2013 Compliance,
Fraud, Waste, and Abuse
Training
Why Do We Have Compliance
Training?
• To improve services for American Behavioral members
• To define expected conduct from providers, members and
American Behavioral associates
• To provide guidance that helps us make informed decisions
concerning what is appropriate and right
• To quickly identify and resolve compliance concerns
• To assist us in abiding by the laws and regulations that govern
our business
• To help American Behavioral meet URAC accreditation
standards
• To avoid legal and financial penalties
The American Behavioral Compliance
Mission
• To direct our business in an ethical manner and in
accordance with all regulations and accreditation
standards
• To foster open, honest and timely communication
between American Behavioral and our providers
• To integrate compliance as an essential part of daily
operations
• To promote the cooperative relationship between
American Behavioral and our providers
The Ultimate Goal
Developing controls and educating providers,
members, and associates in order to reduce the
amount of fraudulent, wasteful or abusive
activities
The American Behavioral Code of
Conduct
• Be honest
• Know the applicable American Behavioral guidelines,
policies and procedures
• Ask questions
• Admit mistakes
• Report concerns
• Don’t be afraid to ask for help
Fraud, Waste and Abuse (FWA)
• FWA is a nationwide problem that affects everyone
either directly or indirectly
• National estimates project that billions of dollars are
lost due to fraud, waste and/or abuse, resulting in
increased health care costs and increased cost for
coverage
• We have the responsibility to prevent, detect and
eliminate FWA
Definition of Fraud
Fraud is when a person intentionally misrepresents
information, knowing that the misrepresentation could
benefit himself/herself or some other person
The most common kind of health care fraud involves a
false statement, misrepresentation or deliberate omission
that is critical to the determination of payable benefits
Definition of Waste
Performing functions in a manner requiring more
resources than are necessary, e.g. using or billing
for more supplies, technology or hours than are
required
Definition of Abuse
Refers to practices that may directly or indirectly
cause financial loss to payers of insurance or
health care benefits. Abuse often involves
administering unnecessary services, improper
billing or providing products or services that are
not consistent with accepted practices
Examples of FWA
• Fraud: Submitting false claims for health care
services that were not provided or filing a claim for
more complicated service than the service performed
• Waste: Unnecessary spending or use of office
supplies, technology, or resources
• Abuse: Billing for services/supplies that are not
medically necessary or providing care that is not
consistent with accepted medical practices
Examples of Health Care Fraud and
Abuse by a Provider
• Billing for services that were not provided
• Double billing: Duplicate submission of a claim for
the same service
• Misrepresenting the service provided
• Up-coding: Charging for a more complex or
expensive service that was actually provided
• Billing for a covered service when the service
actually provided was not covered
Examples of Health Care Fraud and
Abuse by a Provider--Continued
• Kickbacks: Receiving payments or other benefits for
making a referral
• Ordering excessive or inappropriate testing
• Brief or intermediate-length visits coded as lengthy or
comprehensive visits
• Regularly waiving co-pays or co-insurance for
patients, but filing with the insurance company for
reimbursement
Examples of Health Care Fraud and
Abuse by a Member/Client
• Using a member ID card that does not belong to that
person
• Adding someone to a policy that is not eligible for
coverage, e.g. a grandchild
• Failing to remove someone from a policy when that
person is no longer eligible, e.g. a former spouse
Examples of Health Care Fraud and
Abuse by a Member/Client--Continued
• Doctor shopping: Visiting several doctors to obtain
multiple prescriptions/services
• Providing false employer group and/or group
membership information
Laws Regulating FWA
The Anti-Kickback Statute
The Anti-Kickback Statute is a criminal statute that prohibits the
exchange (or offer to exchange), of anything of value, in an
effort to induce (or reward) the referral of federal health care
program business.1
Examples of prohibited activities include:
• Waiving a co-pay or deductible for reasons other than real
financial hardship (or allowable exceptions)
• Accepting a payment that is different from fair market value
as a means to obtain more business
• Demanding or requesting a kickback (i.e. gifts, cash, writeoffs, free supplies for referring patients to specific providers)
1http://www.healthlawyers.org/hlresources/Health%20Law%20Wiki/Anti-Kickback%20Statute.aspx
Laws Regulating FWA--Continued
The Physician Self-Referral Law
(Commonly Known as The Stark Law)
The Stark Law “…prohibits a physician from making a referral for
certain designated health services to an entity in which the
physician (or an immediate member of his or her family) has an
ownership/investment interest or with which he or she has a
compensation arrangement, unless an exception applies.2
Failure to comply with either The Anti-Kickback Statute or The
Stark Law can result in fines, jail and/or exclusion from state health
programs, Medicare or Medicaid
2
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf
The False Claims Act
• The False Claims Act is a Federal law that prohibits a
provider from knowingly submitting false, fictitious,
or fraudulent claims to obtain payment from federal
or state programs
• Knowingly and/or willfully making a false statement
about a claim is a federal felony. Penalties can
include significant fines, jail time and/or exclusion
from participation in federal and state programs.
Self-Disclosure of Criminal Activity
• Felony convictions or other criminal activity (other
than minor traffic violations) occurring prior to or
during a provider’s contract with American
Behavioral must be self-disclosed
• The provider agrees to notify American Behavioral
within seven (7) days of the loss, restriction or
recommended adverse action against his or hospital
privileges or license
Debarment, Exclusion, or Sanctions
The Office of the Inspector General (OIG) and the General Services
Administration (GSA) maintain a list of individual providers and entities
that have been debarred or excluded from working with federal or state
health programs. At the time of the initial credentialing or recredentialing process, American Behavioral reviews and verifies that the
individual or entity is not on that list
The OIG also maintains a list of non-licensed individuals who have had
sanctions levied against them preventing them from working with federal
or state health programs. On a monthly basis, American Behavioral
monitors this list to ensure that no American Behavioral associate has
been sanctioned.
As with other criminal activities, American Behavioral requires selfdisclosure of any information related to debarment, exclusion or any
activity that prevents a provider or American Behavioral associate from
working directly or indirectly with Medicare, Medicaid or state health
programs
Confidential Information
• Compliance with HIPAA regulations is mandatory,
and the confidentiality of records, documents and
business practices must be maintained
• Protected Health Information (PHI) and other
member information must be appropriately
safeguarded This information includes paper,
electronic records and oral communication
• PHI should only be shared if the disclosure is
specifically allowed by HIPAA
Monitoring and Auditing
• Everyone is obligated to monitor compliance
activities and follow all policies and procedures
• Any area of suspected non-compliance should be
reported immediately
• American Behavioral will review claims and other
data submitted by each provider as an internal
monitoring and auditing control
• If compliance issues or concerns are identified
during an audit, corrective actions are developed and
implemented.
Prevention Tips
Teaching American Behavioral Members to be Aware
• Review each Explanation of Benefits to ensure the accuracy of the
name of the provider, dates of service and types of services reported
• Protect his or her insurance card and personal information at all
times
• Count his or her pills each time they pick up a prescription
• Be wary of all advertisements that claim “free” treatments
• Check providers’ credentials with the appropriate state licensing
board. If a member is unsure of a provider’s credentials, tell them to
ask American Behavioral
• Members should report all suspected fraud and abuse to the Quality
Department at American Behavioral 205-868-9633
Reporting a Potential Violation
All reports will be investigated. Individuals expressing
concerns or reporting violations in “good faith” can do so
confidentially without fear of retribution or retaliation as
required by law. “Good faith” means to tell the truth when
reporting a concern or suspected violation.
False reports, stretching the truth, or making statements
made in retaliation against another person, or statements
made for the sole purpose of getting someone in trouble
will result in disciplinary actions.
Reporting a Potential Violation--Continued
Report suspicious practices involving Medicare or other
Federal programs to the Office of the Inspector General
(OIG) Hotline.
Phone:
1-800-HHS-TIPS (1-800-447-8477)
Fax:
1-800-223-8164
Email:
HHSTips@oig.hhs.gov
Address:
HHS Tips Hotline,
P.O. Box 23489
Washington, DC 20026-3489
Getting Assistance When Reporting a
Potential Violation
Obtain assistance from a supervisor. If you suspect your
immediate supervisor of FWA, you can contact the
Quality Department (868-9633) or another trusted
member of management.
Take the route in which you feel most comfortable.
What to Do Once Suspected Fraud or
Abuse is Reported
To confirm that an allegation against a provider is
substantiated:
• Research the provider throughout all billings
• Research pre-billing and post-billing reviews of the provider
• Research submission and payment of claims
• Query the provider history
• Review contract or benefit language.
Potential Investigation/Corrective
Actions
• A pre-payment investigation may be warranted
• Additional documentation may be requested from the provider
before claims payment
• Possible recovery of over-payments may be recommended.
The decision to enact this recommendation would come from
upper administration and/or corporate legal counsel
• Mandatory retraining
• Contract suspension and/or contract termination
Summary
• Fraud: When a person misrepresents information,
knowing that the misrepresentation could benefit
himself/herself or some other person
• Waste: Using more resources than necessary to
complete a task
• Abuse: When an associate, vendor, provider or
contractor furnishes products or services that are
inconsistent with accepted practices or that are clearly
not reasonable or necessary
Summary--Continued
Compliance: The material and policies in this training
are mandatory. Ethical behavior can never be sacrificed
in the pursuit of other objectives
American Behavioral is committed to the highest
standards of ethics and compliance. Everyone is
responsible for their own conduct and behavior. If you
are not sure about potential compliance or FWA issues,
ask
Summary--Continued
If you find yourself in a situation where you are unsure of
what is right, ask yourself a few simple questions:
•
Am I being fair and honest?
•
Is this in the best interest of American Behavioral and the members we serve?
•
Are my actions legal?
•
Is this the right thing to do?
•
How will I feel about my actions afterwards?
•
Will my actions stand the test of time?
•
Would I feel good about my actions if I were to read about it in the
newspaper or see it on the news?
Summary--Continued
Fraud, waste, and abuse are serious
problems.
Report suspected fraud, waste, or abuse as
soon as possible.
Summary--Continued
Remember The Ultimate Goal: Developing
controls and educating providers, members, and
associates in order to reduce the amount of
fraudulent, wasteful or abusive activities
Final Words
Watch the little things; a small
leak will sink a great ship
--Benjamin Franklin
It takes les timet o do a thing
right than it does to explain
why you did it wrong.
--Henry Longfellow
Quality means doing it right
when no one is looking
--Henry Ford
Act as if what you do makes a
difference. It does.
--William James