Waste, Fraud & Abuse Training


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Review of regulations for avoiding and reporting waste, fraud and abuse of public healthcare funds.

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Waste, Fraud & Abuse Training

  1. 1. ICS.01.39, Waste, Fraud & Abuse Training This module will present education concerning False Claims Liability, Anti-retaliation Protections as well as detecting and responding to Fraud, Waste and Abuse. <ul><li>Discussion Points: </li></ul><ul><li>Deficit Reduction Act requirements </li></ul><ul><li>Compliance education </li></ul><ul><li>False Claims Act liability </li></ul><ul><li>Policies and procedures </li></ul><ul><li>Elements of the compliance plan </li></ul>
  2. 2. The Deficit Reduction Act (DRA) <ul><li>The DRA: </li></ul><ul><li>Authorizes data sharing between Medicare and Medicaid; </li></ul><ul><li>Increases the States’ requirements to fight fraud and abuse activities within their State Medicaid plans; </li></ul><ul><li>Requires entities to provide compliance education related to the False Claims Act. </li></ul>The DRA indirectly mandates a compliance program which requires that staff must be informed about the False Claims Act, Administrative remedies under the Act, relevant State Laws and Whistleblowers’ protection.
  3. 3. False Claims Act (FCA) <ul><li>The False Claims Act imposes liability on any person or entity who: </li></ul><ul><li>Knowingly files a false or fraudulent claim to Medicare or other federally funded healthcare program. </li></ul><ul><li>Knowingly uses a false record or statement to obtain payment on a false or fraudulent claim from Medicare or other federally funded healthcare program. </li></ul><ul><li>Conspires to defraud Medicare, Medicaid or other federally funded healthcare program by attempting to have a false or fraudulent claim paid. </li></ul>The full text of the False Claims Statutes is located at: http://www.oregon.gov/DHS/healthplan/tools_prov/dra-guide0608.pdf
  4. 4. Some Examples of Healthcare Fraud <ul><li>Billing for services or goods not provided. </li></ul><ul><li>Falsifying certificates of medical necessity and billing for services not medically necessary. </li></ul><ul><li>Billing separately for services that should be a single service (unbundling). </li></ul><ul><li>Falsifying treatment plans or a medical record to maximize payments. </li></ul><ul><li>Failing to report overpayments. </li></ul><ul><li>Duplicate billing. </li></ul><ul><li>Misuse of provider ID numbers, which results in improper billing and payments. </li></ul>
  5. 5. Policies & Procedures <ul><li>The compliance plan establishes activities that assist in avoiding and identifying activities that could be considered violations of fraud and abuse laws, such as, auditing, implementing practice standards, implementing appropriate response mechanisms to reports, developing open lines of communications and encouraging the reporting of fraud and abuse, as well as the designation of a Compliance Officer who monitors all related activities in the program. </li></ul><ul><li>ICS.01.39 , Fraud and Abuse Guideline outlines the ICS policy for fraud and abuse. It identifies the Business Services Unit as the Compliance Officer for the program. This entity will: </li></ul><ul><li>Promptly investigate every report of any violation regarding claims fraud and/or abuse. </li></ul><ul><li>Promptly refer all verified cases of fraud and abuse to the Medicaid Fraud Control Unit (MFCU) and the DHS Provider Audit Unit. </li></ul><ul><li>Maintain a file to track the disposition of all reports and investigations . </li></ul><ul><li>Disciplinary Guidelines for violations of the fraud and abuse policy include punitive actions up to and including termination of association with ICS and any appropriate and imposed criminal penalties through the justice system. </li></ul>
  6. 6. Education on the Fraud and Abuse Program <ul><li>ICS strives to educate ALL stakeholders on the fraud and abuse laws and the compliance program. </li></ul><ul><li>A DRA Brochure is provided for all patients, clients, current employees, new employees and contractors to provide specific information on the laws, as well as “Whistleblower” protection. </li></ul><ul><li>Training on the DRA and the Multnomah County Compliance Plan is conducted annually for staff to ensure awareness and vigilance within this program. </li></ul><ul><li>The patients and clients of ICS clinics receive this information which is provided upon initial registration and periodically, thereafter. </li></ul>
  7. 7. The Reporting Process <ul><li>Any employee who suspects a violation needs to report concerns to the Supervisor, Department Head or directly to: </li></ul><ul><ul><li>The Compliance Officer (Business Services) 503-988-3663 x-27574. </li></ul></ul><ul><ul><li>The Good Government Hotline: </li></ul></ul><ul><ul><li>1-800-289-6839 http://www.GoodGovHotline.com ; or, </li></ul></ul><ul><ul><li>The Fraud Reporting Hotline: 1-800-372-8301 http://www.oregon.gov/DHS/abouths/fraud/ </li></ul></ul><ul><li>If there is suspected fraud or abuse by a patient, the violation can be reported to the leadership in ICS Administration. </li></ul><ul><li>It is important to remember that failure to report and disclose or assist in an investigation is a breach of the employee’s or contractor’s obligation to ICS and may result in corrective action. </li></ul>
  8. 8. Non-Retaliation <ul><li>Any client, employee or contractor of ICS who reports information regarding potential fraud, waste or abuse will have the right to do so anonymously and will be protected against retaliation for coming forward with such information both under internal Multnomah County Policies and under State and Federal Laws. </li></ul>Retaliation directed at reporters of fraud, waste and abuse is unlawful; see ORS 659A.203 – http://www.leg.state.or.us/ors/659a.html
  9. 9. This completes the Fraud, Waste & Abuse Training Module <ul><li>Please review the Guideline ICS.01.39: </li></ul><ul><li>http://mints.co.multnomah.or.us/Health/hdpolicy/ICS/ICS.01.39.pdf </li></ul><ul><li>If you have any questions, have them answered by your direct Supervisor, other ICS leadership or by the Compliance Officer for the program. </li></ul><ul><li>You may now exit this module. </li></ul>