Blue Cross of Idaho

Medicare Advantage ProviderFraud, Waste and Abuse

Training

Fall 2009

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

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

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.

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

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.

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.

FCA Penalties

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.

Examples of FCA Violations

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.

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.

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.

Examples of AKS Violations

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.

Exclusion List Screening

Record Retention• Providers must maintain service, prescription,

claim, and billing records for ten years.

• Records are subject to CMS or contractor audit.

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.

Examples of Potential Provider 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

Examples of Potential Plan Sponsor 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.

Examples of Potential Beneficiary FWA

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.

FWA Prevention

Reporting FWA Concerns

ConclusionThank 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.