presentation - CarePoint Health Plans

Part C and Part D Medicare Fraud, Waste
and Abuse Comprehensive Training
Why Do I need Training
• Every year millions of dollars are improperly spent because of
fraud, waste, and abuse. It affects everyone.
• Including
• This training is designed to help you detect, correct, and
prevent fraud, waste, and abuse.
are part of the solution.
Overview and Objective
• The Centers for Medicare & Medicaid Services (CMS) requires
Medicare Advantage Organizations and Part D Plan Sponsors to
provide annual fraud, waste, and abuse training to their employees.
• As part of the CarePoint Health Plans Compliance Program, we are
actively engaged in preventing, detecting and resolving any and all
Medicare related Fraud, Waste and Abuse
• It is important that all internal employees and related FDR’s are made
aware of their responsibility in reporting discovered issues of FWA to
the CarePoint Health Plans Compliance Department
• Provide information on laws governing issues of Fraud, Waste and
• Provide information on how to report Fraud, Waste and Abuse
Understanding Fraud, Waste and
• To be properly equip YOU to detect, prevent and report
issues of FWA, it is important to understand the specific
definitions of Fraud, Waste and Abuse
• Fraud: is knowingly and willfully 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 U.S.C. §
Understanding Fraud, Waste and
• Waste: is over-utilization of services or other practices
that, directly or indirectly, result in unnecessary costs to
the Medicare program. Waste is generally not
considered to be caused by criminally negligent actions
but rather misuse of resources.
• Abuse: includes payments, actions that may, directly or
indirectly, result in: unnecessary costs to the Medicare
Program, improper payment, payment for services that
fail to meet professionally recognized standards of care,
or services that are medically unnecessary.
Source: Definitions’ section of Chapter 9 of the CMS Prescription Drug Benefit Manual and Chapter 21 of the CMS Medicare
Managed Care Manual.
Governing Laws on FWA
• Several federal laws prohibits issues of Fraud, Waste and
Abuse; some of the main ones are as follows
• False Claims Act: Prohibits presenting or causing to present a
false claim to the government for payment or approval
• FCA also includes knowingly concealing or knowingly and
improperly avoiding or decreasing and obligation to pay the
• Anti Kickback Statute: Strictly prohibits offering, paying,
soliciting or receiving anything of VALUE for the referral of
services paid in whole under a Federal Health Program
• Violation of this law results in fines of up to $25,000,
imprisonment of up to five (5)years, or both fines and
Governing Laws on FWA
• Health Insurance Portability and Accountability Act: Passed
by congress in 1996, the law is provides the following
• Ability to transfer and continue health insurance coverage for
families or individuals who lose and change jobs
• Mandates industry wide standards for health care information on
electronic billing and patient information
• Reduces health care fraud and abuse
• Beneficiary Inducement Law: Prohibits the offering of
inducement or incentives that the giver should know or have
known would influence the beneficiaries selection of a provider
• Waiver of co-insurance
• Wavier of deductible amounts
• Transfer of items or services for fees
Governing Laws- Exclusions
• Federal agencies like the HHS, OIG, OPM have the
authority to exclude specific individuals cited for FWA
violations from participating in Federal Health Care
• These agencies also have the authority to suspend or
debar individuals receiving government contracts and
grants to provide services under any Federal Health Care
Program (ex. Medicare, Medicaid)
• FDR’s may not employ or contract with entities or
individuals included in the federal debarment list
Governing Laws Cont.
• As an MCO (Managed Care Organization), CarePoint
Health Plans is required to ensure that all employees and
FDR related entities are cross checked against the DHHS
OIG LEIE and GSA EPLS reports
• Individuals or entities found on these reports are excluded
from participating or receiving payments for services
issued under any Federal Health Care Program
• In addition any entity that knowingly employs or contracts
with an excluded or debarred individual for services under
the Federal Health Care Program is subject to monetary
Exclusions Database
• The names of all individuals and entities excluded or
debarred from federal and state health care programs are
listed in databases maintained by the HHS OIG at and by the General Services
Administration at
• For more information, see the HHS OIG Special Advisory
Bulletin on the Effect of Exclusion From Federal Health Care
Program Participation, available on the HHS OIG web site at or
the OPM web site on OPM Administrative Sanctions and
Who Can Commit Health Care FWA
• The reality is that many individuals can commit health
care related Fraud Waste and Abuse violations
• Fraud Waste and Abuse violations can be committed
• Pharmacy
• Managed Care Organization(s)
• Medicare Beneficiaries
• Providers
• FDR and/or Vendors
Examples and Common Types of
Health Care FWA
• Health Care FWA varies and can occur in many forms. Listed below
are common types of FWA
Routinely waiving co-payments and deductibles
Providing treatment that is inconsistent with the diagnosis
Withholding medically necessary services
“Unbundling Claims”
Misrepresenting facts affecting eligibility for benefits, such as
employment status, health history, martial status or identity
Illegal promotion of off-label drug usage
Inappropriate marketing or promotion of products
Lack of data integrity to establish payment or reimbursement
Prescription Shortfills/ Bait and Switch Pricing
Doctor Shopping
Examples and Common Types of
Health Care FWA
• Identity theft
• Improper Coordination of Benefits( Beneficiary failure to
disclose multiple benefits)
Prescription Fraud (Falsifying or modifying prescription)
Inappropriate enrollment and disenrollment practices
MAO marketing schemes
Delaying access to necessary covered drugs
Patient dumping
Altering Medical Records
Dispensing expired drugs or Tainted Drugs
Reporting FWA
• Remember CarePoint Health Plans requires all
employees and related entities to comply will all
outlined federal, state and local laws, regulations
and compliance program requirements.
• If you suspect any CarePoint Health Plans
employee or vendor to be violating laws,
engaging in misconduct or unethical behavior,
you must immediately report them to one of the
Reporting FWA
• Your direct line supervisor/department director
• CarePoint Health Plans Compliance Officer
• CarePoint Health Plans legal and Regulatory director
• CarePoint Health Plans Special Investigations Unit
• CarePoint Health Plans compliance email address
• The CarePoint Health Plans compliance hotline (All calls
can be made anonymously)
Compliance Hotline- 888-671-6191
Compliance email –
Non-Retaliation Policy
• To encourage and protect processes in reporting
violations of FWA, CarePoint Health Plans maintains a
non-retaliation policy that specifically states that
individuals reporting violations of FWA will be protected
from any retaliation or reprisals by any involved parties. A
copy of this policy is readily available
• Additionally these individuals are also protected by the
whistleblower clause provision outlined in the Federal
Claims Act
Internal Review
• CarePoint Health Plans Compliance Department
facilitates an on-going Risk Management forum to discuss
and resolves all operational risk areas alongside issues of
Fraud Waste and Abuse.
• CarePoint Health Plans also conducts periodic reviews of
its operations
• For example, the Medicare Compliance Program maintains an
internal audit work plan with scheduled and unscheduled audits of
the Medicare operations. These audits include, but are not limited
to, marketing, enrollment, data submitted to the Center for
Medicare and Medicaid Standards (referred to as CMS), appeals
and oversight of delegated vendors.
CarePoint Health Plans is highly committed to abiding by
all applicable laws, rules and regulations that govern our
business. CarePoint Health Plans compliance program is
designed to provide sound education and safeguards on
the operational functions of health care provision.
Thank you for your completing this CMS required training
course on the detecting and preventing issues of Health
Care Fraud, Waste and Abuse