2015 General Compliance and
Fraud, Waste and Abuse (FWA)
Training
2015 Annual Training
1
FRAUD WASTE AND ABUSE (FWA)
FRAUD, WASTE AND ABUSE (FWA)
EXECPTION‐NOTICE
 There is one exception to the FWA training and There is one e ception to the FWA training and education requirement. Regulations effective June 7, 2010 implemented a “deeming” exception which p
g
p
exempts FDRs who are enrolled in Medicare Parts A or B from annual FWA training and education. Therefore, if tit i di id l i if an entity or an individual is enrolled in Medicare ll d i M di
Parts A or B, the FWA training and education requirement has already been satisfied. If you are q
y
y
unsure if this “deeming” exception applies to you please contact an IEHP Compliance Manager at compliance@IEHP.org
li
IEHP
f for more information. i f
i 2
Overview & Objectives
 What: Compliance, Fraud, Waste, & Abuse (FWA) program requirements
 Inform you about what you need to be aware of and implement into your practices
 Meet the regulatory requirements for training and education
 Provide information on laws pertaining to fraud, waste, and abuse
 Why: Compliance programs help raise awareness and provide mechanisms
to detect, prevent, and correct FWA
 Provide information on how to report fraud, waste, and abuse
 You must report non compliance and suspected or known FWA activities to a
compliance officer or compliance department representative
 How: Training and education
 You must demonstrate training through completion of this training or an equivalent
training
 You must be able to ensure that training was completed for each of your staff and
that you have a process for new hires.
 Training to be completed by 03/31/2015
3
PREVENTION
4
Why Do I Need Training?
 Every year millions of dollars are improperly spent because of fraud, waste, and abuse. It affects everyone,
including YOU including YOU.  This training will help you detect, correct, and prevent fraud, waste, and abuse. YOU are part of the solution.
5
Where Do I Fit In?
Where Do I Fit In?
 As a First Tier, Downstream, or Related Entity (FDR)
who
h provides
id health
h l h or administrative
d i i
i services
i
to a
Part C or Part D IEHP Member
 You are required to comply with all applicable statutory,
statutory
regulatory, and other Part C or Part D requirements,
including adopting and implementing an effective
compliance program
 You have a duty to the Medicare Program to report any
violations of laws of which you may be aware
 You have a duty to follow your organization’s Code of
Conduct that articulates your and your organization's
commitment to standards of conduct and ethical rule of
behavior.
6
R
i
t
Requirements
 The Social Security Act and CMS regulations and guidance govern the Medicare program, including parts C and D.  Part C and Part D sponsors must have an effective compliance program which includes measure to prevent, detect and correct Medicare non compliance as well as detect and correct Medicare non‐compliance as well as measures to prevent, detect and correct fraud, waste, and abuse.
 IEHP must have an effective training program for employees, managers, and directors, as well as their first tier, downstream, and related entities. (42 C.F.R. §422.503 and 42 C.F.R. §423.504
7
An Effective Compliance Program
An Effective Compliance Program
 Must at a minimum, include the 7 core compliance program requirements  Written compliance policies, procedures, and standards of conduct
 A Compliance Officer, Compliance Committee, and High Level Oversight
 Effective training and education
Effecti e training and education
 Effective lines of communication
 Well publicized disciplinary standards
p
p
y
 Effective system for routine monitoring and identification of compliance risks
 Procedures and system for prompt response to compliance issues 8
LAWS YOU NEED TO KNOW ABOUT
9
Civil Fraud Civil Fraud Claims Act
Prohibits:  Presenting a false claim for payment or approval;  Making or using a false record or statement in support of a false claim;  Conspiring to violate the False Claims Act;  Falsely certifying the type/amount of property to be used by the Government; G
 Certifying receipt of property without knowing if it’s true;  Buying property from an unauthorized Government officer; and  Knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay the Government.  31 United States Code § 3729‐3733 10
Laws
The following slides provide very high level information about specific laws. For details about the specific laws, such as safe harbor provisions consult the applicable such as safe harbor provisions, consult the applicable statute and regulations concerning the law. 11
Ph sician Self-Referral
Self Referral
Physician
Prohibition Statute (Stark Law)
 The Physician Self-Referral Prohibition Statute, commonly referred to
as the “Stark Law,” prohibits:
 A physician from making a referral for certain designated health services
to an entity in which the physician (or a member of his or her family) has
an ownership/investment interest or with which he or she has a
compensation arrangement (exceptions apply).
 Stark Statute Damages and Penalties
 Medicare claims tainted by an arrangement that does not comply with
Stark are not payable. Penalties may include up to a $15,000 fine for
each service provided or up to a $100,000 fine for entering into an
arrangement or scheme.
42 United States Code §1395nn
12
A i Ki kb k S
Anti‐Kickback Statute Prohibits:
Knowingly and willfully soliciting, receiving, offering or
paying remuneration (including
(
any kickback, bribe,
or rebate) for referrals for services that are paid in
whole or in part under a federal health care program
(which includes the Medicare program).
42 United States Code §1320a-7b(b)
13
Health Insurance Portability
and Accountability Act (HIPAA)
Health Insurance Portability and Accountability Act of
1996 (P.L. 104-191)
 Created greater access to health care insurance
insurance,
protection of privacy of health care data, and
promoted standardization and efficiency in the
h lth care iindustry.
health
d t
 Safeguards to prevent unauthorized access to
protected health care information.
 As an individual who has access to protected health
care information, you are responsible for adhering to
HIPAA.
HIPAA
14
DETECTION
15
UNDERSTANDING
UNDERSTANDING FRUAD, WASTE, AND ABUSE
In order to detect fraud, waste, and abuse you need to know the Law
 CRIMINAL FRAUD: Knowingly and willfully CRIMINAL FRAUD K
i l d illf ll executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program; or 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. 18 United States Code §1347 16
Waste and Abuse
 WASTE: Overutilization of services or other practices that directly or indirectly result in unnecessary costs to h di
l i di
l l i the Medicare Program.  Abuse: Includes actions that may directly or indirectly result in unnecessary costs to the Medicare Program. 17
Differences Between
Differences Between Fraud, Waste, and Abuse
 Criminal Fraud: Intentionally submitting false information to the government or a government contractor in order to get money or a benefit. Person has intent to obtain payment or benefit and the p y
knowledge that their actions are wrong.
 Waste and Abuse: May involve obtaining an improper payment, but does not require the same intent and knowledge.
knowledge
18
Quick Reference Chart
Examples of Fraud ¹
Examples of Abuse ²
Examples of Waste • Billing for services not
furnished
• Billing for services at a higher
rate than is actually justified
• Soliciting,
Soliciting offering or
receiving a kickback, bribe or
rebate
• Deliberately misrepresenting
services, resulting in
unnecessary cost, improper
payments or overpayment
• Violations of the physician
self-referral
self
referral ((“Stark”)
Stark )
prohibition
• Charging in excess for
services or supplies
• Providing medically
unnecessary services
• Providing services that do
not meet professionally
recognized standards
• Consistently billing
Medicare based on a
higher fee schedule than
is used for patients not on
Medicare
• Over-utilization
Over utilization of
services
• Misuse of resources
Source: 1 Medicare Physician Guide: A Resource Source: 1. for Residents, Practicing Physicians, & Other Health Care Professionals, 10th
Edition (10/08)
2. CMS Medicare Fraud and Abuse Web‐based Training (April 2007) 19
Medicare Advantage Org /
Part D Plan – FWA
(examples)
Failure to Provide Medically Necessary Services
 Medically necessary items or services fail to be provided which the
organization is required to provide (under law or under the contract) to a Part
C or Part D plan enrollee, and that failure adversely affects (or is likely to
affect) the enrollee.
Inappropriate Enrollment / Disenrollment
 Improperly reporting enrollment and disenrollment data to CMS to inflate
prospective payments. For example, Sponsor fails to effect timely
di
disenrollment
ll
t off b
beneficiary
fi i
ffrom CMS systems
t
upon b
beneficiary’s
fi i ’ request.
t
20
MAO / PDP PLAN – FWA
(examples continued)
M k ti Schemes
Marketing
S h
 Offering beneficiaries a cash payment as an encouragement to enroll in a Plan.
 Gifts that are above the CMS allowed $15 exemption, gifts convertible to cash,




or “meals”
meals (anything beyond the light snacks that guidance allows)
Unsolicited door-to-door marketing.
Use of unlicensed agents, where required by state law.
Enrollment of individual in a Medicare Plan without knowledge or consent
consent.
Stating that a marketing agent / broker works for or is contracted with the Social
Security Administration or CMS
Formulary or Coverage Decisions
 Making inappropriate formulary decisions or coverage decisions based on
inducements.
 Delaying access to necessary covered drugs.
21
Beneficiary (Member) FWA
(examples)
The following are examples of fraud by Medicare beneficiaries (members):
Identity Theft
 Using a different member’s I.D. card to obtain prescriptions, services, equipment, supplies,
doctor visits, and / or hospital stays.
• Individuals who “loan”
loan their I.D.
I D card face significant risks to care (i
(i.e.,
e wrong blood type
in their medical record)
Doctor Shopping
 Visiting several different doctors to obtain multiple prescriptions for painkillers or other drugs
might point to an underlying scheme (stockpiling or black market resale).
Improper Coordination of Benefits
 Beneficiary fails to disclose multiple coverage policies, or leverages various coverage
policies to “game”
game the system.
system
Prescription Fraud
 Resale of Drugs on Black Market.
• Falsely reporting loss or theft of drugs or feigns illness to obtain drugs for resale on the
black market.
 Falsifying or modifying a prescription.
22
Provider FWA (examples)
Kickbacks: Soliciting, offering, or receiving a kickback, bribe, or rebate
 For example, paying for a referral of patients in exchange for the ordering of
diagnostic tests and other services or medical equipment.
Inducements: Such as copay waivers or free services to retain patients
 Caution required when dispensing free medications from pharmacy
companies. Should have consistent policies reviewed by legal.
False
F
l Claims:
Cl i
Billi for
Billing
f services
i
nott rendered
d d or supplies
li nott provided
id d
 For example, billing for appointments the patient failed to keep.
 Billing for a “gang visit” in which a physician visits a nursing home and bills for
20 nursing home visits without furnishing any specific service to individual
patients.
ti t
Double billing:
 Such as billing
g both Medicare and the beneficiary,
y, or billing
g both Medicare
and another insurer.
23
Provider FWA
(examples continued)
Date of Service: Misrepresenting the date services were rendered
rendered.
Identity: Misrepresenting the identity of the individual who received the
services.
Rendering Provider: Misrepresenting who rendered the service.
 Such as billing for an office visit when the only services were an injection
by a medical assistant.
False Coding or Services: Billing for a covered item or service when the
actual item or service provided was a non-covered item or service.
Unnecessary Care: Providing unnecessary procedures or prescribing
unnecessary drugs.
 This includes appropriate review that patients meet the Certification of
Medical Necessity requirements
24
Provider FWA
(examples continued)
Altering Medical Records: Erroneous or false or late entries in the medical
record.
 Late entry in the record, such as an addendum must be entered
sequentially in the record according to coding rules
Delay in Care: Delay in authorizing or providing access to medically necessary
care.
 Physician office errors in non-timely submission of auth requests can
result in delay in care.
Patient Dumping: Encouraging disenrollment for high cost patients to defer
costs and care to original Medicare when in a capitated model.
25
Provider Prescription Drug
FWA (examples)
Over Prescribing: Over-prescription or false prescription of narcotics
Selling Prescriptions: Participating in illegal remuneration schemes
schemes, such as
selling prescriptions.
Inducements: Prescribing medications based on illegal inducements, rather
than the clinical needs of the patient
patient.
 Such as pharmacy manufacturer incentives or discounted services
Not Medically
y Necessary:
y Writing
gp
prescriptions
p
for drugs
g that are not
medically necessary, often in mass quantities, and often for individuals that are
not patients of a provider.
26
Provider Prescription Drug
FWA (examples continued)
Theft – Identity Fraud: Theft of a prescriber’s Drug Enforcement Agency
(DEA) number, prescription pad, or e-prescribing
e prescribing log-in
log in information.
Falsifying Justification: Falsifying information in order to justify coverage,
such as ruling out lower cost generics
Dilution or Illegal Importation: Diluted substances or substituted provider
administered drugs that may be either less than effective or contraindicated or
illegal importation of drugs used or sold as covered drugs.
27
Pharmacists FWA
(examples)
False Billing:
 Billing for prescriptions that are never picked up.
 Billing
Billi ffor a b
brand
d name when
h generics
i are di
dispensed.
d
 Billing for non-covered prescriptions as covered items.
Splitting prescriptions:
 For example, by splitting a 30-day prescription into 4 7-day prescriptions to get
additional copayments and dispensing fees.
Steering & Kickbacks:
 Engaging in unlawful remuneration, such as remuneration for steering a beneficiary
toward a certain plan or drug, or for formulary placement.
Overcharging:
 Failing to offer negotiated prices.
 Collecting higher copays than specified.
Short Fills:
 Prescription drug shorting: Provides less than the prescribed quantity and bills for the
fully-prescribed amount.
28
Pharmacists FWA
(examples continued)
Bait and switch pricing:
 When a beneficiary
f
is led to believe that a drug will cost one price, but at the
point of sale, the beneficiary is charged a higher amount.
Forging and altering prescriptions:
 Modification to scripts or dosage
 Modifications to allowable refills
Expired Drugs or Tainted Drugs:
 Dispensing drugs that are expired or have not been stored or handled in
accordance with manufacturer and FDA requirements.
Manipulating the True Out-of-Pocket cost:
 When a pharmacy falsely pushes a beneficiary through the coverage gap, into
catastrophic coverage before they are eligible,
eligible or keeps a beneficiary in the
coverage gap so that catastrophic coverage never occurs.
29
Pharmaceutical Wholesaler
FWA (examples)
Counterfeit Drugs:
 Counterfeit and adulterated drugs through black and grey market purchases.
 This includes but is not limited to fake, diluted, expired, and illegally
imported drugs
drugs.
Diverters:
 Brokers who illegally
g yg
gain control of discounted medicines intended for p
places
such as nursing homes, hospices and AIDS clinics. Diverters take the
discounted drugs, mark up the prices, and rapidly move them to small
wholesalers. In some cases, the pharmaceuticals may be marked up six times
before being
g sold to the consumer.
Inappropriate documentation of pricing information:
 Submitting false or inaccurate pricing or rebate information to, or that may be
used by any, Federal health care program.
30
Pharmaceutical Manufacturer
FWA (examples)
Kickbacks, inducements, and other illegal remuneration:
 Inappropriate marketing and/or promotion of products.
 Inducements offered if the purchased products are reimbursable by any of
the federal health care programs such as discounts, inappropriate product
support services, educational grants, research funding, etc.
Records Management: Lack of integrity of data to establish payment and/or
determine reimbursement, such as missing or inappropriate documentation of
pricing information.
Formulary and formulary support activities:
 Inappropriate relationships with Pharmacy & Therapeutic Services Committee
Members.
 Payments to PBMs for formulary placement.
31
Pharmaceutical Manufacturer
FWA (examples continued)
Inappropriate relationships with physicians:
 “Switching” arrangements, when manufacturers offer physicians cash
payments
p
y
or other benefits each time a p
patient’s p
prescription
p
is changed
g to the
manufacturer’s product from a competing product.
 Incentives offered to physicians to prescribe medically unnecessary drugs.
 Improper entertainment or incentives offered by sales agents.
Off Label Use: Illegal promotion of off-label drug usage.
Billing for Free Samples: Illegal usage of free samples to physicians knowing
and
d expecting
ti th
those physicians
h i i
tto bill th
the ffederal
d lh
health
lth care programs ffor th
the
samples.
32
REPORTING
33
Reporting
Reporting Fraud, Waste, and Abuse
 Do not be concerned about proving whether it is fraud, waste, or abuse.  You do not have to prove FWA to report it, you only Y d h FWA i l need to suspect it to report it!
 Report any concerns to your Compliance Department or the IEHP Compliance Department .  IEHP’s Compliance Department will investigate and IEHP s Compliance Department will investigate and make the proper determination. 34
Required Reporting
Violations of the code of conduct, ethics or any fraud, waste or abuse must be
reported.
p
Not reporting
p
g fraud or suspected
p
fraud can make yyou a p
party
y to a case
by allowing the fraud to continue.
 Everyone is required to report suspected instances of fraud, waste, and
abuse which is clearly stated in the IEHP Code of Conduct
 Your organization must have internal mechanisms for reporting compliance &
FWA concerns (i.e., your Compliance Officer or a Compliance Hotline)
 IEHP may not retaliate against you for making a good faith effort in reporting.
 Fraud or suspected fraud may be reported anonymously to IEHP
IEHP, your internal
reporting mechanisms, or MEDIC at 1-800-MEDICARE
Refer to the following slide regarding IEHP compliance reporting options
35
Required Reporting (continued)
Health Plan Hotline Information
 IEHP Compliance
Hotline
 IEHP Compliance
Department Email
 IEHP Compliance
C
li
Department Fax #
Mailing
Mailing Address
 866-355-9038
 compliance@iehp.org
 909-477-8536
909 477 8536
 Compliance Officer
IEHP
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
91729 1800
36
Required Reporting (continued)
 Everyone has the right and responsibility to report possible
fraud, waste, or abuse.
 REMEMBER: You may report anonymously and retaliation is
prohibited when you report a concern in good faith.
 WHEN IN DOUBT: Call IEHP fraud, waste, and abuse Hotline or
the Compliance
p
Department
p
IEHP Compliance Hotline 866‐355‐9038
37
PREVENTION IS KEY
38
PREVENTION
 Make sure you are up‐to‐date with laws, g
p
regulations, policies  Ensure you coordinate with other payers.  Ensure data/billing is both accurate and timely
 Verify information provided to you
V if i f
ti id d t  Be on the lookout for suspicious activity
39
Distribution of Compliance Policies
& Procedures and Standards of Conduct
 The distribution of compliance policies, procedures and Standards of
Conduct is essential to effectiveness.
 CMS expects Sponsors to ensure that its employees and employees of
FDRs, as a condition of employment, read and agree to comply with all
written compliance policies, procedures and Standards of Conduct
within 90 days of the date of hire, when there are updates to the
polices and procedures, and annually thereafter.
 IEHP shall demonstrate to CMS that all employees and employees of
FDRs meet these requirements through the distribution of training
materials and tracking of attestation documentation.
40
Best Practices for
Preventing FWA
 Develop an effective compliance program tailored to your organization
 Perform regular internal audits & monitoring against regulatory standards
 Review for outliers / deviations from the norm
 Confirm UM decisions, coding and claims are timely / accurate.
 Confirm prompt refunds of overpayments (within 60 days)
 Ensure effective training & education is occurring, minimally for:
 New hires within 90 days and annually for all Staff
 Confirm training occurs on HIPAA Privacy and breach reporting
 Provide training updates and policy updates when regulations change
 Provide refresher training on policies as part of any Corrective Action Plan
41
Best Practices for
Preventing FWA
 Establish effective lines of communication with colleagues and staff
members.
 Ensure ALL staff are aware of how to report potential/actual FWA or
compliance concerns
 Take action! If you identify a FWA issue – you must report it.
 Ask about potential compliance issues during exit interviews
 Remember: The Provider, Hospital, IPA and the MAO or PDP plan are each
ultimately responsible for all claims and encounters that are submitted for
payment with your name on the claim.
42
Web FWA Resources
Federal government web sites are sources of information regarding detection,
correction,
ti
and
d prevention
ti off ffraud,
d waste,
t and
d abuse:
b
Resource
Link
Department of Health and Human Services Office of Inspector General: http://oig.hhs.gov/fraud/hotline/
Centers for Medicare and Medicaid Services (CMS):
http://www.cms.hhs.gov/FraudAbuseforProfs/
CMS Information about the Physician Self Referral Law:
www.cms.hhs.gov/PhysicianSelfReferral
CMS Prescription Drug Benefit Manual
g
http://www.cms.hhs.gov/PrescriptionDrugCovContr
g
g
a/Downloads/PDBManual_Chapter9_FWA.pdf
Medicare Learning Network (MLN) Fraud & Abuse Job Aid
https://www.cms.gov/Outreach‐and‐
Education/Training/NationalMedicareTrainingProgr
am/Training‐Library‐Items/CMS1248271.html
43
CORRECTION
44
Correction
Identified fraud, waste, or abuse must be promptly corrected. Correcting the problem saves the government money and ensures you are in compliance with CMS requirements. 45
H D IC
I
?
How Do I Correct Issues?
 Once issues have been identified, a plan to correct them needs to be developed. p
 Consult your Compliance Officer or the IEHP Co su you Co p a ce O ce o
e
Compliance Officer to find out the process for corrective action plan (CAP) development.  The actual CAP is going to vary, depending on the g g
g
specific circumstances. 46
Remember to Protect
Confidentiality
Carefully handle all data that can identify the member:
 This includes any of the elements noted below:
 Social Security , Medicare ID (HICN), or Health Plan Member I.D.
number
 Member Name,, Address,, Phone,, Date of Birth
 Medical Record Number / Patient Account Number
 Review your internal HIPAA training.
 Review your internal policies and practices for reporting of any security
and privacy breach to your respective HIPAA security or privacy officer.
 Reporting MUST be done immediately if you become aware of or
suspect a breach may have occurred
occurred.
47
Entities / Individuals
Excluded from Medicare or
Government Programs
 Compliance programs must carefully monitor to ensure payments go to proper
entities. This includes payments to employees, providers, contractors and
subcontractors.
subcontractors
 Medicare Advantage Organizations, Part D Sponsors and contracted entities
are required to review the Department of Health and Human Services (DHHS)
OIG List
Li t off Excluded
E l d d Individuals
I di id l and
dE
Entities
titi (LEIE) and
d th
the G
Generall S
Services
i
Administration (GSA) System for Award Management (SAM) prior to the hiring
or contracting of any new employee, temporary employee, volunteer,
consultant,, governing
g
g body
y member,, or FDR,, and monthlyy thereafter to ensure
that none of these persons or entities are excluded or become excluded from
participation in federal programs.
 OIG List of Excluded Individuals/Entities (LEIE):
htt //
http://exclusions.oig.hhs.gov/search.html
l i
i hh
/
h ht l
 GSA System for Award Management (SAM): https://www.sam.gov
48
Exclusion
No Federal Health Care Program payment may be
made for any item or service furnished,
furnished ordered,
ordered or
prescribed by an individual or entity excluded by the
Office of Inspector General.
42 U.S.C. §1395(e)(1)
42 C.F.R. §1001.1901
49
CONSEQUENCES
50
Consequences of Committing
Consequences of Committing Fraud, Waste, and Abuse
The following are potential penalties. The actual
consequence depends on the violation.
 Civil
C Money Penalties
 Criminal Conviction/Fines
 Civil
Ci il P
Prosecution
ti
 Imprisonment
 Loss
L
off Provider
P id Li
License
 Exclusion from Federal Health Care programs
51
Penalties and
Consequences of FWA
Repayment / Restitution is just the start
 False Claims Act : $5,500 up to $11,000 per claim plus up to triple the
amount of the claim in damages
 Criminal and/or civil prosecution & imprisonment
 Suspension/loss of provider license / Medicare Provider number
 Exclusion from the Medicare program / Government Contracts
 Anti-Kickback Statute Penalties
 Fine of up to $25,000
 Imprisonment up to five (5) years
 Or both, fine and imprisonment
52
Penalties and
Consequences of FWA (continued)
 Criminal Fraud penalties
 If convicted, the individual may be fined, imprisoned, or both.
 If the violations resulted in death, the individual may be imprisoned for any term of
years or life
 18 United States Code §1347
 HIPAA Privacy and Security Breaches
 Payment for credit monitoring and restoration services
 Various State and Federal Monetary penalties
 Health Information Technology for Economic and Clinical Health
(HITECH) Act Penalties

Penalties up to $1.5 Million for all violations of an identical provision
(Note: the Patient Protection and Affordable Care Act (PPACA) may provide for
increased penalties and restitution amounts)
53
CASE SCENARIOS
54
Scenario #1
A person comes to your pharmacy to drop off p
p
y
a prescription for a beneficiary who is a “regular” customer. The prescription is for a q
y
controlled substance with a quantity of 160. This beneficiary normally receives a quantity p
p
of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step? 55
S
i #1 ( ti
d)
Scenario #1 (continued)
A. Fill the prescription for 160 B. Fill the prescription for 60 C. Call the prescriber to verify quantity D. Call IEHP compliance department ll
l
d
E C ll l f
E. Call law enforcement 56
Scenario #1 Answer
Answer: C Call the prescriber to verify that the quantity should be 60 and not 160. Your next step should be to immediately call the IEHP Compliance Hotline. IEHP Compliance Department will provide the next course of action. IEHP C
IEHP Compliance Hotline 866‐355‐9038
li
H tli 866
8
57
S
i #2
Scenario #2
Your job is to submit risk diagnosis to CMS for p p
purposes of payment. As part of this job you p y
p
j y
are to verify, through a certain process, that the data is accurate. Your immediate supervisor tells you to ignore the sponsor’s p
process and to adjust/add risk diagnosis codes j
g
for certain individuals. What do you do? at do you do?
58
S
i #2 ( ti
d)
Scenario #2 (continued)
A. Do what is asked of you by your immediate A
Do what is asked of you by your immediate supervisor B. Report the incident to the compliance department (via compliance hotline or other mechanism) C Discuss concerns ith immediate super isor C. Discuss concerns with immediate supervisor D Contact law enforcement D. Contact law enforcement 59
S
i #2 A
Scenario #2 Answer
A
Answer: B B Report the incident to the compliance department (via compliance hotline or other mechanism) li
h tli th h i ) The compliance department is responsible for investigating and taking appropriate action Your investigating and taking appropriate action. Your sponsor/supervisor may NOT intimidate or take retaliatory action against you for good faith reporting concerning a potential compliance, fraud, waste, or abuse issue. 60
Scenario #3 You are in charge of payment of claims submitted from providers. You notice a certain diagnostic provider (“Doe Diagnostics”) has requested a id (“D Di
i ”) h d substantial payment for a large number of members. Many of these claims are for a certain procedure You Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize that Doe g
p
Diagnostics’ claims far exceed any other provider that you reviewed. What do you do? 61
S
i #3 (
i
d)
Scenario #3 (continued)
A. Call Doe Diagnostics and request additional information for the claims B. Consult with your immediate supervisor for next steps C. Contact the compliance department D. Reject the claims E. Pay the claims 62
S
i #3 A
Scenario #3 Answer
Answers B or C Consult with your immediate supervisor for next steps or Contact the compliance department Either of these answers would be acceptable. You do not Either of these answers would be acceptable
You do not want to contact the provider. This may jeopardize an investigation. Nor do you want to pay or reject the claims until further discussions with your supervisor or the til f th di
i
ith i th compliance department have occurred, including whether y
additional documentation is necessary. 63
Scenario #4
You are performing a regular inventory of the controlled substances in the f h ll d b
i h pharmacy. You discover a minor inventory discrepancy. What should you do? 64
S
i #4 (
i
d)
Scenario #4 (continued)
A. Call the local law enforcement B. Perform another review C Contact your compliance department C.
D. Discuss your concerns with your supervisor E. Follow your pharmacy’s procedures 65
Scenario #4 Answer
Answer E
Follow your pharmacy’s procedures y
p
y p
Since this is a minor discrepancy in the inventory you are not required to notify the DEA. You should follow your t i d t tif th DEA Y h ld f ll pharmacy’s procedures to determine the next steps. 66
Thank
Th
k you ffor participating
ti i ti and
d
expanding compliance program
effectiveness
ff ti
by
b ensuring
i you and
d your
organization incorporate the information
i t your individual
into
i di id l compliance
li
program
and business practices.
67