Fraud, Waste & Abuse
TRAINING COURSE
As of May 2014
Click here to
enter the course.
Provided by Health
Care Service Corporation
& its subsidiaries
The Bottom
Line
Who Am I In
the Big Picture
WHO?
The Action Steps
LAW?
Know
the Law
The Bottom
Line
Who Am I In
the Big
Picture?
The Action
Steps
Know the
Law
The Bottom Line
Who Am I In the Big Picture?
The Action Steps
Know the Law
Back / Forward
Home
CMS requires training
for
New & Existing Employees
who
Work on a government contract
THE BOTTOM LINE
1. Written Policies, Procedures and Standards of Conduct
2. Compliance Officer, Compliance Committee and High Level Oversight
3. Effective Training and Education
4. Effective Lines of Communication
5. Well Publicized Disciplinary Standards
6. Effective System for Routine Monitoring and Identification of
Compliance Risks
7. Procedures and System for Prompt Response to Compliance Issues
THE BOTTOM LINE
1. Written Policies, Procedures and Standards of Conduct
2. Compliance Officer, Compliance Committee and High Level Oversight
3. Effective Training and Education
4. Effective Lines of Communication
5. Well Publicized Disciplinary Standards
6. Effective System for Routine Monitoring and Identification of
Compliance Risks
7. Procedures and System for Prompt Response to Compliance Issues
Click here to view Chapter 9
Click here to view the Federal Sentencing Guidelines
Click here to view HCSC’s Compliance Program
THE BOTTOM LINE
Click on the
magnifying glass
Every patient has
the same diagnosis
Every patient has
the same diagnosis
Billing for more
than 24 hours/day
Every patient has
the same diagnosis
Billing for more
than 24 hours/day
Billing for Individual,
Group & Family Therapy
for most clients
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
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
HCSC
1
Know and abide by terms of
government contract
2
Stay true to your company’s
code
Click here to view HCSC’s Code of Conduct. Save
this page to your favorites.
fully and truthfully
3 Cooperate
with government agencies
RESPONSIBILITIES
INDIRECTLY
DIRECTLY ON
GOVERNMENT
PROGRAM
4
Report improper payment to
government officials
Violations regarding gifts to government employees
can result in serious consequences
5
Comply with the laws that impact
government programs
RESPONSIBILITIES
6
Avoid conflicts of interest
GOOD
FOR ME
GOOD FOR
MY
COMPANY
RESPONSIBILITIES
7
Recognize and
report fraud,
waste & abuse
RESPONSIBILITIES
HCSC/HISC/GHS
Corporate Integrity Compliance Program
WHO AM I?
TOM LUBBEN
HCSC’s Chief
Compliance &
Privacy Officer
HCSC/HISC/GHS
Corporate Integrity Compliance Program
WHO AM I?
TOM LUBBEN
HCSC’s Chief
Compliance &
Privacy Officer
HCSC/HISC/GHS
Corporate Integrity Compliance Program
Government
Programs
Compliance
WHO AM I?
KIM GREEN
Government
Programs
Compliance
HCSC’s
Government Programs
Compliance Officer,
Medicare Compliance
Officer
Specific policies
Oversees compliance
Government contracts
WHO AM I?
HCSC/HISC/GHS
Monitor & Audit
First Tier
Downstream
Independent
Practice
Associations
Plan Sponsor
FDR RESPONSIBILITIES
Call
Centers
Health Services/
Hospital Groups
Fulfillment
Vendors
Field
Marketing
Organization
Credentialing
 Monitor and audit themselves & downstream
Providers
Downstream
Radiology
Hospitals
Mental
Health
Agents
Pharmacy
 Implement policies & procedures
PBM
Quality
Assurance
Firm
Claims
Processing
Firm
Providers
Providers
 Comply with
the law
 Set high ethical standards
 Report suspected FWA to the Plan Sponsor
WHO AM I?
HCSC/HISC
Plan Sponsor
First Tier
Independent
Practice
Associations
Downstream
Providers
Downstream
Call
Centers
Radiology
Health Services/
Hospital Groups
Fulfillment
Vendors
Field
Marketing
Organization
Hospitals
Mental
Health
Agents
Providers
Providers
Credentialing
Pharmacy
PBM
Quality
Assurance
Firm
Claims
Processing
Firm
WHO AM I?
HCSC
Detect
Report
Correct
Prevent
Detect
Fraud Waste Abuse
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
ACTION STEPS
Detect
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
ACTION STEPS
Detect
Fraud
HCSC
$43,904
FRAUD
ACTION STEPS
Law Litmus Test
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.
● Click the box next to
the correct answer.
That’s right!
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.
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.
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.
Detect
Fraud Waste Abuse
Intentional
Not intentional
UNNECESSARY COSTS
ACTION STEPS
Detect
Waste Abuse
• Overutilization of services
• Request for payment
• Generally not considered to
• No legal entitlement
be criminally negligent
• Misuse of resources
• Not knowingly
misrepresented facts
ACTION STEPS
Detect
Which prescription is suspicious?
NO, not this one.
ACTION STEPS
Detect
CORRECT!
It appears that the date on this
prescription has been altered.
ACTION STEPS
Detect
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.
ACTION STEPS
Detect
Which scenario is suspicious?
This is a
simple case of
tonsillitis. You’ll
be out of the
hospital today.
I’m
going
to run a
series
of 12
tests:
an
MRI,
blood
work,
CAT
Scan…
All of
that for
tonsillitis
?
NO, not this one.
ACTION STEPS
Detect
CORRECT!
I’m
going Does
to run a
series
of 12
tests:
an
MRI,
blood
work,
CAT
Scan…
the treatment match the
diagnosis?
All of
that for
tonsillitis
?
ACTION STEPS
Detect
PHYSICIAN
FRAUD CLUES
• Bills for services not
provided
• Prescriptions for a higher
quantity than medically
necessary for the condition
ACTION STEPS
Detect
Read the sales scenarios below.
Which one is suspicious?
If you sign up
for Medicare
today and
make Dr.
Popper your
primary
physician,
you’ll get a
$100 gift card.
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.
NO, not this one.
ACTION STEPS
Detect
CORRECT!
If you sign up to sign
Offering monetary rewards
for Medicare
up for a government
health plan
today and
make Dr.
Popper your
primary
physician,
you’ll get a
$100 gift card.
ACTION STEPS
Law Litmus Test
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
● Click the box next to
the correct answer.
THAT’S RIGHT!
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.
Detect
Report
Report
ACTION STEPS
Report
What’s suspicious about these claims?
Multiple almost identical
Hm…these
claims are all
the same! All
submitted by
XYZ
Diagnostics
on March 31.
One provider / Same day
Exceed normal costs
ACTION STEPS
Report
“Our Company is committed to the policy
that all employees have an obligation to
report problems or concerns involving
ethical or compliance violations…without
fear of retaliation.”
Click here to view HCSC’s Code of Conduct.
HCSC CODE
ACTION STEPS
Report
Reporting is everyone’s responsibility.
Plan Sponsor
ACTION STEPS
Report
Report
Employees of
Plan Sponsor
HCSC/HISC
• Talk to a Manager or Supervisor
• Report through the Website or Hotline
• Call the Medicare Compliance Officer
FDR Employees
• Talk to a Manager or Supervisor
• Call Your Ethics/Compliance Help Line
• Report through the Sponsor
Beneficiaries
• Call the Sponsor’s compliance hotline
• Make a report through Sponsor’s website
• Call 1-800-Medicare
ACTION STEPS
LAW LITMUS TEST
Which of the following is also known as
the Physician Self-Referral Law?
Stark Statute
Exclusion
NO, but we’ll cover this shortly.
HIPAA
NO, but we’ll cover this shortly.
Click the box next to
the correct answer
That’s right!
The Stark Statute is also known as the
Physician Self-Referral Law.
A physician is prohibited from making a
referral for health services to an entity in
which the physician or a relative may have
an ownership or compensation interest
Report
Correct
Correct
Immediate Reporting
Quick Correction
KIM GREEN
HCSC’s
Government Programs
Compliance Officer,
Medicare Compliance
Officer
ACTION STEPS
Correct
Which is the correct response?
I found a
drug listed
on my
Explanation
of
Benefits
that I was
never
given.
No. The member’s
concern should be
reported, not
ignored. This is
possible fraud.
ACTION STEPS
CORRECT!
Correct
What should she do now?
Call her company’s fraud hotline
Contact her compliance officer
Notify her supervisor
Call the pharmacy that filled the
member’s prescription
Call the member’s provider
No, the CSR should
not contact the
member’s pharmacy.
No, the CSR should
not contact the
member’s provider.
ACTION STEPS
Correct
CORRECT!
Call her company’s fraud hotline
Contact her compliance officer
Notify her supervisor
ACTION STEPS
Correct
What happens after the suspected fraud is reported?
One of our
members called to
report an error on
his EOB…
Correct clerical error
Assigned to an investigator
ACTION STEPS
Correct
$200,000.00
REAL LIFE
ACTION STEPS
Law Litmus Test
No federal health care program payment may
be made for any item or service furnished,
ordered or prescribed by an individual or entity
excluded by the Office of Inspector General
(OIG). These exclusions are intended to protect
beneficiaries from the risk of harm by
untrustworthy individuals by barring them from
participation in federal health care programs.
Exclusions may apply to:
Individuals
Almost, but not quite
Organizations
Almost, but not quite
Both
● Click the box next to
the correct answer.
That’s right!
•
Exclusions may apply to individuals and
to organizations. Exclusion periods vary
depending on the reason.
The Office of Inspector General’s (OIG) special
Advisory Bulletin entitled, “The Effect of
Exclusion From Participation in Federal Health
Care Programs” is a great resource that lays out
some of the details concerning exclusions. Click
here to access it.
Correct
Prevent
Prevent
Detect
Monitor
Audit
Prevent
Report
Correct
ACTION STEPS
Appeals &
Grievances
Prevent
Agent /
Broker
Sales &
Marketing
High Risk
Areas
Formulary
Administration
Enrollment &
Disenrollment
Claims
Processing
ACTION STEPS
Prevent
 Verify information is true
 Check billing information
 Put policies in practice
 Know the law
WHAT YOU CAN DO
ACTION STEPS
Law Litmus Test
The Health Insurance Portability
and Accountability Act (HIPAA):
Mandated that organizations implement
safeguards to prevent unauthorized access
to protected health information (PHI)
YES, but it did more than that
Required organization to notify individuals if
there is a breach of their PHI
YES, but it did more than that
Provided individuals with the right to limit
access to their PHI
YES, but it did more than that
All of the above
● Click the box next to
the correct answer.
THAT’S RIGHT!
HIPAA does all of these. While it is a crime to
knowingly obtain or disclose protected health
information (PHI) for fraudulent purposes, it is a
HIPAA violation to disclose PHI to an unintended
recipient even when there is no criminal intent
Prevent

Know and comply with any contractual
obligations that apply

Protect all health, financial and/or
employment information

Limit access, use and sharing of information
to the minimum amount necessary to
achieve the task

Avoid using Social Security numbers when
sending information out externally unless
there is a compelling business need
PROTECT PHI
ACTION STEPS
Prevent
Examples of unauthorized disclosures

Correspondence or a claim goes to the
wrong address

A company report gets into the wrong hands

A data file is sent to the wrong email
address
Organizations are required by the HITECH Act to notify
individuals within 60 days if there is a breach of their PHI
REPORT
ACTION STEPS
• Civil Money Penalties
• Criminal Conviction / Fines
• Civil Prosecution
• Imprisonment
• Loss of Provider License
• Exclusion from Federal Health Care Programs
CONSEQUENCES
Visit our web site at http://hisccompliance.com/ and stay
current on government programs issues. Check out Kim
Green’s quarterly newsletter.
Comments or suggestions concerning training?
HISCCompliance@bcbsil.com
CONGRATULATIONS!
You have completed the course