Fraud, Waste, Abuse - 2, Fraud Waste and Abuse, Preventing Fraud, Abuse & Waste, Fraud, Abuse, and Waste, Fraud Waste and Abuse 2018 AHIP, fraud, waste, and abuse prevention
Rules for gifts to patients
- can't be cash or cash equivalents - Valued at no more than $15 individually or $75 in aggregate for the year - Generally not allowed for Medicare or Medicaid beneficiaries
Taking Action
-contact the compliance officer -stop submitting problematic bills -seek legal counsel -determine whether there are any overpayments to be returned -disentangle yourself from problematic relationships
Waste
-incurring unnecessary costs as a result of deficient management practices, systems, or controls -ex: duplication of services already provided elsewhere
Fraud
-intentional deception or misrepresentation that a person makes to gain a benefit to which they are not entitled -ex: falsifying documentation
Abuse
-payment for items or services that the provider is not entitled to and for which the provider has not intentionally misrepresented facts to obtain payment -ex: billing services that are not medical necessary
False Claims Act
-prohibits "knowing" submission of false claims or the use of a false record or statement for payment to Medicare/Medicaid -"knowing": includes actual knowledge, deliberate ignorance, and reckless disregard
Federal Anti-Kickback Statute
-prohibits anyone from "knowingly & willfully" offering or receiving a form of payment in return for referring a pt to another provider for services covered by Medicare/Medicaid -ex: cash for referrals, gifts, etc.
Physician Self-Referral Law
-prohibits physician referrals for certain health care services (PT) when there is a financial relationship with an entity unless an exception applies -financial relationships include ownership and compensation
Civil Monetary Penalty Law
-providing free services to patients or waiving coinsurance and deductibles is generally prohibited as it may influence a patient to receive your services -exception for financially needy patients (pro-bono service)
Exclusion Authorities/Statute
-the government may exclude inviolate providers from participation in federal health care programs, meaning: the provider may not bill for treating patients & an employer may not bill for the provider's services
Which of the following requires intent to obtain payment and the knowledge that the actions are wrong?
. Fraud
If you have witnessed fraud or abuse, or are in engaged in a relationship or billing practice that you think might be problematic, you should consider taking the following steps:
1) Contact the compliance officer in the facility if there is one. 2) Immediately stop submitting any problematic bills. 3) Seek knowledgeable legal counsel. 4) Determine whether there are overpayments that should be returned. 5) Disentangle yourself from the problematic relationship. 6) When appropriate, consider reporting the information to the Office of the Inspector General, Centers for Medicare and Medicaid Services, or the private payer, particularly if the compliance offer has not responded adequately.
Compliance Program
1) written standards of conduct, policies, and procedures 2) a compliance officer 3) education and training 4) hotline to receive complaints 5) system to respond to allegations of illegal activities 6) audits to monitor compliance 7) investigation & remediation of identified systemic problems
7 core elements of a compliance program
1. Developing and distributing written policies, procedures, and standards of conduct to prevent inappropriate conduct. 2. Designation of a compliance officer who has responsibility for this area. This does not have to be a full‐time job, particularly if you are in a small practice. 3. Providing effective education and training programs for your staff regarding compliance, coding, and billing. 4. Establishing open lines of communication for reporting compliance concerns. This could include a hotline to receive complaints. 5. Having a system in place to respond to any allegations of improper conduct, including disciplinary action. 6. Performing internal evaluation and audits to monitor compliance. 7. Investigating and remediating any problems that are identified.
4 Potential resources for fraud, abuse, and waste concerns
1. Experienced health care lawyers 2. Your state physical therapy board 3. CMS Medicare administrative contractors (MACs) 4. The Office of the Inspector General (OIG
4 Exceptions that allow discounts and waivers of copays
1. The provider does not advertise the discount or waiver 2. The provider does not routinely waive copays and discount care 3. The provider shows extensive efforts were made to collect money from the patient 4. The patient meets federal poverty guidelines or facility-specific poverty/catastrophic guidelines
Ways to report a compliance issue include:
All of the Above
What are some of the consequences for non-compliance, fraudulent, or unethical behavior?
All of the Above
Ways to report a compliance issue include: Select the correct answer.
All of the above
What are some of the penalties for violating Fraud, Waste, and Abuse (FWA) laws? Select the best answer.
All of the above
Which of these actions is most likely to be permitted in dealing with a person with limited English proficiency?
Allowing a child to interpret in an emergency.
false
Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty. : True False
true
Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them. : True False
A person comes to your pharmacy to drop off a prescription for a beneficiary who is a "regular" customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step?
Call the prescriber to verify the quantity
You are in charge of payment of claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize that Doe Diagnostics' claims far exceed any other provider that you reviewed. What should you do?
Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit (SIU), or other mechanism)
Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting Fraud, Waste, and Abuse (FWA)?
Deportation
Which area of potential discrimination is not generally covered by ACA Section 1557?
Employment (with the exception of the provision of health insurance).
You can help prevent Fraud, Waste, and Abuse (FWA) by doing all of the following: • Look for suspicious activity; • Conduct yourself in an ethical manner; • Ensure accurate and timely data/billing; • Ensure you coordinate with other payers; • Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance; and • Verify all information provided to you.
F
Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty.
False
At a minimum, an effective compliance program includes four core requirements.
False
Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.
False
Once a corrective action plan is started, the corrective actions must be monitored annually to ensure they are effective.
False
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?
Follow your pharmacy's procedures
Fraud
Intentional deception or misrepresentation that a person makes to gain a benefit to which they are not entitled (ex. knowingly billing for services not provided, knowingly altering claims forms to receive more payment, falsifying documentation)
For a health plan, what are the possible consequences of violations of ACA Section 1557?
Loss of federal business and compensatory damages.
false
Once a corrective action plan is started, the corrective actions must be monitored annually to ensure they are effective. : True False
Which Medicare programs are covered by ACA Section 1557?
Parts A, C, and D, but not B.
Abuse
Payment for items or services that the provider is not entitled to and for which the provider has not intentionally misrepresented facts to obtain payment (ex. billing services that are not medically necessary, unbundling services and billing, billing services that do not meet professionally recognized standards)
ACA Section 1557 rules for disability concern
Policies and procedures, physical access, and communication.
Anti-Kickback Statute
Prevents anyone from "knowingly and willfully" offering or receiving a form of payment in return for referring a patient to a provider for services or items covered by Medicare or Medicaid - payment could by anything (ex. gifts, money, etc.)
Physician Self Referral Law (Stark Laws)
Prohibits physicians from referring Medicare and Medicaid patients for certain designated health services to entities in which that physician has a financial relationship, unless an exception applies.
What is the policy of non-retaliation?
Protects employees who, in good faith, report suspected non-compliance
Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job you verify, through a certain process, that the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust/add risk diagnosis codes for certain individuals. What should you do?
Report the incident to the compliance department (via compliance hotline or other mechanism)
False Claims Act
Says that it is illegal to submit false claims or use a false record to obtain payment from the Medicare or Medicaid programs - The penalties for violation of this law are significant—they can as high as $22,000 per claim, plus 3 times the damages sustained by the government - strong incentives for whistleblowers to report fraud
Ways to report potential Fraud, Waste, and Abuse (FWA) include:
Special Investigations Units (SIUs)
Standards of Conduct are the same for every Medicare Parts C and D Sponsor.
T
Exclusion Statute
The government has the authority to exclude providers from participation in federal health care programs, such as Medicare and Medicaid. Excluded providers may not bill for treating patients, and their employers may not bill for their services.
true
These are examples of issues that should be reported to a Compliance Department: suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee misconduct. : True False
Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
True
Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them.
True
Medicare Parts C and D plan Sponsors are not required to have a compliance program.
True
Once a corrective action plan begins addressing non-compliance or Fraud, Waste, and Abuse (FWA) committed by a Sponsor's employee or First-Tier, Downstream, or Related Entity's (FDR's) employee, ongoing monitoring of the corrective actions is not necessary.
True
Once a corrective action plan is started, the corrective actions must be monitored annually to ensure they are effective.
True
Some of the laws governing Medicare Parts C and D Fraud, Waste, and Abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA); the False Claims Act; the Anti-Kickback Statute; the List of Excluded Individuals and Entities (LEIE); and the Health Care Fraud Statute.
True
These are examples of issues that can be reported to a Compliance Department: suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee misconduct.
True
These are examples of issues that should be reported to a Compliance Department: suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee misconduct.
True
Waste includes any misuse of resources such as the overuse of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program.
True
You can help prevent Fraud, Waste, and Abuse (FWA) by doing all of the following: • Look for suspicious activity; • Conduct yourself in an ethical manner; • Ensure accurate and timely data/billing; • Ensure you coordinate with other payers; • Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance; and • Verify all information provided to you.
True
Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them.
True Correct
true
Waste includes any misuse of resources such as the overuse of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. : True False
e
Ways to report potential Fraud, Waste, and Abuse (FWA) include: a. Telephone hotlines b. Mail Drops c. In-person reporting to the compliance department/supervisor d. Special Investigations Units (SIUs) e. All of the above
As a result of violations of ACA Section 1557 nondiscrimination rules,
a health plan may revoke an agent or broker's appointment with the health plan.
Which of these actions is most likely to be permitted in dealing with a person with limited English proficiency?
a. Allowing a child to interpret in an emergency. Correct
Which Medicare programs are covered by ACA Section 1557?
a. Parts A, C, and D, but not B. Correct
Section 1557 of the Affordable Care Act applies to
all health programs and activities administered by or receiving federal financial assistance from HHS
What are some of the penalties for violating Fraud, Waste, and Abuse (FWA) laws?
all of the above
For a health plan, what are the possible consequences of violations of ACA Section 1557?
b. Loss of federal business and compensatory damages. Correct
Which area of potential discrimination is not generally covered by ACA Section 1557?
c. Employment (with the exception of the provision of health insurance). Correct
As a result of violations of ACA Section 1557 nondiscrimination rules,
c. a health plan may revoke an agent or broker's appointment with the health plan. Correct
Section 1557 of the Affordable Care Act applies to
c. all health programs and activities administered by or receiving federal financial assistance from HHS. Correct
Under ACA Section 1557, a person
c. cannot be discriminated against based on her legal or illegal immigration status or ability to speak English. Correct
If a health plan violates ACA Section 1557 nondiscrimination protections, it may be
c. required to take corrective action and sometimes pay damages, and it may be sued by individuals. Correct
Under ACA Section 1557, sex discrimination includes a person's
c. sex, pregnancy, sex stereotypes, or gender identity. Correct
Under ACA Section 1557, a person
cannot be discriminated against based on her legal or illegal immigration status or ability to speak English.
Under ACA Section 1557, a health plan
cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge
Under ACA Section 1557, a health plan sold through a state exchange may, based on an individual's age,
charge higher premiums.
ACA Section 1557 rules for disability concern
d. Policies and procedures, physical access, and communication. Correct
Under ACA Section 1557, a health plan
d. cannot deny coverage to LEP individuals and is required to provide language assistance to them, free of charge. Correct
Under ACA Section 1557, a health plan sold through a state exchange may, based on an individual's age,
d. charge higher premiums. Correct
Under ACA Section 1557, prohibited actions involve
d. eligibility, claims, and marketing. Correct
Ways to report potential Fraud, Waste, and Abuse (FWA) include:
e. All of the above Correct
Under ACA Section 1557, prohibited actions involve
eligibility, claims, and marketing.
Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
false
Some of the laws governing Medicare Parts C and D Fraud, Waste, and Abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA); the False Claims Act; the Anti-Kickback Statute; the List of Excluded Individuals and Entities (LEIE); and the Health Care Fraud Statute.
false
T/F: You can bill for services provided by an aide
false
Waste
incurring unnecessary costs as a result of deficient management practices, systems, or controls (ex. duplication of services already provided elsewhere, spending on services that don't provide better outcomes than services that are less expensive)
Correcting non-compliance ______________.
just A
If a health plan violates ACA Section 1557 nondiscrimination protections, it may be
required to take corrective action and sometimes pay damages, and it may be sued by individuals.
ACA Section 1557 differs from earlier legislation in providing broader protection against discrimination based on
sex
Under ACA Section 1557, sex discrimination includes a person's
sex, pregnancy, sex stereotypes, or gender identity
ACA Section 1557 differs from earlier legislation in providing broader protection against discrimination based on
sex.
T/F: A physical therapist is not allowed to collect out of pocket money from a medicare beneficiary to cover a service that's not covered by Medicare
true