Compliance Training A

FDetect & Report: If you detect potential non- compli-Select the correct answer.ance, report it!A. Refuse to change the date or waive the premiums, but decide not to mention the request to aCorrect: Correct non-compliance to protect beneficiariessupervisor or the compliance departmentand save money!B. Make the requested changes because the salesagent determines the beneficiary’s start date andLesson Review - Knowledge Checkmonthly premiumsC. Tell the sales agent you will take care of it,butNow that you have completed the Compliance Programthen process the application properly (withoutTraining lesson, let’s do a quick knowledge check. The fol-the requested revisions)–you will not file a reportlowing questions do not contribute to your overall coursebecause you don’t want the sales agent to retali-score in the Post-Assessment.1.ate against youD. Process the application properly (without theYou discover an unattended email address or fax ma-requested revisions)–inform your supervisor andchine in your office that receives beneficiary appealsthe compliance officer about the sales agent’srequests. You suspect that no one is processing therequestappeals. What should you do?E.Contact law enforcement and the Centers forSelect the correct answer.Medicare & Medicaid Services (CMS) to report theA. Contact law enforcementsales agent’s behaviorB. NothingCORRECT ANSWER: DC. Contact your compliance department (via compliance hotline or other mechanism)D. Wait to confirm someone is processing the appeals before taking further actionE.Contact your supervisor3.You work for a Sponsor. Last month, while reviewinga monthly report from CMS, you identified multipleenrollees for which the Sponsor is being paid, who arenot enrolled in the plan. You spoke to your supervisorwho said not to worry about it. This month, you haveCORRECT ANSWER: Cidentified the same enrollees on the report again.2.A sales agent, employed by the Sponsor’s First-Tieror Downstream entity, submitted an application forprocessing and requested two things: 1) to back-datethe enrollment date by one month, and 2) to waive allmonthly premiums for the beneficiary. What shouldyou do?Compliance TrainingWhat should you do?Select the correct answer.A. Decide not to worry about it as your supervisorinstructed – you notified him last month and nowit’s his responsibility{General Compliance and Fraud, Waste & Abuse Prevention}2021

B. Although you have seen notices about the Sponsor’s non-retaliation policy, you are still nervousabout reporting – to be safe, you submit a reportthrough your compliance department’s anonymous tip line so you cannot be identifiedC. Wait until the next month to see if the sameenrollees appear on the report again, figuring itmay take a few months for CMS to reconcile itsrecords – if they are, then you will say somethingInteractive TrainingReminderCompliance Training isan interactive trainingprogram in which you canaddress questions withother staff members orsupervisors toobtain clarification forsituations in your worksetting.Write down any questionsthat you have about thetraining topic and addressthem with your TrainingCoordinator or supervisor.to your supervisor againD. Contact law enforcement and CMS to report thediscrepancyE.4.Part II: Combating Medicare Parts C & D Fraud,Waste, And Abuse - Lesson IIntroduction and Learning ObjectivesThe following lesson describes Fraud, Waste, and Abuse(FWA) and the laws that prohibit it. Upon completing thelesson, you should be able to correctly:·Recognize FWA in the Medicare Program;·Identify the major laws and regulations pertaining toFWA;·Recognize potential consequences and penalties associated with violations;Ask your supervisor about the discrepancy again·Identify methods of preventing FWA;·Identify how to report FWA; andCORRECT ANSWER: B·Recognize how to correct FWA.You are performing a regular inventory of the con-Fraudtrolled substances in the pharmacy. You discover aminor inventory discrepancy. What should you do?Fraud is knowingly and willfully executing, or attemptingto execute, a scheme or artifice to defraud any healthcare benefit program, or to obtain, by means of false orSelect the correct answer.fraudulent pretenses, representations, or promises, anyA. Call local law enforcementof the money or property owned by, or under the custodyB. Perform another reviewor control of, any health care benefit program.C. Contact your compliance department (via compliance hotline or other mechanism)D. Discuss your concerns with your supervisorE.Follow your pharmacy’s proceduresCORRECT ANSWER: EIn other words, fraud is intentionally submitting false information to the Government or a Government contractorto get money or a benefit.The Health Care Fraud Statute makes it a criminal offenseto knowingly and willfully execute a scheme to defraud ahealth care benefit program. Health care fraud is punishable by imprisonment for up to 10 years. It is also subjectto criminal fines of up to 250,000.Compliance Training{General Compliance and Fraud, Waste & Abuse Prevention}20219G

Waste and Abuse·Knowingly altering claim forms, medical records, orreceipts to receive a higher payment.Waste includes overusing services, or other practicesthat, directly or indirectly, result in unnecessary costs toExamples of actions that may constitute Medicare wastethe Medicare Program. Waste is generally not consideredinclude:to be caused by criminally negligent actions but rather bythe misuse of resources.·Abuse includes actions that may, directly or indirectly,·prescriptions;Abuse involves payment for items or services when thereis not legal entitlement to that payment and the providerhas not knowingly and/or intentionally misrepresentedfacts to obtain payment.For the definitions of fraud, waste, and abuse, refer toChapter 21, Section 20 of the “Medicare Managed Guidance/Guidance/Manuals/Downloads/mc86c21.pdf; andChapter 9 of the “Prescription Drug Benefit ads/Chapter9.pdf·Ordering excessive laboratory tests.Examples of actions that may constitute Medicare abuseinclude:·Unknowingly billing for unnecessary medical services;·Unknowingly billing for brand name drugs when generics are dispensed;·Unknowingly excessively charging for services orsupplies; and·Unknowingly misusing codes on a claim, such as upcoding or unbundling codes.Differences Among Fraud, Waste, and AbuseThere are differences among fraud, waste, and abuse.One of the primary differences is intent and knowledge.Examples of FWAFraud requires intent to obtain payment and the knowl-Examples of actions that may constitute Medicare fraudinclude:·Prescribing more medications than necessary for thetreatment of a specific condition; andresult in unnecessary costs to the Medicare Program.·Conducting excessive office visits or writing excessiveedge that the actions are wrong. Waste and abuse mayinvolve obtaining an improper payment or creating anunnecessary cost to the Medicare Program, but do notKnowingly billing for services not furnished or sup-require the same intent and knowledge.plies not provided, including billing Medicare for appointments that the patient failed to keep;·Billing for non-existent prescriptions; andCompliance Training{General Compliance and Fraud, Waste & Abuse Prevention}2021H

Understanding FWAmitted to increase risk capitation payments from theCenters for Medicare & Medicaid Services (CMS);To detect FWA, you need to know the law. The following·Was informed by the outside company that certain di-sections provide information about the laws that prohibitagnosis codes previously submitted to Medicare wereFWA:undocumented or unsupported;·Civil False Claims Act (FCA)Failed to report the unsupported diagnosis codes toMedicare; and·Agreed to pay 22.6 million to settle FCA allegations.The civil provisions of the FCA make a person liable topay damages to the Government if he or she knowingly:Whistleblowers·Conspires to violate the FCA;A whistleblower is a person who exposes information or·Carries out other acts to obtain property from theactivity that is deemed illegal, dishonest, or violates pro-Government by misrepresentation;fessional or clinical standards.···Knowingly conceals or knowingly and improperly avoidsor decreases an obligation to pay the Government;Protected: Persons who report false claims or bringMakes or uses a false record or statement supportinglegal actions to recover money paid on false claims area false claim; orprotected from retaliation.Presents a false claim for payment or approval.Rewarded: Persons who bring a successful whistleblow-Damages and Penaltieser lawsuit receive at least 15 percent but not more than30 percent of the money collected.Any person who knowingly submits false claims to theGovernment is liable for three times the Government’sFor more information on the Civil False Claims Act, referdamages caused by the violator plus a penalty. Theto 31 United States Code (U.S.C.) Sections 3729-3733:Civil Monetary Penalty (CMP) may range from 5,500 ti- 11,000 for each false ap37-subchapIII.pdfExample:Health Care Fraud StatuteA Medicare Part C plan in Florida:·Hired an outside company to review medical recordsThe Health Care Fraud Statute states that “Whoeverto find additional diagnosis codes that could be sub-knowingly and willfully executes, or attempts to execute,Compliance Training{General Compliance and Fraud, Waste & Abuse Prevention}20219I

a scheme to . defraud any health care benefit programJCriminal Fraud. shall be fined . or imprisoned not more than 10years, or both.”Persons who knowingly make a false claim may be subjectto:Conviction under the statute does not require proof thatthe violator had knowledge of the law or specific intent toviolate the law.Examples:Criminal fines up to 250,000;·Imprisonment for up to 20 years; or·Both.If the violations resulted in death, the individual may beimprisoned for any term of years or for life.A Pennsylvania pharmacist:··Submitted claims to a Medicare Part D plan fornon-existent prescriptions and for drugs not dispensed;·Pleaded guilty to health care fraud; and·Received a 15-month prison sentence and was ordered to pay more than 166,000 in restitution to theplan.For more information, refer to 18 U.S.C. Section c1347.pdfAnti-Kickback StatuteThe Anti-Kickback Statute prohibits knowingly and willful-The owners of multiple Durable Medical Equipment (DME)ly soliciting, receiving, offering, or paying remunerationcompanies in New York:(including any kickback, bribe, or rebate) for referrals for·Falsely represented themselves as one of a nonprofitservices that are paid, in whole or in part, under a Federalhealth maintenance organization’s (that administeredhealth care program (including the Medicare Program).a Medicare Advantage plan) authorized vendors;·Provided no DME to any beneficiaries as claimed;·Submitted almost 1 million in false claims to thenonprofit; 300,000 was paid; and·Pleaded guilty to one count of conspiracy to commithealth care fraud.For more information, refer to 18 U.S.C. Section 17-ti-Damages and PenaltiesViolations are punishable by:·A fine of up to 25,000;·Imprisonment for up to 5 years; tI-chap63-sec1346.From 2012 through 2015, a physician operating a painpdfmanagement practice in Rhode Island:Compliance Training{General Compliance and Fraud, Waste & Abuse Prevention}2021

··Conspired to solicit and receive kickbacks for prescrib-There may also be up to a 161,000 fine for entering intoing a highly addictive version of the opioid Fentanylan unlawful arrangement or scheme.Reported patients had breakthrough cancer pain toExample:secure insurance payments·Received 188,000 in speaker fee kickbacks from thedrug manufacturer·Admitted the kickback scheme cost Medicare and other payers more than 750,000·The physician must pay more than 750,000 restitution and is awaiting sentencing.A California hospital was ordered to pay more than 3.2million to settle Stark Law violations for maintaining 97 financial relationships with physicians and physician groupsoutside the fair market value standards or that wereimproperly documented as exceptions.For more information on Physican Self-Referral Law, refer to:For more information, refer to 42 USC Section1320a-7b(b): https://www.govinfo.gov/content/pkg/· For more information, refer to the Social Security Act,· cianSelfReferralSection 1128B(b): https://www.ssa.gov/OP Home/ssact/title11/1128B.htm· https://www.ssa.gov/OP Home/ssact/title18/1877.htmStark Statute (Physician Self-Referral Law)The Stark Statute prohibits a physician from making referrals for certain designated health services to an entitywhen the physician (or a member of his or her family) has:·An ownership/investment interest; or·A compensation arrangement (exceptions apply).Damages and PenaltiesCivil Monetary Penalties LawThe Office of Inspector General (OIG) may impose Civilpenalties for a number of reasons, including:·Arranging for services or items from an excluded individual or entity;·Providing services or items while excluded;·Failing to grant OIG timely access to records;·Knowing of an overpayment and failing to report andreturn it;Medicare claims tainted by an arrangement that does notcomply with the Stark Statute are not payable. A pen-·Making false claims; oralty of up to 24,250 may be imposed for each service·Paying to influence referrals.provided.Compliance Training{General Compliance and Fraud, Waste & Abuse Prevention}20219K

Damages and Penaltiesal agencies, including the OIG. You may access the EPLSat https://www.sam.gov. If looking for excluded individu-The penalties range from 15,000 to 70,000 depend-als or entities, make sure to check both the LEIE and theing on the specific violation. Violators are also subject toEPLS since the lists are not the same.three times the amount:Note Regarding Screeningfor Exclusion:In 2012, the U.S. General Services Administration mergedthe Excluded Parties ListSystem (EPLS) into the System for Award Management(SAM). The EPLS no longerexists. In addition, the Officeof Inspector General statesthe following in its “SpecialAdvisory Bulletin on the Effectof Exclusion from Participation in Federal Health CarePrograms”:“We recommend that providers use the LEIE as theprimary source of informationabout OIG exclusions becausethe LEIE is maintained byOIG; is updated monthly; andprovides more details aboutpersons excluded by OIG thanGSA’s SAM, such as the statutory basis for the exclusionaction, the person’s occupation at the time of exclusion,the person’s date of birth, andaddress information.”[See Note in column at left.]·Claimed for each service or item; or·Of remuneration offered, paid, solicited, or received.Example:A pharmaceutical company pleaded guilty to two felonyExample:counts of criminal fraud related to failure to file requiredA California pharmacy and its owner agreed to pay overreports with the Food and Drug Administration concerning 1.3 million to settle allegations they submitted claims tooversized morphine sulfate tablets. The executive of theMedicare Part D for brand name prescription drugs thatpharmaceutical firm was excluded based on the compa-the pharmacy could not have dispensed based on inven-ny’s guilty plea. At the time the executive was exclud-tory records.ed, he had not been convicted himself, but there wasFor more information, refer to 42 USC apXI-partAsec1320a-7a.pdfevidence he was involved in misconduct leading to thecompany’s conviction.For more information, refer to 42 U.S.C. Section1320a-7 at: hapXI-partA-sec1320a-7.pdfNo Federal health care program payment may be madefor any item or service furnished, ordered, or prescribedby an individual or entity excluded by the OIG. The OIGhas authority to exclude individuals and entities fromfederally funded health care programs and maintains theList of Excluded Individuals and Entities (LEIE). You canaccess the LEIE at https://exclusions.oig.hhs.gov.The United States General Services Administration (GSA)administers the Excluded Parties List System (EPLS),and 42 Code of Federal Regulations Section 1001.1901 dfHealth Insurance Portability and Accountability Act(HIPAA)HIPAA created greater access to health care insurance,protection of privacy of health care data, and promotedstandardization and efficiency in the health care industry.which contains debarment actions taken by various Feder-Compliance Training{General Compliance and Fraud, Waste & Abuse Prevention}2021L

MHIPAA safeguards help prevent unauthorized access to·Criminal conviction/fines;protected health care information. As an individual with·Exclusion from participation in all Federal health careaccess to protected health care information, you mustcomply with HIPAA.programs;·Imprisonment; or·Loss of provider license.Damages and PenaltiesFor details about the specific laws, such as safe harborViolations may result in Civil Monetary Penalties. In someprovisions, consult the applicable statute and regulations.cases, criminal penalties may apply.FWA- Lesson 1 Review - Knowledge

Compliance Training {General Compliance and Fraud, Waste & Abuse Prevention}2021 · Recognize how compliance program violations should be reported. Compliance Program Requirement The Centers for Medicare & Medicaid Services (CMS) requires Sponsors to implement and maintain an effective compliance program for its Medicare Parts C and D plans.