Transcript Medicare Advantage/Part D Fraud, Waste, and Abuse Training

Medicare Advantage/Part D
Fraud, Waste, and Abuse
Training
The CMS Mandate
• The Centers for Medicare & Medicaid
Services (CMS) requires all Medicare
Advantage-Prescription Drug health plans
to ensure that their participating providers
complete Fraud, Waste, and Abuse
training no later than December 31, 2009.
Learning Objectives
By the end of this course, you will be able to:
• Describe the Medicare Advantage-Prescription
Drug Fraud, Waste, and Abuse (FWA) training
requirements
• Recognize examples of health care FWA
• Describe steps taken to prevent and combat
FWA
• Describe how you can prevent health care FWA
• Report suspected health care FWA
Key Terms and Acronyms
Part C Medicare
Advantage Plans (MA)
• Provide all of a
person’s Part A and
Part B coverage
• Most MA plans are
offered by private
companies and many
include Part D
coverage
Medicare Part D Plans
• Optional drug
coverage available to
all Medicare recipients
• Most Part D plans are
either stand-alone
prescription drug plans
(PDPs) or MA plans
offering drug coverage
(MA-PD)
Key Terms and Acronyms, Cont’d.
Medicare Advantage
Organizations
• A public or private entity
organized and licensed
by a state as a riskbearing entity (with the
exception of provider
sponsored organization
receiving waivers) that is
certified by CMS as
meeting the MA contract
requirements.
Part D Sponsors
• Refers to a PDP Sponsor,
MA organization offering a
MA-PD plan, a PACE*
organization offering a
PACE plan including
qualified prescription drug
coverage, and a Cost
Plan offering qualified
prescription drug
coverage. This includes
employer- and unionsponsored plans.
*Program of All-Inclusive Care for the Elderly
How Does CMS
Combat Fraud?
1. Close coordination with contractors, providers, and law
enforcement agencies
2. Developing Medicare Program compliance requirements
that protect stakeholders
3. Applying fair and firm enforcement policies
4. Early detection through Medical Review and data
analysis
5. Effective education of physicians, providers, suppliers
and beneficiaries
Among other things, the fifth strategy led to the development of this
FWA training requirement.
FWA Training Requirement
• Required annually for all Part C and D first tier,
downstream, related and delegated entities,
including MA providers who administer Part D
benefit or provide health care services to MA
enrollees .*
– Such entities must advise MA organizations
and Part D sponsors with whom they contract
that the training has been completed.
*The following pages define first tier, downstream, and related entities.
First Tier Entities
• Any party that enters into a written arrangement
with an MA organization to provide
administrative services or health care services
for a Medicare eligible individual.
1
• First tier entities include Pharmacy Benefit
Managers (PBMs)
– SummaCare’s PBM: Catalyst
1
CMS Pub. 100-16 (http://www.cms.hhs.gov/transmittals/downloads/R79MCM.pdf)
Downstream Entities
• Any party that enters
into an acceptable
written arrangement
below the level of the
arrangement between
the MA organization
(and contract
applicant) and a first
tier entity.
1
• Downstream entities
include:
– Pharmacies and
pharmacists
– Subcontractors such as
claims processing firms
– Hospitals
– Primary care providers
– Specialists
– Ancillary providers
– Dentists
1 CMS Pub. 100-16 (http://www.cms.hhs.gov/transmittals/downloads/R79MCM.pdf)
Related Entities
• Any entity that is related to the MA organization by
common ownership or control and:
1.
2.
3.
•
Performs some of the MA organization’s management functions
under contract or delegation;
Furnishes services to Medicare enrollees under an oral or
written agreement; or
Leases real property or sells materials to the MA organization
1
at a cost of more than $2,500 during a contract period.
An example of a related entity would be one where a
sponsor is the parent company of its own in-house
PBM.
1
CMS Pub. 100-16 (http://www.cms.hhs.gov/transmittals/downloads/R79MCM.pdf)
Plan Responsibilities
CMS stipulates that MA
Organizations and Part D
Plan Sponsors are ultimately
responsible for training
entities and providers who
render service to Medicare
health plan members to meet
CMS’ contractual
requirements.
Provider Responsibilities
• By 12/31/09, and annually thereafter, affected
providers and entities must:
1. Complete training as defined in 42 CFR
422.503 (“Medicare Advantage Programs”)
and 42 CFR 423.504 (“Voluntary Medicare
Prescription Drug Benefit”).
2. Submit an attestation to each of the health
plans which you are contracted to provide
services for MA and/or Part D
beneficiaries.
Health Care Fraud
• Intentionally, or knowingly and willfully
attempting to execute a scheme to falsely
obtain money from any health care benefit
program.
• Considered a crime by the federal
government and all 50 states.
FRAUD
Medicare Fraud
• Purposely billing Medicare for services
that were never provided or received
http://www.medicare.gov/FraudAbuse/Tips.asp
Health Care Abuse
• Improper behaviors or billing practices that
create unnecessary costs
Fraud is distinguished from abuse in that, in
the case of fraudulent acts, there is clear
evidence that the acts were committed
knowingly, willfully, and intentionally or with
reckless disregard.
Health Care Waste
• Health care spending that can be eliminated
without reducing the quality of care
Quality waste
Overuse, underuse, and ineffective
use of drugs, medical care, and
surgical services.*
Inefficiency waste
Redundancy, delays, and
unnecessary process complexity
*Examples include the underuse of generic drugs and the overuse of antibiotics
and non-urgent use of emergency department care.
Stakeholders and Risks
for FWA
• Stakeholders include:
–
–
–
–
–
MA Organizations and Part D Sponsors
Providers
Pharmacies
Pharmacy Benefit Managers
Beneficiaries
• Schemes:
– Vary in degree of severity
– Are not necessarily unique to a single stakeholder
– May involve multiple types of fraud, waste, or abuse
Potential Risks – MA Organizations
and Part D Sponsors
• Failure to provide medically necessary services
• Marketing schemes such as offering
beneficiaries a cash payment as an inducement
to enroll in Part D
• Selecting or denying beneficiaries based on their
illness profile or other discriminating factors
• Inappropriate formulary decisions in which costs
take priority over criteria such as clinical efficacy
and appropriateness
Potential Risks – Providers:
Prescription Drug FWA
• Illegal remuneration schemes, such as
selling prescriptions
• Prescription drug switching
• Script mills
• Theft of a prescriber’s Drug Enforcement
Agency (DEA) number, prescription pad,
or e-prescribing log-in information
• Falsifying information in order to justify
coverage
False Claims Act (FCA)
The False Claims Act prohibits any false or fraudulent claims
for government money or property, whether or not the claim is
presented to a government official, and whether or not the
defendant specifically intended to defraud the government.
Liability attaches to government funds dispersed through
intermediaries including state agencies, and may apply to
subcontractors as well as funds received from MA Plans and
Medicaid HMOs.
American Recovery and Reinvestment Act of 2009 (ARA)
Anti-Kickback Statute
• The Anti-Kickback Statute makes it a criminal
offense to knowingly and willfully offer, pay,
solicit, or receive any remuneration to induce or
reward referrals of items or services
reimbursable by a Federal health care program.
• Remuneration includes anything of value,
directly or indirectly, overtly or covertly, in cash
or in kind.
Examples: Free drugs or supplies,
inflated consulting contracts, and gifts of
travel and entertainment.
Combating Fraud:
A Collaborative Effort
The following entities collaborate to combat
Medicare fraud and abuse.
• Department of Justice (DOJ), including the Federal
Bureau of Investigation (FBI)
– criminal enforcement authority
• Office of Inspector General (OIG) and the Department of
Health and Human Services (HHS)
– civil enforcement authority
• Quality Improvement Organizations
– contribute to the effort to prevent and detect fraud
Possible Remediation Processes
•
•
•
•
Education
Administrative sanctions
Civil litigation and settlements
Criminal prosecution
– Automatic debarment
– Prison time
Best Practices for
Preventing FWA
• Develop a compliance program
• Monitor claims for accuracy
– ensure coding reflects services provided
• Monitor medical records
– ensure documentation supports services
rendered
• Perform regular internal audits
Best Practices for
Preventing FWA, Cont’d.
• Maintain open lines of communication with
colleagues and staff members
• Ask about potential compliance issues in
exit interviews
• Take action if you identify a problem
Remember that you are ultimately responsible for claims
bearing your name, regardless of whether you submitted
the claim.
Exclusion Lists
• Check the OIG and General Services
Administration (GSA) List of Excluded
Individuals/Entities (LEIE*) for all new employees
and at least once a year thereafter to ensure that
employees and other entities that assist in the
administration or delivery of services to Medicare
beneficiaries are not included in such lists.
– LEIE: http://exclusions.oig.hhs.gov/search.aspx
– GSA: https://www.epls.gov/
*Individuals who have been reinstated are
removed from the LEIE.
Whistleblower Protections
• Whistleblower: An employee, former
employee, or member of an organization who
reports misconduct to people or entities that
have the power to take corrective action.
• Generally, the misconduct is a violation of
law, rule, regulation, or direct threat to public
interest.
• Examples include fraud, health/safety
violations, and corruption.
Whistleblower Protections, Cont’d.
• The Whistleblower Provision of the False Claims Act
allows individuals to:
– Report fraud anonymously
– Bring suit against an organization on behalf of the
government and collect a portion of any settlement that
results*
* The US Department of Justice reviews each case initiated by the
individual , who is called a qui tam relator, and decides whether or
not to take action against the organization. The qui tam relator can
share the recovery, even if he or she participated in the false claim.
If the court finds that an employee was terminated for helping the
government investigate false health claims, that person is entitled to
reinstatement, double the amount of back pay, plus interest, and
compensation for expenses, such as legal fees.
Confidential Methods for
Reporting FWA
OIG
• Phone: 1-800-HHSTIPS
CMS
• Phone: 1-800MEDICARE
– (1-800-8477- 8477)
– (1-800-633-4227)
• TTY: 1-800-377-4950
• Email:
[email protected]
• TTY: 1-877-486-2048
Callers are encouraged to provide
information on how they can be contacted
for additional information, but they may
remain anonymous if they choose.
SummaCare
Compliance Hotline
• SummaCare investigates all reported cases of fraud and
abuse.
• Compliance hotline: 330-996-8821 or 1-800-361-3908
– Available 24 hours a day, 7 days a week
• May leave your name, number, and other info, or may
remain anonymous. Either way, please include the
following:
– The reason you believe that a fraudulent or abusive situation has
occurred.
– Information regarding the situation in question.
– The name of the individual, provider or group that may have
committed fraud or abuse.
– The date(s) that the situation has occurred.
Appendix
The following section is the appendix.
Online Resources
• CMS’ Prescription Drug Benefit Manual
– http://www.cms.hhs.gov/prescriptiondrugcovcontra/12_Part
DManuals.asp
• Code of the Federal Register (see CFR 422.503 and CFR
423.504)
– http://www.cms.hhs.gov/quarterlyproviderupdates/downloa
ds/cms4124fc.pdf
• Office of the Inspector General
– http://www.oig.hhs.gov/
• Medicare Learning Network (MLN) Fraud & Abuse Job Aid
– http://www.cms.hhs.gov/MLNProducts/downloads/081606_Medicare_Fr
aud_and_Abuse_brochure.pdf
The Cost of Healthcare Fraud
• U.S. spent $2.2 trillion on health care in
2007
• Estimates suggest that 3%-10% of health
care dollars are lost to fraud
1
If 5% is the correct figure, that means the U.S. lost
about $100 billion to health care fraud in 2007
alone – or about $300 million per day.
Prescription Drug Fraud
• Prescription drugs constitute
approximately 10% of all health care
spending .
1
1
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=56280
Risks to Individuals
How does fraud harm individuals?
• Unnecessary procedures may cause injury or
death
• Falsely billed procedures create an erroneous
record of the patient’s medical history
• Diluted or substituted drugs may render
treatment ineffective or expose the patient to
harmful side effects or drug interactions
• Prescription narcotics on the black market
contribute to drug abuse and addiction
Examples of Risks for Wholesalers
• Counterfeit and adulterated drugs through black and grey
market purchases
– This includes but is not limited to fake, diluted, expired,
and illegally imported drugs.
• Diverters
– Brokers who illegally gain control of discounted medicines
intended for places such as nursing homes, hospices and
AIDS clinics. Diverters take the discounted drugs, mark up
the prices, and rapidly move them to small wholesalers. In
some cases the pharmaceuticals may be marked up six
times before being sold to the consumer.
• Inappropriate documentation of pricing information
– Submitting false or inaccurate pricing or rebate information
to or that may be used by any Federal health care
program.
Examples of Risks for
Pharmaceutical Manufacturers
• Lack of integrity of data to establish payment and/or
determine reimbursement
– Inappropriate documentation of pricing information:
Manufacturers must maintain accurate and complete
documentation of their pricing information.
• Kickbacks, inducements, and other illegal remuneration
– Inappropriate marketing and/or promotion of products (sales,
marketing, discounting, etc.) reimbursable by federal health
care programs.
– Inducements offered if the purchased products are
reimbursable by any of the federal health care programs.
Examples of potentially improper inducements include
inappropriate discounts, inappropriate product support
services, inappropriate educational grants, inappropriate
research funding, or other inappropriate remuneration.
Examples of Risks for Pharmaceutical
Manufacturers, Cont’d.
• Formulary and formulary support activities
– Examples of potential fraud and abuse include
inappropriate relationships with formulary committee
members, payments to PBMs, and formulary
placement payments in order to have manufacturer’s
products included on a Plan’s formulary.
• Illegal off-label promotion: Illegal promotion of off-label
drug usage through marketing, financial incentives, or
other promotion campaigns.
• Illegal usage of free samples: Providing free samples to
physicians knowing and expecting those physicians to
bill the federal health care programs for the samples.
Examples of Risks for Pharmaceutical
Manufacturers, Cont’d
• Inappropriate relationships with physicians
– “Switching” arrangements, when manufacturers offer
physicians cash payments or other benefits each time a
patient’s prescription is changed to the manufacturer’s
product from a competing product.
– Incentives offered to physicians to prescribe medically
unnecessary drugs.
– Consulting and advisory payments, payments for
detailing, business courtesies and other gratuities, and
educational and research funding.
– Improper entertainment or incentives offered by sales
agents.
Administrative Sanctions
• Denial or revocation of Medicare provider
number
• Suspension of provider payments
• Addition to the OIG List of Excluded
Individuals/Entities (LEIE)
• License suspension or revocation
• Civil Monetary Penalties
Civil Monetary Penalties (CMPs)
• The Social Security Act
authorizes the imposition of
CMPs when Medicare
determines that an
individual or entity has
violated Medicare rules and
regulations.
• Typically, penalties involve
assessments of significant
damages such as CMPs up
to $25,000 for each
Medicare Advantage
enrollee directly affected.
Civil Litigation and Settlements
• The United States’ Attorney’s Office may file a
civil suit or decide that the interest of the
Medicare Program is best served by settling a
case out of court.
• The civil suit or settlement may include a
Corporate Integrity Agreement (CIA).
– A CIA requires the individual or entity to accomplish
specific goals (e.g. educational plan, corrective action
plan, reorganization) and be subject to periodic audits
by the federal government.
Possible Civil and
Criminal Penalties
• False Claims Act
– For each false claim: $5,500-$11,000
– If the government proves it suffered a loss,
the provider is liable for three times the loss
• Up to five years in prison and fines of up to
$25,000 for violations of the Anti-kickback
Statute
• If a patient suffers bodily injury as a result of the
scheme, the prison sentence may be 20+ years
Acknowledgement
SummaCare gratefully acknowledges
Health Care Administrative Solutions, Inc.
for granting permission to reproduce the
content of this course.
Original content available at: http://www.hcasma.org/MedicalTraining.aspx