Healthcare Fraud, Waste, and Abuse Overview: General Compliance Training 2023
Healthcare fraud, waste, and abuse (FWA) pose significant challenges to the healthcare system, with billions lost annually to deceptive practices. Understanding FWA definitions - fraud, waste, abuse, and errors - is crucial to combatting them effectively. Compliance programs are essential to prevent, detect, and correct FWA, ensuring adherence to legal and regulatory requirements. Recognizing the signs of FWA and reporting suspicious activities are responsibilities we all share. Stay informed about laws addressing FWA in the US to promote a culture of compliance and integrity in healthcare.
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Fraud, Waste & Abuse Overview: General Compliance Training 2023
Healthcare Fraud, Waste and Abuse Fraud, waste and abuse (FWA) continue to take a heavy toll on the healthcare system. In 2021, the Federal Government won or negotiated more than $5 billion in healthcare fraud judgments and settlements. A compliance program contains measures to prevent, detect and correct FWA. We all have a role to play in detecting FWA. Be alert for suspicious activities and report anything you notice. 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 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 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. Some examples of waste include: Prescribing more prescriptions than necessary Conducting excessive and/or unnecessary laboratory tests Scheduling and billing unnecessary office visits
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 can rise to the level of fraud. 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
These are some of the laws in the U.S. that address healthcare fraud, waste and abuse. HIPAA (Health Insurance Portability and Accountability Act) Health Care Fraud Statute Anti-Kickback/Stark Laws Federal & State False Claims Acts U.S. Fraud, U.S. Fraud, Waste and Waste and Abuse Laws Abuse Laws
Enforcement Awareness Healthcare FWA 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. LegalConsequences There are legal consequences for committing fraud, waste and abuse. The actual consequence depends on the violation. The following are potential penalties: Civil MonetaryPenalties CriminalConviction/Fines CivilProsecution Imprisonment Loss of Provider License Exclusion from Federal Healthcare 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 protects against medical identitytheft 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 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.
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.
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 ClaimsAct Prohibits filing of false or fraudulent records, statements or claims for payment 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 FCA 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 FCA 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. The U.S. Health Care Reform Law of 2010 (Patient Protection and Affordable Care Act, PPACA further referenced as ACA) expanded the FCA to add liability for reverse false claims. Under the reverse false claims provisions, overpayments or any funds received or retained under a federal program (like Medicare, Medicaid or TRICARE, etc.) 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 ACA 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 (ex. Commercial insurance). Under Section 1313 of the Affordable Care Act, payments made by, through or in connection with an Exchange are subject to the FCA if the payments include any federal funds. The FCA also applies to actions an issuer takes outside of an Exchange that may also involve the receipt of U.S. federal payments. Commercial insurance business (primarily individual and small employer group) can also be subject to FCA and U.S. federal enforcement if a false statement is made in connection with some types of administrative or health care services. 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. *Medicaid is administered at the state level and many states refer to their Medicaid programs using alternative names, or refer to it as their State Plan, or as Title XIX.
Enforcement Awareness - U.S. State False Claims Acts U.S. State False ClaimsActs Penalties Failure to comply with the prohibitions of the FCA could result in civil and criminal sanctions imposed on individual persons and business entities (ex. healthcare provider or company, employees of the entity such as the medical director, president, CEO, or CFO of the healthcare company). This could include: Civil penalties,plus; Multiple (3X 6X) damages,plus; Suspension or exclusion from participation in Medicare, Medicaid, and other state-basedhealthcareprograms. 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. False Claims Act Protection Provisions - The False Claims Act protects reporters from retaliation, including the following: Harassment Demotion Wrongful termination
Prevent, Detect and Correct Lifecycle An effective compliance program includes measures to prevent, detect and correct FWA.
Prevent 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 LevelOversight Written Standards, Policies & Procedures Effective Training & Education Effective Lines of Communication & Reporting Mechanisms Enforcement & Disciplinary Guidelines Monitoring &Auditing Prompt Responses to Identified Issues
Detect Detect Detection is a key component of fighting healthcare FWA, which may come in many forms. Companies may use sophisticated data analytics and both prospective (pre- payment) and retrospective (after payment) 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 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 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
Examples of Suspicious Activity 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 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
Examples of Suspicious Activity 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. *These are only some examples of potential fraud and abuse
Correct 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.
Report Report Do you know where to report suspicious situations? Here are some options: Healthcare Fraud Tip Line Phone: <insert company fraud hotline number or use UHC reporting information 1-866- 242-7727> Online: <insert applicable resource or reference> or use the UHG ethics point website: uhghelpcenter.ethicspoint.com <enter information regarding where your employees can report suspicious activity within your organization> <insert your company s non-retaliation policy/link> Please update this slide with information relevant to your organization. You may include the UnitedHealthcare resources provided if on our Resource slide as applicable.
Resources Delegated Entity Compliance Program website *FWA/General compliance training deck & additional links and informational resources http://www.unitedhealthgroup.com/Suppliers/ComplianceProgram.aspx HHS-OIG List of Excluded Individuals and Entities (LEIE) http://oig.hhs.gov/exclusions/index.asp GSA System for Award Management (SAM) SAM.gov | Entity Information Anti-Kickback Statute 42 United States Code (U.S.C.) Section 1320a 7b(b) http://www.ecfr.gov/cgi- bin/searchECFR?idno=42&q1=422&rgn1=PARTNBR&op2=and&q2=&rgn2=Part eCFR :: 42 CFR 422.503 -- General provisions Medicare Advantage Parts C Code of Federal Regulations 42 Code of Federal Regulations (CFR) Section 422.503 http://www.ecfr.gov/cgi- bin/searchECFR?idno=42&q1=423&rgn1=PARTNBR&op2=and&q2=&rgn2=Part eCFR :: 42 CFR 423.504 -- General provisions Medicare Advantage Parts D Code of Federal Regulations 42 CFR Section 423.504 Chapters 21/9 Medicare Managed Care & Part D Manual Compliance Program Guidelines https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf Physician Self-Referral Law (Stark Law) 42 U.S.C. Section 1395nn Online: https://www.uhc.com/fraud or by phone: 844-359-7736 UnitedHealthcare Vendor Fraud Hotline at 877-401-9430 To report FWA concerns (UnitedHealthcare Resources) Federal False Claims Act 31 United States Code (U.S.C) Sections 3729-3733 Compliance & Ethics hotline: 800-455-4521 or email: EthicsOffice@uhg.com Online: UHGhelpcenter.ethicspoint.com To report other Compliance and Ethics concerns (UnitedHealthcare Resources)
Attestation (optional) 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: This sample attestation can be used and retained to track FWA/General Compliance training within your organization.
DISCLAIMER This course was prepared as a service and is not intended to grant rights or impose obligations. This course may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not legal advice nor a substitute for independent review of the applicable laws, statutes, or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents, and consult independent legal counsel.
