Transcript the 2013 Medicare Part D

2013 Medicare Part D
Compliance & FWA Training
For Blue Shield of California Contracted Network Pharmacies
H0504_13_378C 11082013
S2468_13_378C 11082013
April 7, 2015
Welcome
Welcome to the 2013 Medicare Part D
Compliance & FWA Training course!
This is Blue Shield of California’s 2013 Medicare Part
D Compliance & FWA Training for contracted
pharmacies.
At the end of this training, pharmacies will be
asked to complete and submit an attestation for
completing the training.
 Medicare Part D Compliance Training for contracted
pharmacies
 Fraud, Waste & Abuse for contracted pharmacies
 Attestation
Introduction to the Medicare
Part D program
Part D overview
 Part D (prescription drugs) is
the biggest change in
Medicare in 40 years.
 The Medicare Modernization
Act (MMA) of 2003 provided
prescription drug coverage
for Medicare beneficiaries.
Part D overview, continued
 Part D is embodied in statute
through the Code of Federal
Regulations under Title 42, CFR 423
VOLUNTARY MEDICARE PRESCRIPTION
DRUG BENEFIT
 Part D is a voluntary benefit
offered through health plans,
qualified contractors, and some
employers
Part D players
CMS
PBMs
Centers for Medicare & Medicaid Services
Government agency that supervises the administration of Medicare
benefits, including Part D
Pharmacy Benefit Managers
Companies that manage pharmacy benefits, create formularies, process
pharmacy claims, and negotiate discounts with drug manufacturers. (Some
plan sponsors, like Blue Shield of California, may perform some or all of these
functions rather than outsourcing to a PBM.)
Plan
Sponsors
MEDICs
IREs
Plan Sponsors
Pharmaceutical chains, health insurance companies, and others that
contract with CMS to deliver PDP plans (Prescription Drug Plan – Part D
benefits only) and MAPD plans (Medicare Advantage Prescription Drug
Plan – Part C & Part D benefits)
Medicare Drug Integrity Contractors
Agencies contracted by CMS to investigate fraud, waste, and abuse in the
Parts C & D programs, including compliance and enforcement work.
Independent Review Entities
Agencies contracted by CMS to review Plan denials of coverage decisions
First-Tier and downstream entities
•Some plan functions may be delegated by a Plan Sponsor to a first-tier or
downstream entity.
•You are considered a first-tier entity, because we contract directly with you.
•Even when plan functions are delegated to a first-tier or downstream entity,
the Plan Sponsor is still responsible for meeting all CMS requirements and
must establish oversight.
•One of CMS’ requirements is that each Plan Sponsor (i.e. Medicare health
plan) have a comprehensive compliance program.
What’s covered under Part D
 Commencing 1/1/2013, benzodiazepines
(all medically accepted indication) and
some barbiturates (for the treatment of
epilepsy, cancer or chronic mental health
disorder) are covered under Part D
 Outpatient prescription drugs
– Approved by the FDA
–
Used & sold in the United States
–
Used for a medically accepted
indication
 Vaccines & biologicals not covered by
Part B
 Insulin & medical supplies associated with
the injection of insulin
Note: Commencing
January 1, 2014, all
barbiturates that otherwise
meet the definition of a Part
D drug may be covered
under Part D when used for
any medically accepted
indication (as defined in The
Affordable Care Act of 2010
§1927(k)(6)).
What’s NOT covered under Part D
 Drugs listed under Title XIX of the
Social Security Act
 Drugs currently covered under
Part B
 Drugs for erectile & sexual
dysfunction
 Beginning January 1, 2011, drugs from
pharmaceutical manufacturers that
did not sign a manufacturer discount
agreement with CMS
– Drugs used for anorexia, weight
loss, or weight gain
– Drugs used to promote fertility
– Drugs used for cosmetic purposes
or hair growth
– Drugs used for symptomatic relief
of cough & colds
– Prescription vitamins & minerals,
except prenatal vitamins &
fluoride preparation products
– Over-the-counter drugs
– Drugs for which the manufacturer
requires that associated tests and
monitoring services be purchased
exclusively from the manufacturer
or its designee
2013 standard benefit coverage
design
*Amounts will change for 2014
Coverage
Part D Pays
Beneficiary Pays
Annual Deductible
$0
$325
Initial Coverage Period $2970
75% of $2970
25% of $2970
Coverage Gap (“Donut hole”) Once your
total drug cost (what you and your plan pay)
exceeds $2970, you are in the ”donut hole.”
$0 (The 52.5% discount for brand
name drugs comes from drug
manufacturers, and the 14% subsidy
for generic drugs comes from
Medicare.)
47.5% of covered brand name
drugs plus dispensing fee;
79% of covered generic drugs
Catastrophic Coverage
This begins once you have reached your ”outof-pocket” threshold of $4750 in 2013.
95% or the drug cost minus the
copay
Greater of 5% of the drug
costs, or $2.65 for a generic
drug or $6.60 for a brand
name drug
TrOOP = true out of pocket
deductible + initial coverage + money spent in the coverage gap = TrOOP
 The total amount of money
spent by the beneficiary
 Because the catastrophic level
of coverage is dependent upon
the TrOOP calculation, it is very
important for plans to record
TrOOP accurately.
 Plans may offer an “enhanced”
benefit to reduce or eliminate
the deductible and/or
beneficiary costs during the
coverage gap.
The Medicare Coverage Gap
Discount Program
Starting in January 2013, Medicare Part D members (excluding low income
subsidy members) will get a 47.5% discount under the Medicare Coverage
Gap Discount Program on “applicable” brand drugs and a 79% subsidy for
generic drugs while in the coverage gap.
Over the next 10 years the goal of this program is to increase coverage of all
covered drugs in the coverage gap to decrease what Medicare Part D
members (excluding low income subsidy members) pay until it reaches 25%
in 2020.
How should pharmacies prepare for
the Medicare Coverage Gap
Discount Program?
1. Manage the Supply Chain: Pharmacies should work with Medicare Part D
contractors to review the list of labeler codes on the CMS Web site to
determine if their inventories have applicable drugs. This can be done by
comparing inventory against CMS’s list of labeler codes that are covered
by a signed agreement in 2013. The Medicare Coverage Gap Discount
Program labeler code list can be used to identify which manufacturers’
applicable drugs will continue to be covered under Medicare Part D in
2013.
2. Educate Staff: Pharmacy staff should be made aware of the Medicare
Coverage Gap Discount Program and be prepared to answer patient
inquiries about it.
To obtain more information regarding this program and specific claims go to
www.Medicare.gov or call the applicable plan sponsor.
Member rights to coverage
Members under Part D are entitled to
the benefit coverage offered by Blue
Shield. As part of the entitlement
process, members have specific rights to
appeal coverage determinations.
Who can request a coverage
determination?
 A beneficiary or their authorized
representative
 A beneficiary’s prescribing physician or
other authorized prescriber
If a member disagrees
with a plan’s coverage,
the member should
contact the health plan.
Doing business with the
government
Office of Inspector General (OIG) &
General Services Administration
(GSA) exclusion lists
 CMS prohibits any employee, provider,
contractor, or subcontractor that is listed in the
General Services Administration (GSA) database
of excluded individuals/entities or the Office of
Inspector General’s (OIG) database of excluded
individuals or entities from performing any activity
related to Medicare Part D or other federal
programs.
 Human Resources, Procurement, Pharmacy,
Credentialing, Corporate Compliance, Producer
Services, and other contractors, and
subcontractors must review the exclusion lists for
all staff working with Medicare Part D ―upon
employment and annually thereafter.
Exclusion list (cont’d)
You must notify Blue Shield of California immediately if an exclusion is
identified. Excluded persons or entities are prohibited from receiving
payment.
OIG: http://exclusions.oig.hhs.gov
GSA: http://sam.gov
Data accuracy
 Never falsify certifications or attestations or any
transmissions to CMS on Medicare enrollment
data, disenrollment data, coordination of
benefits status, or applicable true out-of-pocket
costs. Any outliers in your oversight process
should be included as footnotes in your
pharmacy’s certifications or attestations.
 All data used in calculation of your submissions is
subject to audit and must be accurate. It must
also be retained for ten years.
 If you become aware of a systems issue that
affects the accuracy of any data used in your
pricing or submissions to the plan, report it to your
pharmacy manager or one of your compliance
resources.
Laws
Here are important laws you need to be aware of when
working with Medicare Part D:
The False Claims Act - Prohibits knowingly presenting (or causing to be
presented) to the federal government a false or fraudulent claim for
payment or approval.
The Anti-Kickback Statute - Section 1128B(b) of the Social Security Act
(42 U.S.C. 1320a-7b(b)) provides criminal penalties for individuals or
entities that knowingly and willfully offer, pay, solicit, or receive
remuneration in order to induce or reward business payable (or
reimbursable) under the Medicare or other federal health care
programs.
The Health Insurance Portability and Accountability Act 75 - All
member information under Part D must be done in compliance with
HIPAA regulations and internal policies to manage and maintain
adequate controls in use and handling of member data.
Health Information Technology for Economic and Clinical Health Act
Penalties -Penalties up to $1.5 Million for all violations of an identical
provision
Additional vulnerabilities
 Coordination with State Pharmacy
Assistance Programs (SPAPS)
 National Council for Prescription Drug
Programs (NCPDP) and National
Association of Drug Diversion
Investigators (NADDI)’s lists of
susceptible pharmaceuticals
 Drugs excluded From Part D coverage
 Part B and Part D coverage issues
 Inappropriate duplicate coverage
between A, B, and D drugs (Home
Infusion, Crossover Drugs, Differential
Copays)
– Prevent double billing
– Ensure that the Part D
Plans remain the primary
payer
– Ensure that benefits are
coordinated so that
TrOOP tracking of SPAPs
is taken into account
– Ensure that expenditures
by other plans are
excluded for the
purposes of reaching
the beneficiaries true
out-of–pocket (TrOOP)
expenditures
Medicare Part D fraud, waste,
and abuse training
Prescription drug fraud, waste, and abuse
cost the United States billions of dollars
annually.
By learning how to detect, correct and
prevent Medicare Part D prescription drug
fraud, waste, and abuse, you can
save money for your pharmacy, Medicare,
and your customers.
The Centers for Medicare and Medicaid
Services (CMS) requires that all individuals
who work with Medicare Part D in any way
receive training on identifying and
controlling fraud, waste, and abuse.
This training lesson is designed to help you
become an active participant in the fight
against Medicare Part D prescription drug
fraud, waste, and abuse.
What is Blue Shield doing about it?
Special Investigations Department
In 1989, Blue Shield established the
Special Investigations Department to
centralize the company’s efforts to
combat fraud. The department’s
investigators work to detect and
prevent medical fraud, and now
partner with Pharmacy Services to
include prescription drug fraud.
Medicare Compliance Program
With the introduction of the Medicare
Prescription Drug Benefit (Part D) in
2006, Blue Shield updated its existing
Medicare Compliance Program to
include Fraud, Waste, and Abuse
(FWA) for Part D.
Elements of the updated
Medicare Compliance
Program include:
 FWA Training
 Procedures for reporting
non-compliance with
Medicare Program
requirements & WA
 Reviewing OIG and GSA
exclusions lists
 Internal Monitoring/
Auditing
 Pharmacy Network
Monitoring/Auditing
What can you do?
You can help to detect prescription
drug fraud, waste, and abuse related
to Medicare Part D plans by reporting
suspicious incidents to Blue Shield.
To do so, you need to be able to
recognize activities that may constitute
Medicare Part D fraud, waste, or abuse
committed by a pharmacy, provider,
customer, subcontractor, or plan
employees, and then report incidents
as quickly as possible.
It’s the right thing to do!
What is prescription drug fraud?
Definition
Fraud means that someone is trying to
obtain something of value by
intentionally deceiving,
misrepresenting, or concealing.
Proof of fraud involves the following
components:
 An intentional misrepresentation, a
lie, a false statement, an omission,
or a concealment of the truth,
related to a pharmacy prescription
or claim, or
 An individual or company receiving
money or pharmacy prescription
drug benefits.
Examples
Fraud
 A person uses someone else’s
insurance card to receive
Medicare Part D benefits. This
person intentionally posed as
someone else and received
Medicare Part D benefits they were
not entitled to.
 A provider intentionally prescribes
drugs that are not medically
necessary.
Not Fraud
 A pharmacy bills for a full 30-day
supply, fills only 15 days, but later
revises the claim to 15 days. The
intent to misrepresent is not present.
Who commits fraud?
Just about anybody could potentially
commit prescription drug fraud:
 Providers
 Members
 Pharmacies
 Wholesalers
 Pharmaceutical manufacturers
 Medicare Part D sponsor
employees
On the next few slides you’ll see examples of
fraud committed by each of the groups
above.
Provider fraud examples
Providers could participate in Medicare Part D
fraud that involve:
 Prescribing drugs without reviewing a
patient’s condition.
 Prescribing drugs in exchange for payment,
usually involving narcotics and physicians
with “marks” on their licenses.
 Writing a prescription for a higher quantity
than appropriate to assist member with
minimizing their copay.
Member fraud examples
Medicare Part D members may participate in
fraud that involves:
 Stealing a prescription pad and writing
their own prescriptions.
 Using someone else’s ID card to get
Medicare Part D benefits.
 Modifying a prescription to add more
refills, increase quantities, etc.
Pharmacy fraud examples
Pharmacies could participate in fraud that
involves:
 Billing for the full amount prescribed
but filling only a portion, and not
crediting the difference back to the
plan sponsor.
 Billing for brand but dispensing
generic, or for the wrong NDC code.
 Manipulating calculations to keep
beneficiaries in the coverage gap or
to push beneficiaries into catastrophic
coverage.
Wholesaler fraud examples
Wholesalers may participate in fraud that
involves:
 Selling counterfeit and adulterated
drugs through black and gray market
purchases, including fake, diluted,
expired, and illegally imported drugs.
 Illegally gaining control of discounted
medicines intended for nursing homes,
hospices, and AIDS clinics, marking up
the prices, and selling to small
wholesalers who sell to consumers
(people who do this are referred to as
“diverters”).
Pharmaceutical manufacturer
fraud examples
Pharmaceutical manufacturers may participate
in fraud that involves:
 Offering inducements if the purchased
products are reimbursable by any of the
federal healthcare programs.
 Promoting off-label drug usage illegally
through marketing, financial incentives, or
other promotion campaigns.
 Using free samples illegally by knowingly
providing them to physicians who will bill
the federal health care programs for the
samples.
Part D sponsor fraud examples
Medicare Part D sponsor employees
could participate in fraud that involves:
 Violating the Medicare marketing
guidelines, such as offering beneficiaries
a cash payment as an inducement to
enroll in Part D.
 Bait and switch pricing.
 Payment for prescriptions written by
dead or sanctioned physicians.
 Misrepresenting or falsifying information
furnished to CMS or to an individual
under the Part D drug benefit program.
 Altering or manipulating Part D claims
data to avoid paying interest.
Red flags of Part D fraud
Now you know the two main components
of prescription drug fraud and some
examples, but how would you actually
identify prescription drug fraud in your daily
work in the pharmacy?
Let’s take a look at some “red flags” that
would lead you to suspect prescription
drug fraud may have occurred:
 Multiple Pharmacies
 Repetition and Excessive Billing
 Large Pharmacy Claims/Excessive Billing
 High-Prescribing Physicians
 Medical Conditions Don’t Match or Don’t Exist
We’ll explain each of these on the next few slides.
Red flag: multiple pharmacies
You see that a Medicare
Part D recipient has used
three or four pharmacies long
distances from each other
within a six-month period for
the same prescription.
This can be indicative of
substance abuse or narcotics
trafficking.
Red flag: repetition and excessive
billing
Pharmacy bills a high
volume of only one type or
limited type of medication.
This may be a case where
pharmacy is billing for
medication not being
dispensed.
You start to notice a pattern of
the same claims for
prescriptions being submitted
on a weekly, monthly, or yearly
basis, and you know that is
inconsistent with how the drug
is typically administered.
Red flag: large pharmacy claims
High-dollar claims are worth
inspecting further.
The bill is three or more times
the usual and customary price
contracted rate for a drug.
Excessive numbers of refills for
one patient or same family
members, which may
indicate pharmacy employee
collusion.
Red flag: high-prescribing
physicians
You notice that a physician is
one of the highest prescribers,
but he has relatively few
patients. This may be a case
where medications are used
for illegal sale, especially with
medications that have a high
likelihood of being abused.
Red flag: medical conditions don’t
match or exist
The prescribed medications
are out of line with the
medical history/claim history
of the patient.
For example, a pharmacy
bills for a large number of
antipsychotic medications,
with no patient history of
psychiatric illness.
Difference between fraud and abuse
There is a fine line between fraud and
abuse, based on whether there was
intent to deceive.
 Fraud involves intentional deception
or misrepresentation intended to
result in an unauthorized pharmacy
benefit.
 Abuse may be similar to fraud except
that it may not be possible to
establish that the abusive acts were
done with an intent to deceive the
insurer.
Can you prove that the person knew
they were committing a crime? If so, it’s
fraud. If not, it’s probably abuse. In
either case, you should report it.
abuse examples
 Charging for Medicare Part D
benefits when it should be Part B
 Using multiple NDCs for a
compounded drug and billing
separately when only the highest
NDC should be charged
 Incorrectly billing for secondary
payers that resulted in an
increased reimbursement
What is waste?
A portion of Medicare Part D dollars are
spent on waste. Waste and inefficiencies
continue to increase, costing taxpayers
more while providing beneficiaries with
less.
Waste is described as:
“The extravagant, careless, or needless
expenditure of funds, or the
consumption of property that results
from deficient practices, systems,
controls, or decisions.”
Think about how you can help reduce
waste in the administration of Part D
benefits.
waste examples
 Submitting a claim with an
inflated ingredient cost for extra
payment rather than the actual
price of the drug
 Consistently filling prescriptions for
a 30-day supply (when a 15-day
supply will suffice)
 Drugs prescribed that are not
medically necessary
 Making payment and other errors
in the administration of Part D
benefits
Why should I report?
The Centers for Medicare and Medicaid
Services (CMS) requires you to report
fraud.
By detecting and reporting fraud, waste,
and abuse, you are doing the right thing.
What if I’m not sure?
In some cases you may want to do a little
research to find an explanation for the
unusual claim. But if you suspect that
something is not right, report it.
If you are concerned that you could be
wrong about suspecting Part D fraud, waste,
or abuse, don’t be. Rest assured that Blue
Shield of California’s Medicare Compliance,
Pharmacy Services, and Special Investigations
Department appreciate all tips and will work
to screen the case and collect the evidence
to determine if there is a reason to suspect
fraud.
If you suspect,
report
All tips are welcome
How to report
There are several ways to report Blue Shield of California
Medicare Part D fraud, waste & abuse:
 Form
Access the Fraud Report Form
Pharmacists and other people outside of Blue Shield of California:
https://www.blueshieldca.com/bsca/about-blue-shield/fraudprevention/report/home.sp
Part D-related calls and
 Phone
Call Blue Shield of California Anti-Fraud Hotline
at 800-221-2367.
 Email
Send an email to
[email protected]
emails related to all
suspected fraud, waste &
abuse will be routed to the
appropriate area for
screening, then submitted
to our Pharmacy Services
and/or Special
Investigations departments
for further assessment.
 Contact the Blue Shield of California Medicare Compliance Officer,
Mark Andes. Telephone: 818-228-2655 or via email at
[email protected]
 When you report a suspicious incident, you can identify yourself or you
may remain anonymous.
What happens after I report?
1. Routing of Forms, Calls, and Emails
 Prescription drug fraud forms and Medicare Part D
fraud, waste, and abuse calls/emails are routed to
Pharmacy Services and/or Special Investigations.

Compliance issues are routed to Medicare
Compliance.
2. Assessment, Investigation, and Coordination with CMS
 When Pharmacy Services and Special Investigations
determine that an issue is a
potential prescription drug fraud, Special
Investigations follows their investigation process to
follow up on fraud issues reported.


MEDIC (Medicare
Drug Integrity
Contractor) is an
This process involves Special Investigations
organization that
coordinating with Blue Shield of California’s Medicare
CMS has contracted
Compliance department, CMS, MEDIC, and other law
with to manage
enforcement (as needed) for resolution.
CMS’ audit,
You may report anonymously and retaliation is
oversight, and antiprohibited when you report a concern in good
fraud and abuse
faith.
efforts related to the
Part D benefit.
Module I summary
We’ve covered a lot of information about
Medicare Part D in this training module.
So what are the key points to remember?
 It’s important for you to understand the basics of
Medicare Part D, the standard benefit, and Blue Shield of
California's requirements for offering Medicare Part D
plans.
 To do business with CMS we all have to follow the rules
they’ve set regarding exclusion lists and data accuracy,
as well as all applicable laws. As an entity processing and
accepting payment for Medicare part D claims, your
pharmacy and all staff are responsible to abide by all
Federal and State requirements of this program.
 Identifying and reporting prescription drug fraud, waste,
and abuse is the right thing to do because it may reduce
the money spent by the government, plans, and
ultimately taxpayers due to fraudulent, wasteful, and
abusive practices.
If you suspect any possible
fraudulent, wasteful or
abusive activity, please let us
know right away!
Call Blue Shield of California AntiFraud Hotline:
800-221-2367
Submit form:
https://www.blueshieldca.com/b
sca/about-blue-shield/fraudprevention/report/home.sp
Email:
[email protected]
Contact the Medicare
Compliance Officer:
Mark Andes
818-228-2655
[email protected]
Module II
The second part of the training will review the following information.
•Compliance Plan
•Health Insurance Portability and Accountability Act (HIPAA)
•Legal Actions
•Conflict on Interest
•Code of Business Conduct
•Non-Retaliation
•FWA Recap
What is a compliance plan?
•A compliance plan is a series of internal controls and measures to ensure the plan sponsor follows
applicable laws and regulations that govern Federal programs, like Medicare.
•The adoption and implementation of a compliance program significantly reduces the risk of fraud,
waste and abuse in the health care setting, while providing quality of services and care to patients.
•Fraudulent behavior and non compliance will result in mandatory retraining and may result in
disciplinary action, including possible termination when such behavior is serious or repeated or when
knowledge of a possible violation is not reported.
•Attendance and participation in compliance and FWA training programs is a condition of
continued employment and a criterion to be included in employee evaluation
•The Compliance plan should reference the policies related to contracting with the government,
such as the laws addressing gifts and gratuities for Government employees.
•
Organizations contracting directly or indirectly with the federal government are obligated to:
Report fraud, waste and abuse;
Demonstrate their commitment to eliminating fraud, waste and abuse; and
• Implement internal policies and procedures to identify and combat health care fraud.
•
What is a compliance plan?
(cont’d)
An effective Compliance Plan includes 7 core elements:
1. Written Standards of Conduct: Development and distribution of written
Standards of Conduct and Policies and Procedures that promote our
Plan Sponsors’ commitment to compliance and that address specific
areas of potential fraud, waste and abuse.
2. Designation of a Compliance Officer: Designation of an individual and a
committee charged with the responsibility and authority of operating and
monitoring the compliance program.
3. Effective Compliance Training: Development and implementation of
regular, effective education and training, such as this training.
4. Internal Monitoring and Auditing: Use of risk evaluation techniques and
audits to monitor compliance and assist in the reduction of identified
problem areas.
5. Disciplinary Mechanisms: Policies to consistently enforce standards and
address dealing with individuals or entities that are excluded from
participating in CMS programs
What is a compliance plan?
(cont’d)
6. Effective Lines of Communication: Between the compliance officer and
the organization’s employees, managers and directors and members of the
compliance committee, as well as first tier, downstream and related entities.
•Includes a system to receive, record and respond to compliance questions,
or reports of potential or actual non-compliance, while maintaining
confidentiality
•First tier, downstream, and related entities must report compliance
concerns and suspected or actual misconduct
7. Procedures for Responding to Detected Offenses and Corrective Action:
Policies to respond to and initiate corrective action to prevent similar
offenses including a timely, reasonable inquiry.
Health Insurance Portability and
Accountability Act (HIPAA)
• Among other things, HIPAA, was enacted to improve the efficiency and
effectiveness of health information systems through the establishment of standards and
requirements for the electronic transmission of certain health information.
• Regulations include standards for certain electronic transactions, minimum
security requirements, and minimum privacy protections for individually
identifiable health information covered entities (i.e., protected health
information).
•
HIPAA includes a provision that established the Medicare Integrity Program (MIP)
• The goal of the MIP is to pay it right -pay the right amount, to the right provider or
supplier, for the right service, to the right beneficiary.
• The CMS staff, Fiscal Intermediaries, and carriers work within a wide range of
Medicare programs to improve payment accuracy.
- These programs include cost report auditing, the Medicare
Secondary Payment (MSP) provisions, Medical Review (MR),
and anti-fraud activities to improve payment accuracy.
Legal actions
•
A provider, supplier or health care organization that has been convicted
of fraud may receive a significant fine, prison sentence or be temporarily
or permanently excluded from the Medicare program or other Federal
health care programs, and in some states, lose their license. Failure to
comply with fraud and abuse laws may result in:
◦ Investigations referred to the Office of Inspector General (OIG)
◦ Civil monetary penalties that can result in up to $10,000 per violation and
exclusion from the Medicare program
◦ Denial or revocation of a Medicare Provider Number
◦ Suspension of payment
Conflict of interest
A conflict of interest occurs when an individual's private interest interferes
in any way — or even appears to interfere — with the interests of the
Company as a whole. The Company expects all employees, officers and
directors to exercise good judgment and the highest ethical standards in
their activities on behalf of the Company as well as in their private
activities outside the Company. Merely an appearance of a conflict can
reflect negatively on the Company and its reputation, even if there is no
actual conflict present. The Company's employees and officers are
expected to devote their full time and attention to company business
during regular working hours and for any additional hours that are required
to complete their day to day operations.
Code of business conduct
Blue Shield of California and its subsidiaries are committed to doing the right thing. It is
the first of our Company Values. Integrity, honesty, and compliance with our policies
and the law guide the way we do business. These principles are the foundation of our
Code of Business Conduct, and of the Corporate Compliance and Ethics Program
overall. The Code gives us a framework for doing business the right way. It provides
standards of conduct that enhance the efficiency and effectiveness of our
organization and help us fulfill our mission to ensure that Californians have access to
high-quality health care at an affordable price. By adhering to the principles of the
Code, we exemplify what it means to do the right thing.
CMS expects Blue Shield of California to share our standards of conduct with our first
tier, downstream and related entities (FDRs) and either ensure that these entities
adhere to our standards or make certain that these entities adopt and follow their own
standards of conduct. These standards reflect a commitment to detecting, preventing
and correcting noncompliance with Medicare requirements, including detecting,
preventing and correcting fraud, waste and abuse.
Below is Blue Shield of California's Code of Business Conduct.
https://www.blueshieldca.com/bsca/documents/about-blueshield/corporate/Blue_Shield%20_Code_of_%20Conduct.pdf
Non-Retaliation
Remember, we are committed to providing steps to help individuals report
violations without fear of retaliation. Anyone who, in good faith, reports a
potential violation or cooperates with an investigation is protected against
intimidation or retaliation (e.g., demotion or discharge). Anyone who
retaliates against a person who has filed a report or cooperation in an
investigation is subject to corrective action, up to, and including, contract
termination.
Compliance program requirement:
fraud, waste and abuse (FWA)
As indicated previously, CMS requires Plan Sponsors to have measures in
place as part of its Compliance Program to detect, correct and prevent
FWA.
In accordance with these requirements, we have established a FWA
Program that includes:
•Policies and procedures that address how to identify and address FWA.
•Processes for asking questions, requesting clarification and reporting issues.
•Disciplinary guidelines for non-compliant or fraudulent behavior.
Compliance violations
CMS and other federal agencies can seek civil, criminal and monetary
penalties from Plan Sponsors for compliance violations, including:
Monetary penalties;
Suspension of enrollment activities;
Suspension of payment for Medicare Beneficiaries who enroll, and
Suspension of all marketing activities to Medicare Beneficiaries
Module II summary
Recap of the module and important points to remember:
•The 7 core elements of an effective compliance program
•HIPPA
•Legal Actions
•Conflict of Interest
•Code of Business Conduct
•Non-Retaliation
•Compliance violations
Modules complete!
Congratulations! You’ve completed the
Medicare Part D Compliance & FWA
Training for Pharmacies!
What should you do next?
Complete the attestation and submit it to
Blue Shield of California.
Click this link to access the attestation.