Fraud, Waste, and Abuse in Healthcare Compliance
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 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.
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:
1.
Intentional dishonest action or misrepresentation of fact
2.
Committed by a person or entity
3.
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:
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.
U
.
S
.
F
r
a
u
d
,
W
a
s
t
e
a
n
d
A
b
u
s
e
L
a
w
s
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
Prevent, Detect and Correct Lifecycle
An effective compliance program includes measures to prevent, detect and
correct FWA.
P
r
e
v
e
n
t
•
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
D
e
t
e
c
t
•
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
Examples of
Suspicious
Activity
Examples of
Suspicious
Activity
Examples of
Suspicious
Activity
C
o
r
r
e
c
t
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.
R
e
p
o
r
t
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>
Enforcement
Awareness
Health
care
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
Health
care
programs
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.
Enforcement
Awareness - U.S.
Federal Health
Care Fraud
Statute
U.S.
Federal
Health C
are
Fraud
Statute
•
Makes
it
a crime
to defraud
any
health
care
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.
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
health
care
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
health
care
programs.
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.
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
.
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
health
care
programs.
Collateral consequences
include
debarment from government
contracts, exclusion
from
participation
in
federal
health
care
programs,
and
reputational
harm.
Note:
The
amount
of the
false
claim doesn’t
matter.
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
health
care programs.
•
Medicaid
programs
and
related
submissions
are
subject
to
both the
Federal
and
State False
Claims
Acts.
A
t
t
e
s
t
a
t
i
o
n
(
o
p
t
i
o
n
a
l
)
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:
Healthcare fraud, waste, and abuse pose significant challenges to the healthcare system, leading to financial losses and potential harm. This overview emphasizes the importance of compliance programs in detecting and preventing fraudulent activities. By recognizing the signs of fraud, waste, and abuse, individuals can play a vital role in safeguarding the integrity of the healthcare industry.
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Presentation Transcript
Fraud, Waste & Abuse Overview: General Compliance Training 2021
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. Healthcare Fraud, Waste and Abuse
To recognize healthcare fraud, you need to be aware of what it is. Become familiar with these terms: 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: 1. Intentional dishonest action or misrepresentation of fact 2. Committed by a person or entity 3. With knowledge that the dishonest action or misrepresentation could result in an inappropriate gain or benefit FWA Definitions 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.
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. FWA Definitions 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.
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 U.S. Fraud, U.S. Fraud, Waste and Waste and Abuse Laws Abuse Laws
Prevent, Detect and Correct Lifecycle An effective compliance program includes measures to prevent, detect and correct FWA.
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 Prevent Prevent
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 Detect Detect
Provider Fraud and Abuse Key Indicators: Submitting bills or claims for treatment or services that were never provided Falsifying the date of service to correspond with a member s coverage period Billing for non-covered services using incorrect codes to have the services covered Examples of Suspicious Activity Sales Agent Fraud and Abuse Key Indicators: Enrolling a member by forging a signature on an application for benefits Coaching individuals on how to fill out their insurance enrollment information by supplying false or misleadinginformation Using a nonexistent company to enroll a group of individuals Falsifying the geographic location of a group in order to obtain insurance or lower premium rates *These are only some examples of potential fraud and abuse.
Pharmacy Fraud and Abuse Key Indicators: Inappropriate pharmacy billing: Billing for medication that was never dispensed; Billing for brand name drugs, but dispensing generics Prescription drug shorting: Intentionally providing less than the prescribed quantity and not informing the patient Prescription forging or altering: Increasing the quantity of tablets or number of refills without the provider s permission; Substituting more expensive brand name drugs in place of generic drugs Examples of Suspicious Activity Member or Patient Fraud and Abuse Key Indicators: Submitting false claims Prescription stockpiling and unlawful sales of goods Concealing information about additional coverage in order to lower out-of- pocket payments, or receiving inappropriate reimbursement from multiple plans Identity theft Doctor shopping - multiple providers are seen to obtain multiple prescriptions. *These are only some examples of potential fraud and abuse.
Employee Fraud and Abuse Key Indicators: Falsification of patient records by an employee Recording untrue information in a patient record Note: If the patients that had their records falsified were being served through a government program, billing for services related to these documented visits could violate the U.S. False Claims Act. Identity theft Using a member s ID number to obtain prescriptions, services, supplies, etc. Examples of Suspicious Activity *These are only some examples of potential fraud and abuse.
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. Correct Correct
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> Report Report
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 Enforcement Awareness 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
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. Enforcement Awareness - HIPAA
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 Enforcement Awareness - U.S. Federal Health Care Fraud Statute 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.
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 Enforcement Awareness - Anti-Kickback Statutes 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.
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. Enforcement Awareness - U.S. Stark Law
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. Enforcement Awareness - U.S. False Claims Act 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.
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. Enforcements Awareness - U.S. False Claims Act (cont.) 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.
U.S. State False Claims Acts Enforcement Awareness - 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.
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. Attestation Attestation (optional) (optional) First Name/Last Name: Date completed:
