2022 Fraud, Waste, & Abuse Training

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Medicare Part C and Part D:
Fraud, Waste and Abuse Training
Windstone Health Services
2022

2. 2
Overview
 The Centers for Medicare & Medicaid Services (CMS)
requires annual Fraud, Waste and Abuse (FWA)
training for organizations providing health services to
Part C Medicare Advantage (MA) enrollees. All training
must be completed annually.
 All entities are required to complete the Attestation of
Training Completion.
 Organizations must maintain internal training logs and
submit copies of the training logs along with required
attestations demonstrating that employees received
FWA training.

3. Why Do You Need Training?
 Every year billions of dollars are improperly spent because of
Fraud, Waste, and Abuse (FWA). It affects everyone – including
you. This training helps you detect, correct, and prevent FWA.
You are part of the solution.
 Combating FWA is everyone’s responsibility. As an individual who
provides health or administrative services for Medicare enrollees,
every action you take potentially affects Medicare enrollees, the
Medicare Program, or the Medicare Trust Fund.
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FWA requirements…
 Organizations contracting directly or indirectly with
the federal government are obligated to:
 Report fraud, waste and abuse;
 Demonstrate their commitment to eliminating fraud,
waste and abuse; and
 Implement internal policies and procedures to identify
and combat health care fraud.

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Best Practices for Preventing FWA
 Develop the seven (7) core compliance program.
 Ensure all employees are familiar and up-to-date with
laws, regulations, company policies/procedures and
compliance program
 Monitor claims for accuracy – ensure coding reflects
services provided.
 Monitor medical records – ensure documentation
supports services rendered.
 Perform regular internal audits.
 Maintain effective line of communication

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The SEVEN elements of a compliance
plan
An effective Compliance Plan includes 7 core
elements:
1. Written Policies, Procedures and Standards of
Conduct
2. Designation of a Compliance Officer, Compliance
Committee and High Level Oversight.
3. Effective Compliance Training and Education.
4. Internal Monitoring and Auditing to Identify
Compliance Risks.

7. 7
The SEVEN elements of a compliance
plan
5. Disciplinary Mechanisms.
6. Effective Lines of Communication.
7. Procedures and Systems for Prompt Response
to Detected Offenses and Corrective Action.

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Definitions
Fraud:
• an intentional act of deception, misrepresentation, or
concealment in order to gain something of value.
• occurs when an individual knows or should know that
something is false and makes a knowing deception
that could result in some unauthorized benefit to
him/herself or another person.
Waste:
• over utilization of services (not caused by criminally
negligent actions) and the misuses of resources.

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Definitions
Abuse:
• Excessive or improper use of services or actions that are
inconsistent with acceptable business or medical
practice.
• Refers to incidents that, although not fraudulent, may
directly or indirectly cause financial loss.
• Involves payment for items or services where there was
no intent to deceive or misrepresent, but the
outcome results in unnecessary costs.

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Definitions
Examples include:
 Charging in excess for services or supplies
 Billing for items or services that should not be
paid for by Medicare.
 Billing for services that were never rendered
 Billing for services at a higher rate than is
actually justified.
 Falsifying information in order to justify
coverage.
.

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Definitions
Examples include:
 Failing to provide medically necessary services.
 Marketing schemes such as offering beneficiaries a
cash payment as an inducement to enroll in Part D.
 Selecting or denying beneficiaries based on their
illness profile or other discriminating factors.
 Writing prescriptions for drugs that are not medically
necessary.

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Relevant FWA Laws: False Claims Act
The False Claims Act:
 Enacted in 1863 to fight procurement fraud in the
Civil War
 Amended through the American Recovery and
Reinvestment Act of 2009 (ARRA) - expanded the
scope of liability and gave the government enhanced
investigative powers
 Prohibits knowingly presenting a false claim for
payment or approval; or making or using a false
record or statement in support of a false claim.

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Relevant FWA Laws:
Anti-Kickback Statute
 The Anti-Kickback Statute:
 Makes it a criminal offense to knowingly and willfully
offer, pay, solicit, or receive any compensation to
induce or reward referrals of items or services
reimbursable by a federal health care program.
 Remuneration includes anything of value, directly or
indirectly, overtly or covertly, in cash or in kind.
 Up to five years in prison and fines of up to $25,000
for violations of the anti-kickback status
If the patient suffers bodily injury as a result of
a scheme, the prison sentence may be 20+
years.

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Relevant FWA Laws:
Beneficiary Inducement Statute
 Beneficiary Inducement Statue prohibits certain
inducements to Medicare beneficiaries. i.e. waiving the
coinsurance and deductible amounts
 Red Flag Rule (Identity Theft Protection)
requires creditors to implement programs to identify, detect
and respond to patterns, practices, or specific activities that
could indicate identify theft.

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Relevant FWA Laws: Physician Self-
Referral Prohibition Statute (Stark Law)
The Physician Self-Referral Prohibition Statute,
commonly referred to as the “Stark Law,” prohibits:
 Prohibits physicians from referring Medicare patients
to an entity with which the physician or physician’s
immediate family member has a financial
relationship—unless an exception applies.
 Up to a $15,000 fine for each service provided. Up to a
$100,000 fine for entering into an arrangement or
scheme.

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Possible Civil and Criminal Penalties
False Claims Act
 For each false claim: Criminal fines up to $250,000
 Imprisonment up to 20 years
 If the government proves it suffered a loss, the
provider is liable for three times the loss.

17. Administrative Sanctions
 Denial or revocation of Medicare
provider number application
 Suspension of provider payments
 Addition to the OIG / SAM Lists of
Excluded Individuals/Entities (LEIE)
 License suspension or revocation
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Examples of Potential FWA: Beneficiary
 Identity Theft
 Doctor Shopping
 Improper Coordination of Benefits

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Examples of Potential FWA: Prescriber
 Illegal Payment Schemes
 Script Mills
 Theft of Prescriber’s Drug
Enforcement Agency (DEA) Number
or Prescription Pad

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Examples of Potential FWA:
Pharmaceutical Manufacturer
 Illegal Off-label Promotion
 Illegal Usage of Free Samples
 Kickbacks, Inducements, Other Illegal
Payments

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Partnership for FWA Prevention
 Centers for Medicare & Medicaid Services
 Medicare beneficiaries
 Medicare contractors
 Physicians, suppliers, and other providers
 Quality Improvement Organizations (QIOs)
 State and federal law enforcement agencies such as:
 Office of Inspector General (OIG) and System of Award Management
(SAM) of the Department of Health and Human Services (HHS)
 Federal Bureau of Investigation (FBI)
 Department of Justice (DOJ)
Prevention and detection of fraud,
waste and abuse requires the
involvement and collaboration between:

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Your Responsibilities
How can you prevent potential fraud, waste and
abuse?
 Comply with all federal and state laws and regulations, and
company policies and procedures and the company’s
compliance program.
 Report any potential FWA
 Know compliance officer/maintain effective communication
 Participate in training and education
 Comply with Standards of Conduct/Code of Conduct
 Cooperate with internal monitoring and auditing.
 Maintain confidentiality of protected health information
(PHI)

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Reporting FWA
 Everyone is requested to report suspected fraud, waste
or abuse.
 You may report anonymously.
 Retaliation is prohibited when you report a concern in
good faith.
 Take action if you identify a problem.
 Remember that you could be held responsible for claims
bearing your name, regardless of whether you submitted
the claim.
• Erin Woodmas, Compliance Officer: x 238
• Patricia Rothstein, QI/Compliance Spec.: x 300
• Leanne Poploff, QI/Compliance Spec.: x 213

24. Reporting FWA
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WEBSITE:
1. Go to “windstonehealth.com”
2. Click on “Provider Resources”
3. “Submit a Compliance Question or Concern
REMINDER:
Feel free to contact Erin Woodmas (ext. 238) or
Patty Rothstein (ext. 300) or
Leanne Poploff (ext. 213) for HIPAA Privacy
Rules or
Any questions or concerns you may have.

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FWA Resources
Resource Link
Centers for Medicare and
Medicaid Services (CMS)
www.cms.hhs.gov
Fraud & Abuse General
Information
www.cms.gov/About-CMS/Components/
CPI/CPIReportingFraud.html
Federal Bureau of Investigation www.fbi.gov/
Medicare Learning Network
(MLN)
www.cms.hhs.gov/MLNGenInfo/
Office of Inspector General
Department of Health and
Human Services
www.oig.hhs.gov/
Physician Self Referral Law www.cms.hhs.gov/PhysicianSelfReferral
Medicare Managed Care
Manual
www.cms.hhs.gov/Manuals/IOM/

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Exclusion Lists
 We do not contract with any providers who appear on
the Office of the Inspector General (OIG) or System of
Award Management (SAM) lists, and now included are
also CMS Preclusion List. (Per contract requests)
 Human Resources checks the OIG and SAM
exclusions lists for all employees.
 This is part of the new hire and credentialing process and
is conducted prior to hire/contracting and monitored on a
monthly basis.

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Compliance
 Windstone ensures compliance with applicable
statues, regulations and guidance from:
 The Federal Trade Commission
 The United States Department of Justice, Anti Trust
Division

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Attestation of Training Completion
Congratulations!
You’ve completed the FWA training
requirement for calendar year 2022.