Mhpr fraud waste and abuse training for providers

1. Presented by: Niurka Adorno González, Esq., CHC,
MHPR Compliance Director

2.  Compliance Director of Molina Healthcare of
Puerto Rico, Inc.

3.  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.

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

5. 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.

6.  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.

7. 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.

8.  False Claims Act
 Deficit Reduction Act
 Anti-kickback Statute
 Physician Self-Referral
Statute
 Exclusion Statute
 Civil Monetary Penalty Law

9.  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.

10.  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.

11.  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.

12.  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

13.  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

14.  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.

15.  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.

16.  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.

17.  https://molinahealthcare.alertline.com/gcs/welcome?lo
cale=es
 Toll free: (866) 606-3889

18.  MHPR Compliance Department:
Molina Healthcare of Puerto Rico
Attn: Compliance
PO Box 364988
San Juan, PR 00936-4988
 Office of Inspector General
◦ 1-800-HHS-TIPS (1-800-447-8477)
◦ https://forms.oig.hhs.gov/hotlineoperations/index.
aspx

19. Ethics is doing the right
thing even when nobody’s
looking.
Questions?