Fraud, Waste and Abuse Training for

ProvidersPresented by: Niurka Adorno González, Esq., CHC,

MHPR Compliance Director

Compliance Director of Molina Healthcare of Puerto Rico, Inc.

Disclosures

Identify what is fraud, waste or abuse.

Distinguish the different fraud and abuse laws.

Use the different ways to refer of potential fraud, waste and abuse cases.

Objectives:

Introduction Definitions Fraud, Waste, and Abuse (FWA) Laws Examples of FWA Reporting FWA Questions

Agenda

Molina Healthcare of Puerto Rico (MHPR) is dedicated to the detection, prevention, investigation and reporting of health care fraud, waste, and abuse.

As such, we regard fraud as unacceptable, unlawful and harmful to the provision of quality health care in a efficient and affordable manner.

Introduction

The federal government spends almost a trillion dollars per year on the Medicaid and Medicare programs.

Experts estimate fraudulent billings to these programs range between 3-10%.

FWA also puts members’ health at risk by exposing them to unnecessary services and taking money away from needed patient care.

Heath Care Fraud is a Serious Problem

Fraud Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.

Waste Health care spending that can be eliminated without reducing quality of care. Quality waste includes overuses, underuse, and ineffective use. Inefficient waste includes redundancy, delays and unnecessary process complexity.

Abuse Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary costs to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare.

Definitions

False Claims Act Deficit Reduction Act Anti-kickback Statute Physician Self-Referral

Statute Exclusion Statute Civil Monetary Penalty Law

Fraud and Abuse Laws

Establishes liability to any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment.

Knowingly is defined to mean that a person with respect to the information:◦ Has actual knowledge or falsity of the information in the claim◦ Acts in deliberate ignorance of the truth or falsity of the

information or acts in reckless disregard of the truth.

Does not require proof of specific intent to defraud the U.S. government.

False Claims Act

Violations◦ Treble damages (3X loss)◦ Up to $11,000 per claim◦ Exclusion from participating in federal health care programs

Strong financial incentive to whistleblowers◦ Up to 30% of any False Claims Act recovery

Often whistleblowers turn out to be ex-business partners, office staff, competitors, or even patients.

False Claims Act

Health care entities who receive or pay out at least $5M in Medicaid funds per year must comply.

Providers and staff have the same obligation to report any actual or suspected violation of Medicare/Medicaid funds either by fraud, waste, or abuse.

Entities must have written policies that inform employees, contractors and agents of the following:◦ Federal False Claims Act and Commonwealth laws

pertaining to submitting false claims; ◦ How providers will detect and prevent FWA; and,◦ Employee protection rights as a whistleblower.

Deficit Reduction Act

Prohibits knowingly or willfully soliciting, receiving , offering, or paying any remuneration (including any kickback, bribe, or rebate in order to induce or reward business that is payable under a federal health care program.

Potential penalties for violation:◦ Criminal penalty of fines of up to $25,000, and/or

imprisonment of up to 5 years◦ Civil penalty of up to $50,000 per act plus treble

damages◦ Exclusion from federal health care programs

The Anti-kickback Statute

Prohibits a physician from making referrals for certain designated health services to an entity in which the physician, or member or his/her family has an ownership/investment interest or with which he/she has a compensation arrangement .

Potential penalties for violation:◦ Up to $15,000 for each claim submitted in violation

of the law◦ Treble damages◦ Exclusion from federal health care programs

Physician Self- Referral

The Office of Inspector General (OIG) may exclude providers from participation in federal health care programs.

There are two categories of exclusions:◦ Mandatory- imposed on certain criminal convictions◦ Permissive- based on sanctions by other agencies

Excluded physicians may not bill for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or group practice.

There are currently more than 5K physicians excluded.

Exclusion Statute

The OIG is authorized to impose civil monetary penalties for violations of law.

Penalties range from $10,000 to $50,000 or treble damages.

Examples:◦ Penalties apply to those services that were not

rendered as claimed.◦ Claims that were part of a pattern to provide article

or services that the claimant knew or should have known were not medically necessary.

Civil Monetary Penalty

Billing for services, procedures or supplies that have not actually been rendered.

Providing services to patients that are not medically necessary.

Balance-billing a Medicaid member for Medicaid covered services.

Concealing patients’ misuse of MHPR ID Card.

Failure to report a patient’s forgery/alteration of a prescription.

Examples of FWA by a Provider

https://molinahealthcare.alertline.com/gcs/welcome?locale=es

Toll free: (866) 606-3889

Reporting FWA

MHPR Compliance Department:Molina Healthcare of Puerto Rico

Attn: CompliancePO Box 364988San Juan, PR 00936-4988

Office of Inspector General◦ 1-800-HHS-TIPS (1-800-447-8477) ◦ https://forms.oig.hhs.gov/hotlineoperations/index.

aspx

Reporting FWA

Ethics is doing the right thing even when

nobody’s looking.

Questions?