Transcript Document

AvMed Health Plans
Fraud, Waste and Abuse Training
2009
Objectives
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Define fraud, waste, and abuse
Recognize the financial impact of fraud
Identify where fraud can be committed
Share examples of suspect fraud
Understand preventive efforts
Review AvMed’s Anti-Fraud Plan
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What is Fraud
• Fraud
– The intentional deception or
misrepresentation that an individual or
entity knows to be false or does not believe
to be true and makes, knowing the
deception could result in some
unauthorized benefit to himself/herself or
some other person.
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What is Waste
• Health care spending that can be
eliminated without reducing the quality
of care such as quality waste (overuse,
underuse, and ineffective use) and
inefficiency waste (redundancy, delays,
and unnecessary process complexity)
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What is Abuse
• Abuse
– Practices by facilities, physicians, and
suppliers, while not usually considered
fraudulent, are nevertheless inconsistent
with accepted medical, business, and fiscal
practices.
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Five Elements of Fraud
False
Representation
Resulting
Damage
Justifiable
Reliance by
Intended
Victim
Knowledge
of
Falsity
Intent
to
Defraud
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Audit vs. Investigation
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Regular, recurring
General
Opinion
Non-adversarial
Financial data
Professional
skepticism
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Non-recurring
Specific allegation
Determination
Affix blame
Interviews
Proof to support
allegation
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Impact of Fraud
• The United States spent in excess of $2.2
trillion on health care in 2007
• Fraud is estimated to be between 3% 10% of health care dollars
• If 5% is the average lost to health care
fraud, that would equal to losing
approximately $100 billion in 2007 or
about $300 million per day
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Vulnerabilities
• Where can fraud and abuse occur?
– Hospitals, Physicians, Members, Nursing
Homes, Home Health Care, Ambulance
Services, Office Staff, Chiropractors, Clinics,
Brokers and Agents, Durable Medical
Equipment, Laboratories, Accident Claims,
Pharmacies, Employees, Drug Manufacturers,
Pharmacy Benefit Managers, Group
Enrollments, Wholesalers, Workers
Compensation, to name a few…
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Examples of Pharmacy Fraud
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Billing for higher supply than dispensed
Employee fraud with dispensing
Enhance revenue of brand vs. generic
Kickbacks using manufacturers products
Controlled drugs without physician service
Outlier of reversal rates
Prescription splitting
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Examples of Pharmacy Fraud
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Altering prescriptions
Drug diversion
Pharmacist billing for “gang visits”
Excessive quantity dispensed
Prescription price with inflating AWP
Prescription drug shorting
True Out-of-Pocket (TrOOP) manipulation
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Examples of Pharmacy Fraud
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Double billing
No prescription on file
Unauthorized refills
Incorrect days of supply billed
Unit billing issues
Dispensing without validation of customer
Dispensing expired prescription drugs
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Examples of Facility Fraud
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Unbundled supplies and equipment
Non-covered services hidden
Inflating costs
Charge master inconsistencies
Up coding
Unlicensed ambulatory surgical centers
Skilled nursing failure of care
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Examples of Facility Fraud
• Failure to report credit balances
• Seeking reimbursement for costs not
related to patient care
• Failing to disclose relationship between
business entities
• Diagnostic unnecessary testing
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Examples of Member Fraud
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Stolen card falsification
Misrepresentation on enrollment forms
Stolen prescription pads
Altering prescriptions
Physician or pharmacy shopping
Excessive visits for controlled substances
Beneficiary ID card sharing
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Examples of Physician Fraud
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Coding (up, down, modifiers, rule playing)
Place of service falsification
Non-rendered or phantom billing
Medically unnecessary or unbelievable
Kickbacks or bribery
Billing free services
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Examples of Physician Fraud
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Duplicate billing
Waiver of co-pay or deductible
Misrepresentation on claim
Selling filled scripts on black market
Prescribing to self or family
Over prescribing to patients
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Examples of Physician Fraud
• Excessive scripts of controlled substances
• Excessive quantities of controlled
substances
• Overutilization
• Unlicensed office-based surgeries
• Resubmission of denied claim with
different code(s)
• Medical treatment unrelated
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Prevention
• Combating Fraud is a Collaborative Effort
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AvMed Health Plans Anti-Fraud Program
Department of Justice
Federal Bureau of Investigation
Office of Inspector General
Centers for Medicare & Medicaid Services
Education
Administrative Sanctions
Civil Litigation and Settlements
Criminal Prosecution
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Prevention
• Develop a Compliance Program to include
Fraud, Waste, and Abuse
• System for monitoring claims for accuracy
• Review medical records to validate
documentation supports services rendered
• Perform regular internal audits
• Take action when an issue is identified
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AvMed’s Anti-Fraud Plan
• Fiduciary Responsibility
• Mission Statement
• Compliance
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Section 626.9891(a)(b), Florida Statutes
Section 626.9891(3), Florida Statutes
Rule Chapter 69D-2.001-005, Administrative Code
42 C.F.R. 422.503, Medicare Advantage Program
42 C.F.R. 423.504(b)(4)(vi)(H), CMS Part D
Federal Employees Health Benefit Program
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Fiduciary Responsibility
• The Board of Directors has a fiduciary
responsibility to AvMed specifically and to the
broader health care community to resist criminal
behavior, instances of false claims and improper
billing and coding practices, and other schemes
that adversely impact patient safety, the quality
of health care services being delivered and that
impose a tremendous financial burden on the
health care system.
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Mission Statement
• Fraud and Abuse Program Mission
Statement seeks to meet the customer’s
expectation that we will reimburse only
for services that are medically necessary
and appropriate and that the benefits will
be issued only to eligible subscribers and
providers.
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Anti-Fraud Plan
Education
Training
Prevention
Prosecution
Reporting
Compliance
Detection
Investigation
Tracking
Recovery
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Resources
• Tips
• Websites
– Internal
– External
– U.S. Government
– Regional CMS Carrier
– Professional Physician
• Coding Texts
– ICD-9-CM, CPT, HCPCS
• Data Mining and Profiling
• National Health Care AntiFraud Association
• American Medical Association
• American Health Information
Management Association
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Medicare Drug Contractors
Law Enforcement
Federal Bureau Investigation
Office Inspector General
Vendors
Media
Anonymous (Hotline)
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Healthcare Fraud and You
• Healthcare fraud is a menace to you, your
family, and the future of your health care
• It causes higher premiums or fewer
benefits, higher taxes, and higher copayments
• Your detection and referrals are critical to
the success of all anti-fraud efforts
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Training Attestation
Now that you have completed Fraud, Waste,
Abuse, and Compliance Training in
accordance with CMS regulations, please
click here to attest completion of the
program.
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