Fraud, Waste & Abuse Overview: General Compliance
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Fraud, Waste Abuse Overview: General Compliance Training 2021 Healthcare Fraud, Waste and Abuse Fraud, waste and abuse (FWA) continue to take a heavy toll on the healthcare system. In 2019 the Office of Inspector General (OIG) doubled the
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Fraud, Waste & Abuse Overview: General Compliance Training 2021<br>
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Healthcare Fraud, Waste and Abuse Fraud, waste and abuse (FWA) continue to take a heavy toll on the healthcare system. In 2019 the Office of Inspector General (OIG) doubled the amount of money recovered from healthcare fraud schemes from $2.9B to $5.9B
A compliance program contains measures to prevent, detect and correct fraud, waste and abuse. We all have a role to play and be alert for suspicious activities that have the potential for fraud, waste and abuse and respond by reporting anything you may notice.
Compliance Program
Compliance programs are designed to ensure that we meet all legal, regulatory and business requirements, both domestic and international. They reflect our commitment to reduce the potential for non-compliance with these requirements.<br>
A compliance program contains measures to prevent, detect and correct fraud, waste and abuse. We all have a role to play and be alert for suspicious activities that have the potential for fraud, waste and abuse and respond by reporting anything you may notice.
Compliance Program
Compliance programs are designed to ensure that we meet all legal, regulatory and business requirements, both domestic and international. They reflect our commitment to reduce the potential for non-compliance with these requirements.<br>
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FWA Definitions Fraud is intentional deception. Fraud is the misrepresentation or concealing of facts to obtain something of value; for example, billing for services or supplies that were not provided.
The complete definition has three primary components:
Intentional dishonest action or misrepresentation of fact
Committed by a person or entity
With knowledge that the dishonest action or misrepresentation could result in an inappropriate gain or benefit
This definition applies to all persons and all entities. However, there are special rules around intentional misrepresentations to government programs such as Medicare & Medicaid, or TRICARE.
Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system.
Inefficient or ineffective practices or systems can produce waste; for example, providing services that are medically unnecessary. To recognize healthcare fraud, you need to be aware of what it is. Become familiar with these terms:<br>
The complete definition has three primary components:
Intentional dishonest action or misrepresentation of fact
Committed by a person or entity
With knowledge that the dishonest action or misrepresentation could result in an inappropriate gain or benefit
This definition applies to all persons and all entities. However, there are special rules around intentional misrepresentations to government programs such as Medicare & Medicaid, or TRICARE.
Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system.
Inefficient or ineffective practices or systems can produce waste; for example, providing services that are medically unnecessary. To recognize healthcare fraud, you need to be aware of what it is. Become familiar with these terms:<br>
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FWA Definitions Abuse is a bending of the rules; for example, improper billing practices such as upcoding (assigning an inaccurate billing code to increase reimbursement).
Abuse includes actions that may, directly or indirectly, result in:
Unnecessary costs to the healthcare system,
Improper payment,
Payment for services that fail to meet professionally recognized standards of care, or
Services that are medically unnecessary.
Errors are mistakes; for example, unintentional incorrect coding.
Error includes situations that may look like potential fraud, waste and abuse but are errors made by providers, members, vendors, employees or contractors. Below are some examples of possible errors.
Incorrect procedure codes
Date of service errors
Incorrect patient name
Accounting errors by a vendor that results in an inaccurate bill or payment
Typographical errors by an employee processing a claims payment or other payment check that results in an inaccurate payment.<br>
Abuse includes actions that may, directly or indirectly, result in:
Unnecessary costs to the healthcare system,
Improper payment,
Payment for services that fail to meet professionally recognized standards of care, or
Services that are medically unnecessary.
Errors are mistakes; for example, unintentional incorrect coding.
Error includes situations that may look like potential fraud, waste and abuse but are errors made by providers, members, vendors, employees or contractors. Below are some examples of possible errors.
Incorrect procedure codes
Date of service errors
Incorrect patient name
Accounting errors by a vendor that results in an inaccurate bill or payment
Typographical errors by an employee processing a claims payment or other payment check that results in an inaccurate payment.<br>
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U.S. Fraud, Waste and Abuse Laws These are some of the laws in the U.S. that address healthcare fraud, waste and abuse.
Federal & State False Claims Acts
HIPAA (Health Insurance Portability and Accountability Act)
Health Care Fraud Statute
Anti-Kickback/Stark Laws<br>
Federal & State False Claims Acts
HIPAA (Health Insurance Portability and Accountability Act)
Health Care Fraud Statute
Anti-Kickback/Stark Laws<br>
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Prevent, Detect and Correct Lifecycle An effective compliance program includes measures to prevent, detect and correct FWA.<br>
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Prevent A first step to prevention is having a compliance program in place that supports early detection and remediation of violations of law and company policies addressing FWA.
The seven core elements of an effective compliance program are:
High Level Oversight
Written Standards, Policies & Procedures
Effective Training & Education
Effective Lines of Communication & Reporting Mechanisms
Enforcement & Disciplinary Guidelines
Monitoring & Auditing
Prompt Responses to Identified Issues<br>
The seven core elements of an effective compliance program are:
High Level Oversight
Written Standards, Policies & Procedures
Effective Training & Education
Effective Lines of Communication & Reporting Mechanisms
Enforcement & Disciplinary Guidelines
Monitoring & Auditing
Prompt Responses to Identified Issues<br>
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Detect Detection is a key component of fighting healthcare fraud, waste and abuse.
Healthcare fraud, waste and abuse come in many forms. Companies may use sophisticated data analytics and both prospective and retrospective methods to detect FWA.
Healthcare fraud examples include:
Medical identify theft
Falsification of records
Other situations that may seem suspicious to you in your role<br>
Healthcare fraud, waste and abuse come in many forms. Companies may use sophisticated data analytics and both prospective and retrospective methods to detect FWA.
Healthcare fraud examples include:
Medical identify theft
Falsification of records
Other situations that may seem suspicious to you in your role<br>
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Examples of Suspicious Activity<br>
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Examples of Suspicious Activity<br>
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Examples of Suspicious Activity<br>
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Correct Prompt response and corrective action for detected offenses are important parts of the Prevent, Detect and Correct lifecycle. This includes, but is not limited to:
Investigate: It is important for the appropriate department to conduct a timely, well-documented and reasonable inquiry or investigation into the detected offense.
Notify Provider(s): If the detected offense impacts a provider, notification, education and recovery efforts may be warranted by the appropriate team.
Refer to enforcement agency: Refer suspected healthcare fraud, waste and abuse matters to law enforcement and regulatory agencies as appropriate or as required by law.<br>
Investigate: It is important for the appropriate department to conduct a timely, well-documented and reasonable inquiry or investigation into the detected offense.
Notify Provider(s): If the detected offense impacts a provider, notification, education and recovery efforts may be warranted by the appropriate team.
Refer to enforcement agency: Refer suspected healthcare fraud, waste and abuse matters to law enforcement and regulatory agencies as appropriate or as required by law.<br>
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Report Do you know where to report suspicious situations? Here are some options:
Healthcare Fraud Tip Line
Phone: <insert company fraud hotline number>
Online: <insert applicable resource>
<enter information regarding where your employees can report suspicious activity>
<insert your company’s non-retaliation policy><br>
Healthcare Fraud Tip Line
Phone: <insert company fraud hotline number>
Online: <insert applicable resource>
<enter information regarding where your employees can report suspicious activity>
<insert your company’s non-retaliation policy><br>
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Enforcement Awareness Healthcare fraud, waste and abuse is on the rise. Anti-fraud and abuse laws protect insurers, their employees and members, as well as public health benefit programs and taxpayer dollars.
Legal Consequences
There are legal consequences for committing fraud, waste and abuse. The actual consequence depends on the violation. The following are potential penalties:
Civil Money Penalties
Criminal Conviction/Fines
Civil Prosecution
Imprisonment
Loss of Provider License
Exclusion from Federal Healthcare programs<br>
Legal Consequences
There are legal consequences for committing fraud, waste and abuse. The actual consequence depends on the violation. The following are potential penalties:
Civil Money Penalties
Criminal Conviction/Fines
Civil Prosecution
Imprisonment
Loss of Provider License
Exclusion from Federal Healthcare programs<br>
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Enforcement Awareness - HIPAA HIPAA
The U.S. Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Includes fraud and abuse provisions that strengthen Federal enforcement tools
Protects patient privacy and against medical identity theft
Title II of HIPAA includes provisions related to the prevention of healthcare fraud and abuse including:
The creation of the Fraud, Abuse and Control program for coordination of state and federal healthcare fraud investigation and enforcement activities.
The expansion of the Exclusion Authority so that any healthcare fraud conviction, even if the fraud is not related to a government program, results in mandatory exclusion from participation in the Medicare or Medicaid programs.
The creation of new criminal provisions that expanded what actions could be considered 'healthcare fraud' and strengthened the tools available to prosecute violations at the federal level.<br>
The U.S. Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Includes fraud and abuse provisions that strengthen Federal enforcement tools
Protects patient privacy and against medical identity theft
Title II of HIPAA includes provisions related to the prevention of healthcare fraud and abuse including:
The creation of the Fraud, Abuse and Control program for coordination of state and federal healthcare fraud investigation and enforcement activities.
The expansion of the Exclusion Authority so that any healthcare fraud conviction, even if the fraud is not related to a government program, results in mandatory exclusion from participation in the Medicare or Medicaid programs.
The creation of new criminal provisions that expanded what actions could be considered 'healthcare fraud' and strengthened the tools available to prosecute violations at the federal level.<br>
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Enforcement Awareness - U.S. Federal Health Care Fraud Statute U.S. Federal Health Care Fraud Statute
Makes it a crime to defraud any healthcare benefit program
Only requires evidence that fraud has occurred to prosecute
The Federal Health Care Fraud Statute applies to all healthcare benefit programs - not just programs funded by the government.
The Health Care Reform Law of 2010 (Patient Protection and Affordable Care Act) updated the Health Care Fraud Statute so that now, proof of actual knowledge or intent to violate the statute is not required.
Violations may result in felony conviction, with potential penalties including imprisonment and fines.<br>
Makes it a crime to defraud any healthcare benefit program
Only requires evidence that fraud has occurred to prosecute
The Federal Health Care Fraud Statute applies to all healthcare benefit programs - not just programs funded by the government.
The Health Care Reform Law of 2010 (Patient Protection and Affordable Care Act) updated the Health Care Fraud Statute so that now, proof of actual knowledge or intent to violate the statute is not required.
Violations may result in felony conviction, with potential penalties including imprisonment and fines.<br>
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Enforcement Awareness - Anti-Kickback Statutes U.S. Federal and State Anti-Kickback Statutes
Makes it a crime to reward others or themselves for medical referrals
Prevents providers from profiting from referrals
Federal and state anti-kickback statutes make it a crime to knowingly and willfully offer, pay, solicit, or receive, directly or indirectly, anything of value to induce or reward referrals of items or services reimbursable by a federal or state healthcare program. In addition to kickbacks, some of the state level statutes prohibit fee-splitting, patient brokering and self-referrals.
Violations may result in a felony conviction, with penalties including imprisonment and fines. In addition, civil penalties can involve fines and exclusion from government healthcare programs.<br>
Makes it a crime to reward others or themselves for medical referrals
Prevents providers from profiting from referrals
Federal and state anti-kickback statutes make it a crime to knowingly and willfully offer, pay, solicit, or receive, directly or indirectly, anything of value to induce or reward referrals of items or services reimbursable by a federal or state healthcare program. In addition to kickbacks, some of the state level statutes prohibit fee-splitting, patient brokering and self-referrals.
Violations may result in a felony conviction, with penalties including imprisonment and fines. In addition, civil penalties can involve fines and exclusion from government healthcare programs.<br>
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Enforcement Awareness - U.S. Stark Law U.S. Stark Law
The U.S. Stark Law focuses on physician self-referrals and is related to anti-kickback statutes. The Stark Law is intended to prevent healthcare providers from inappropriately profiting from referrals.
The Stark Law prevents a physician from referring a patient for certain designated services to an entity where the physician has an ownership or financial arrangement if the service is covered by Government programs such as Medicare or Medicaid.
Violation may result in a denial for payment for the prohibited transaction, require the refund of payments received, civil penalties, and exclusion from government healthcare programs.<br>
The U.S. Stark Law focuses on physician self-referrals and is related to anti-kickback statutes. The Stark Law is intended to prevent healthcare providers from inappropriately profiting from referrals.
The Stark Law prevents a physician from referring a patient for certain designated services to an entity where the physician has an ownership or financial arrangement if the service is covered by Government programs such as Medicare or Medicaid.
Violation may result in a denial for payment for the prohibited transaction, require the refund of payments received, civil penalties, and exclusion from government healthcare programs.<br>
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Enforcement Awareness - U.S. False Claims Act U.S. False Claims Act
Prohibits filing of false or fraudulent records, statements or claims
Provides protection for those who report suspicions of fraud
The U.S. Federal False Claims Act (FCA) prohibits any person from knowingly presenting or causing the presentation of a false or fraudulent claim for payment to the federal government.
The Act creates liability for anyone, person or company, who knowingly submits, uses or causes to be submitted a false or fraudulent claim, or uses a false record, statement or claim to obtain payment from the government. The Act potentially applies to any program or project that receives government funding. The FCA is the government’s principal weapon for combating fraud involving federal funds.
False Claims Act Protection Provisions - The False Claims Act protects reporters from retaliation, including the following:
Harassment
Demotion
Wrongful termination
The U.S. Health Care Reform Law of 2010 (Patient Protection and Affordable Care Act) expanded the False Claims Act to add liability for reverse false claims. Under the reverse false claims provisions, overpayments or any funds received or retained under a federal program to which a person or organization is not entitled must be reported within 60 days of identification.<br>
Prohibits filing of false or fraudulent records, statements or claims
Provides protection for those who report suspicions of fraud
The U.S. Federal False Claims Act (FCA) prohibits any person from knowingly presenting or causing the presentation of a false or fraudulent claim for payment to the federal government.
The Act creates liability for anyone, person or company, who knowingly submits, uses or causes to be submitted a false or fraudulent claim, or uses a false record, statement or claim to obtain payment from the government. The Act potentially applies to any program or project that receives government funding. The FCA is the government’s principal weapon for combating fraud involving federal funds.
False Claims Act Protection Provisions - The False Claims Act protects reporters from retaliation, including the following:
Harassment
Demotion
Wrongful termination
The U.S. Health Care Reform Law of 2010 (Patient Protection and Affordable Care Act) expanded the False Claims Act to add liability for reverse false claims. Under the reverse false claims provisions, overpayments or any funds received or retained under a federal program to which a person or organization is not entitled must be reported within 60 days of identification.<br>
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Enforcements Awareness - U.S. False Claims Act (cont.) U.S. False Claims Act (cont.)
The Affordable Care Act also expanded the range of health plan business subject to the FCA and compliance must now be a significant concern in “non-government” lines of business.
Penalties
Failure to comply with the prohibitions of the FCA could result in civil and criminal sanctions imposed on individuals, [Your organization] and/or its subsidiaries. This could include:
Civil Penalties, plus;
Multiple (3X) damages, plus;
Suspension or exclusion from participation in Medicare, Medicaid, and other state-based healthcare programs.
Collateral consequences include debarment from government contracts, exclusion from participation in federal healthcare programs, and reputational harm.
Note: The amount of the false claim doesn’t matter.<br>
The Affordable Care Act also expanded the range of health plan business subject to the FCA and compliance must now be a significant concern in “non-government” lines of business.
Penalties
Failure to comply with the prohibitions of the FCA could result in civil and criminal sanctions imposed on individuals, [Your organization] and/or its subsidiaries. This could include:
Civil Penalties, plus;
Multiple (3X) damages, plus;
Suspension or exclusion from participation in Medicare, Medicaid, and other state-based healthcare programs.
Collateral consequences include debarment from government contracts, exclusion from participation in federal healthcare programs, and reputational harm.
Note: The amount of the false claim doesn’t matter.<br>
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Enforcement Awareness - U.S. State False Claims Acts U.S. State False Claims Acts
U.S. State False Claims Acts have been enacted in several U.S. states to discourage fraud against state healthcare programs.
Medicaid programs and related submissions are subject to both the Federal and State False Claims Acts.<br>
U.S. State False Claims Acts have been enacted in several U.S. states to discourage fraud against state healthcare programs.
Medicaid programs and related submissions are subject to both the Federal and State False Claims Acts.<br>
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Attestation (optional) My Commitment
We are all responsible for reporting any suspected misconduct, including suspected violations of Company policies or procedures and applicable laws and regulations.
I attest that I have completed the Healthcare Fraud, Waste and Abuse Overview and General Compliance training and understand the information presented. I acknowledge that I am required to follow reporting guidelines as outlined in the course.
First Name/Last Name:
Date completed:<br>
We are all responsible for reporting any suspected misconduct, including suspected violations of Company policies or procedures and applicable laws and regulations.
I attest that I have completed the Healthcare Fraud, Waste and Abuse Overview and General Compliance training and understand the information presented. I acknowledge that I am required to follow reporting guidelines as outlined in the course.
First Name/Last Name:
Date completed:<br>