate billing and billing for

non-covered services5. Substituting Services6. Incorrect coding to generate

more revenue7. Overutilization

If slide does not advance automatically please manually click the next slide from the “Outline” to the left

The False Claims “Whistleblower” Employee protection Act

Laws Regulating Fraud

Deficit Reduction Act

False Claims Act (FCA)

HIPAA

The Anti-Kickback Statute

Physician Self-Referral (“Stark”) Statute

Administrative Remedies for False Claims and Statements

The False Claims “Whistleblower” Employee protection Act

Laws Regulating Fraud

Deficit Reduction Act

False Claims Act (FCA)

HIPAA

The Anti-Kickback Statute

Physician Self-Referral (“Stark”) Statute

Administrative Remedies for False Claims and Statements

…remember, every employee is protected from retribution for reporting Fraud, Waste or Abuse

It is especially important to…

The law about Whistleblower Protection sounds very important

…health care spending that can be eliminated without reducing quality of care That makes

sense…so what is Waste then?

Waste is…

Yes Paul. There are two types of Waste…

…and, “Inefficiency Waste” is redundancy, delays, and unnecessary process complexity

…“Quality Waste” is over, under or ineffective use

Zack and Angi are both correct

Tell her about Abuse

Abuse is…

…inconsistent practices that result in an unnecessary cost to Medicaid, Medicare or the MVBCN

Abuse can also be reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care

False Claims Act Under the False Claims Act (FCA), 31 U.S.C

3729-3733, those who knowingly submit, or cause another person or entity to submit false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim– The FCA applies to any health care entity

that receives more than $5 million in Medicaid funds • MCHD receives in excess of $5 million

annually Back

HIPAAThe Health Insurance Portability and Accountability Act (HIPAA), 45 CFR, Title II, 201-250, provides clear definition for Fraud & Abuse control programs, establishment of criminal and civil penalties and sanctions for noncompliance• Established the national Health Care Fraud and

Abuse Control Program (“HCFAC”) that coordinates Federal, state, and local law enforcement activities with respect to health care Fraud, Waste and Abuse. It created the offense of “health care Fraud” and established criminal penalties for violation.

• Penalties:• Fines• Imprisonment Back

Deficit Reduction ActThe Deficit Reduction Act (DRA), Public Law No. 109-171, 6032, passed in 2005, is designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries The Act requires compliance for continued participation in the programs. The development of policies and education relating to false claims, whistleblower protections and procedures for detecting and preventing Fraud & Abuse must be implemented

Back

The False Claims “Whistleblower” Employee protection Act

The False Claims Act Whistleblower Employee 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

• Every employee is protected with ZERO retribution for making referrals whether they are made anonymously or not

Back

The False Claims “Whistleblower” Employee protection Act

The False Claims Act Whistleblower Employee 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

• Every employee is protected with ZERO retribution for making referrals whether they are made anonymously or not

Back

Administrative Remedies for False Claims and Statements

Administrative Remedies for False Claims and Statements, 31 U.S.C Chapter 8, 3801, states that any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim

Back

The Anti-Kickback StatuteThe Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b), prohibits knowingly or willfully soliciting, receiving, offering, or paying any remuneration (including any kickback, bribe or rebate) in order to induce or reward business that is payable under a Federal health care program.

Penalties for violation:• Criminal penalty of fines of up to $25,000; and/or

imprisonment of up to 5 years• Civil penalty of up to $50,000 per act plus 3 times the

amount of remuneration• Exclusion from Federal health care programs

Back

Physician Self-Referral (“Stark”) Statute

Back

The Physician Self-Referral, “Stark” Statute, 42 U.S.C. 1395nn, prohibits a physician, from making referrals for certain designated health services to an entity in which the physician, or a member of his/her family, has an ownership/investment interest or with which he/she has a compensation arrangement. Penalties for violation:

• Up to $15,000 for each claim submitted in violation of the law

• Up to $100,000 for each “scheme” that violates the law• Penalties of up to 3 times the amount claimed• Exclusion from Federal health care programs

MCHD has it’s own Anti-Fraud Strategy. Let’s take a closer look…

I suspect Fraud, now what do I do?

That’s a very important question, Ming.

Reporting Fraud Anonymous Hotline :1-877-706-4445 Email:

reporthealthfraud@co.marion.or.us Mail, submit or fax the Fraud, Waste

and Abuse Referral Form located on both the MCHD Internet and Intranet) to:

Mail: Marion County Health DeptAttn: FWA Compliance

Officer3180 Center St NESalem, OR 97301

Fax: (503) 364-6552

Back

Additional Contacts Medicaid Fraud Control Unit

(971) 673-1880

515 SW 5th Ave Suite 410

Portland, OR 97301

DHS Fraud Investigation Unit

(503) 378-6826

PO Box 14150

Salem, OR 97309

MCHD Compliance Officer

Remember: there is never a ‘bad’ referral and failure to report may result in disciplinary action.

Employee Rights and Responsibilities

Have the right to remain anonymous To the extent allowed by the law Protection from retaliation

Employees are obligated to report potential Fraud, Waste or Abuse

Failure to report could require MCHD to pay excessive fines and potentially be excluded from Federal health care programs

Back

MCHD Compliance OfficerDivision Director:

Roy Deede (503) 588-5405

His duties: Represent the Health Department on external

Fraud and Abuse Committees May act as the lead on internal or external

investigations of Fraud, Waste and Abuse

Back

Maintain appropriate and legible documentation

Understand which services are covered and which are not covered Don’t submit

duplicate claims

How do I make sure I stay in compliance?

Record start and stop times accurately

Avoid ‘up-coding’ or ‘down-coding’

Cooperate with any audits or reviews

Comply with State licensure regulations

As your supervisor, feel free to contact me if you have questions about Fraud, Waste or Abuse or reporting requirements. I’ll be glad to help!

YEAH!

YEAH! YEAH!

Together, we can eliminate Fraud, Waste and Abuse!

Quiz Instructions

1. You have just completed the Fraud, Waste, and Abuse training. To receive credit please complete the 10 question quiz by clicking on the link below.

2. It is very important that you enter your first and last name at the end of the quiz to receive credit.

3. Your results are electronically submitted. You do not need to print them .

Click HERE to proceed to the quiz