Medicare Compliance Training 2 of 2

Fraud, Waste, and Abuse Training for Contracted Facilities and Their Key Employees 2013

Fraud, Waste, and Abuse Training for Contracted Facilities and Their Key Employees

2013 v.2

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Topics Covered 1. Identifying General Fraud, Waste, and Abuse

2. Your Protections as a Contracted Facility or Key Employee of a Contracted Facility When Reporting Fraud, Waste, and Abuse

3. Federal Health Care Fraud Standards, Laws, and Policies

4. Identifying Up-Coding, Unbundling, and Non-Rendered or Medically Unnecessary Services

5. ASH’s Anti-Fraud Policy and Your Facility’s Compliance Plan

6. Consequences for Noncompliance with This Training Requirement

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Identifying General Fraud, Waste, and Abuse

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Definitions of Fraud, Waste, and Abuse

Fraud: An intentional act of deception, misrepresentation, or concealment to gain something of value. Examples include:

• Submitting utilization or billing reports that are not accurate, are untruthful, or that omit information regarding full utilization of all Silver&Fit members

• Billing for utilization occurrences that never happened, e.g. exercising

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Definitions of Fraud, Waste, and Abuse (Continued)

Waste: Over-utilization of services (not caused by criminally negligent actions) and the misuse of resources.

Abuse: Excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Abuse refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss. An example would be fee forgiving; waiving an applicable annual member fee.

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Examples of waste or abuse in the fitness facility setting:

• Re-selling or giving away Silver&Fit equipment for non-permitted purposes

• Allowing personal trainers to use Silver&Fit equipment while training non-Silver&Fit members.




Red Flags and Risks for Fitness Facility Fraud and Abuse

To help you identify fraud, waste, and abuse, here are

some red flags to look for and examples of high-risk areas

for fitness facility providers.

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Red Flags:

• No documentation or records available for utilization occurrences.

• Discrepancy between a member’s use of the facility and the facility’s record of the member’s use.

• Same dates billed for every member regardless of actual utilization; e.g. billing for all Silver&Fit members on the 1st, 5th, 10th, 15th, 20th, and 25th of every month.

• Alterations on billing or utilization reports; falsification of reports.

• Pressure for reimbursement that is not compliant or consistent with the ASH Fitness Facility Services Agreement.

• Person attempts to access the fitness facility with a fake Silver&Fit Identification card, or a person attempts to access the fitness facility using another persons identity, or identification card.



Potential Beneficiary Fraud and Abuse

To help you identify fraud, waste, and abuse, here is an example of high-risk areas for Medicare beneficiaries:

• Identity theft; a Silver&Fit member using another person’s health plan ID card or Silver&Fit card to obtain services

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If you suspect fraud, you must report it to the ASH Special Investigations Unit

or the Office of Inspector General!



Reporting Suspected Fraud or Abuse

There are two options for reporting suspected fraud:

ASH Special Investigations Unit; (SIU) or

Office of Inspector General (OIG)

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Reporting Suspected Fraud or Abuse (Continued)

ASH SIU

• If you suspect fraud, do not tell a member, fellow employee, or fitness facility owner: “This sounds like fraud!”

• If you suspect fraud:

– Contact the ASH SIU via [email protected] – Call the ASH Anti-Fraud hotline at 877.427.4722; or – Write the SIU: American Specialty Health

Attn: Special Investigations Unit P.O. Box 509002 San Diego, CA 92150-9002

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Reporting Suspected Fraud or Abuse (Continued)

Office of Inspector General (OIG):

• The OIG is a federal agency whose mission is to protect the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs. The Medicare program is provided by HHS.

• Reporting to the OIG Hotline:

– Call 800.HHS.TIPS (800.447.8477)

– Fax 800.223.8164

– Email [email protected]

– Mail to: Office of Inspector General Department of Health and Human Services Attn: HOTLINE P.O. Box 23489 Washington, D.C. 20026

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Your Protections as a Contracted Facility or

Employee of a Contracted Facility When Reporting

Fraud, Waste, and Abuse


Your Protections as a Contracted Facility or Employee of a Contracted Facility When Reporting Fraud, Waste, and Abuse

Whistleblower Protections

As a downstream entity of a Medicare Advantage plan sponsor (e.g., a

contracted facility or key employee of a contracted facility) you have the

right and responsibility to report possible fraud, waste, and abuse. As

stated in a previous slide, please report suspected fraud, issues, or

concerns to the ASH SIU or the OIG.

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• You can report anonymously and retaliation is prohibited when you report a concern in good faith.

• Resources of information regarding detection, correction, and prevention of fraud, waste, and abuse:

– OIG Web site: http://oig.hhs.gov/fraud.asp

– Centers for Medicare and Medicaid Services (CMS): http://cms.hhs.gov/MDFraudAbuseGenInfo/


Federal Health Care Fraud Standards, Laws, and Policies



There are several federal laws regarding fraud, waste, and abuse:

• Federal False Claims Act (31 U.S.C. §§ 3729-3733)

• Anti-Kickback Statute (42 U.S.C. §§ 1320a-7b)

• Physician Self-Referral Statute (a.k.a. “Stark Statute” 42 U.S.C. §1395nn)

• Health Insurance Portability and Accountability of 1996 (HIPAA)

• Beneficiary Inducement Law (42 U.S.C. 1320a–7a(a)(5))

• Exclusion List

• Record Retention

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Federal False Claims Act

• The Federal False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows, or should know, is false.

• A person can be found liable under the act for:

– Knowingly misrepresenting or causing a false claim to be presented to the federal government for payment or approval;

– Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim;

– Knowingly concealing and/or improperly avoiding or decreasing an obligation to pay or transmit money or property to the federal government; and

– Conspiring to commit a violation of the liability sections of the act.

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Examples

• As it applies to fitness facilities, a facility that submits a false billing or utilization report to ASH for reimbursement.

• In the health care setting, a physician who submits a bill to Medicare for medical services he/she knows he/she has not provided.

• A government contractor who submits records that he knows (or should know) is false and that indicates compliance with certain contractual or regulatory requirements.

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Penalties of the Federal False Claims Act

• Civil penalties between $5,000 and $11,000 plus three times the total damages sustained by the government per claim;

• Possible exclusion from Medicare and Medicaid (e.g. no longer being eligible to support ASH’s Silver&Fit program); and

• Possible criminal prosecution.




Anti-Kickback Statute

• The Anti-Kickback Statute provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward the referral of business payable or reimbursable under the Medicare or other federal health care programs (e.g., Medicaid, Indian Health Services, etc.).

• The types of remuneration prohibited include kickbacks, bribes, and rebates, whether made directly or indirectly, overtly or covertly, in cash or in kind.

• Example: Bribing people to enroll in a Medicare Advantage plan with the Silver&Fit program.

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Anti-Kickback Statute Penalties

• Criminal penalty of fines of up to $25,000 and/or imprisonment of up to five years

• Civil penalty of up to $50,000 per act plus three times the amount of remuneration

• Exclusion from participation in Medicare or other federal health care programs

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Physician Self-Referral Statute—“Stark Statute”

• The Stark Statute prohibits physicians from referring Medicare patients to an entity with which the physician or a physician’s immediate family member has a financial relationship (e.g., ownership, investment, or compensation arrangement), unless an exception applies.

• Improper financial relationships between physicians and entities to which they refer patients can compromise the physician’s professional judgment as to whether an item or service is medically necessary, safe, effective, and of good quality.

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• The statute broadly defines prohibited financial relationships to include any “compensation” paid directly or indirectly to a referring physician. The statute’s exceptions then identify specific transactions that will not trigger its referral and billing prohibitions.

Although this statute does not apply to fitness facilities,

it is being presented for informational purposes.



Physician Self-Referral Statute (“Stark Statute”) Penalties

• Up to $15,000 for each claim submitted in violation of law

• Up to $100,000 for each “scheme” that violates the law

• Penalties of up to three times the amount claimed

• Exclusion from participation in Medicare or other federal health care programs




HIPAA

HIPAA established the national Health Care Fraud and Abuse Control Program (HCFAC) that coordinates federal, state, and local law enforcement activities with respect to health care fraud and abuse. It also created the offense of “health care fraud” and established criminal penalties for violation.

HIPAA Penalties

• Fines

• Imprisonment of up to 10 years

• Violations resulting in physical injury can be punished by imprisonment of up to 20 years

• Violations resulting in death can be punished by imprisonment for life

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Beneficiary Inducement Law

• Prohibits offering a remuneration that a person knows, or should know, is likely to influence a beneficiary to select a particular provider, practitioner, or supplier

• Civil monetary penalties of up to $10,000 for each wrongful act

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Exclusion List

• The OIG has the authority to exclude individuals or organizations from participating in Medicare, Medicaid, and other federal programs.

• Medicare Advantage plans, first-tier and downstream entities must perform exclusion list screenings to ensure that no payments are made by any federal health care program from any item or service furnished, ordered, or prescribed by an excluded individual or entity.

– Key employees must be checked at the time of hire and at least annually thereafter. Key employees include those that interact with members, such as front desk staff and Silver&Fit group exercise class instructors, and employees that perform billing and reimbursement functions for the Silver&Fit program.

– No excluded individual or entity may provide services reimbursed by a federal health care program.

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Reasons for Exclusion

• Conviction of fraud or abuse

• Default on federal student loans

• Controlled substance violations

• Licensing board actions

• OIG: http://exclusions.oig.hhs.gov/search.aspx

• SAM: https://www.sam.gov/portal/public/SAM/




Record Retention

• Fitness facilities must maintain membership and billing records in accordance with State law(s). ASH will maintain all records with regard to each contracted Silver&Fit fitness facility for 10 years.

• Records are subject to CMS, ASH, or contractor audit.

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ASH’s Anti-Fraud Policy and Your Facility’s Compliance Plan


ASH’s Anti-Fraud Policy and Your Facility’s Compliance Plan

• ASH has established anti-fraud measures to comply with state and federal anti-fraud requirements and to meet generally accepted, industry anti-fraud program standards. For a copy of ASH’s Anti-Fraud Policy, please log on to ASHLink®, call our Contract Services department, or e-mail ASH at: [email protected].

• As a provider of services to Medicare beneficiaries, your fitness facility should consider creating and implementing its own compliance program to prevent, detect, and correct fraud, waste, and abuse.

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Fraud, Waste, and Abuse Training for Contracted Facilities and Their Key Employees 2013 29

Consequences for Noncompliance with

This Training Requirement


Consequences for Noncompliance with This Training Requirement

• CMS requires that all Medicare Advantage plan sponsors, first-tier, and downstream entities complete an annual fraud, waste, and abuse training program. Training must occur upon initial hiring and annually thereafter, so long as you remain a Contracted Facility that provides services to Medicare beneficiaries.

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• At the completion of the training, the Contracted Facility must complete the attestation that all key employees (as defined in this training) who may interface with Medicare beneficiaries have completed fraud, waste, and abuse training. You must also maintain training logs and information regarding who completed the training and the date on which the training was completed.


Please keep a copy of the signed attestation for 10 years.


Consequences for Noncompliance with This Training Requirement

Noncompliance • Fitness facilities who are not

compliant will initially be contacted by telephone by a Contract Services representative.

• If the fitness facility does not comply after this outreach, the Contract Determination Committee (CDC) will issue a Corrective Action Plan (CAP) inquiry letter to encourage compliance.

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• If, after the CDC has issued a CAP inquiry letter, the fitness facility is still not in compliance, the CDC will issue a formal CAP with the expectation that the fitness facility comply.

• Failure to reply or comply with the CAP will result in the fitness facility being excluded from participation in all Medicare Advantage health plan payors who provide the Silver&Fit benefit through ASH.


Attestation and Sample Training Log


Attestation Sample Training Log

Fraud, Waste & Abuse Training Access these documents on ASHLink

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Fraud, Waste & Abuse Training Requirement Attestation As required by the Centers for Medicare & Medicaid Services (CMS) all Contracted Facilities

who provide health care services to Medicare beneficiaries and their employees who interface

with Medicare beneficiaries, must complete a Fraud, Waste & Abuse general training program.

An “authorized representative” (either the Contracted Facility’s owner or manager) must attest

to the completion of this training program. Training must be conducted annually, and upon hire

of new employees who interface with Medicare beneficiaries. Failure to do so could result in

you no longer being eligible for reimbursement for services provided to Medicare Advantage

beneficiaries. Employees that must be trained include, but are not limited to the following:

1. Owner

2. Front-desk attendees that track Silver&Fit member utilization, and

3. Individual fitness instructors that lead Silver&Fit themed group exercise classes. The training completed by my office consisted of the learning points listed below, which fulfills

the requirement for Fraud, Waste & Abuse General Training. Fraud, Waste & Abuse Training Learning Points

1. Identify general fraud, waste and abuse;

2. Describe your protections as a contracted facility or key employee of a Contracted Facility When Reporting Fraud, Waste, and Abuse;

3. Explain the general federal health care fraud standards, laws and policies;

4. Identify up coding, unbundling and non-rendered and/or medically unnecessary

services;

5. Identify ASH’s health care fraud policies and procedures; and

6. Describe the consequences for non-compliance.

Fitness FWA Training Attestation Page 1 of 2 10/17/2013

Attestation Statement

By checking this box and signing below, I hereby certify that I am the authorized

representative of my organization having responsibility directly or indirectly for all employees of

my organization who have direct contact with Medicare business and hereby certify all of the

aforementioned individuals have completed the ASH Medicare Fraud, Waste & Abuse Training

as mandated by the Centers for Medicare & Medicaid Services (42 CFR §422.503(b)(4)(vi)(C),

§ 423.504(b)(4)(vi)(C)). Fitness Facility Owner or Designee Attesting (signature) Date

Fitness Facility Owner or Designee Attesting name (print)

Name of Contracted Facility (print)

For audit purposes please maintain a copy of this signed attestation along with the training

program completed and a log of staff trained each year. If you’d like to submit your attestation and

training materials to ASH, please fax them to 877.545.2746.

Fitness FWA Training Attestation Page 2 of 2 10/17/2013

Medicare Fraud, Waste and Abuse Training Log Name of Contracted Facility:

Name of Contracted Facility Owner or Designee:

# Employee Name Department Date of Training Employee Signature

FWA Training Log Page 1 of 1 10/17/2013

Medicare Compliance Training 2 of 2

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