Post on 30-Apr-2020
transcript
2/3/2012
1
Independent Licensee of the Blue Cross and Blue Shield Association
1GR-P11-322/1.PPT (1/6/2012)
Fraud, Waste, and AbuseThe Whys, the Whats, and the Hows
February 13, 2012
2Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/2.PPT (1/6/2012)
Fraud, Waste, and Abuse
1. United States Federal Sentencing Guidelines (USFSG)
– Focus on ethical behavior
– Focus on Board engagement
– Require Board understanding of the elements of an effective
compliance program
Why does our Board care?
2/3/2012
2
3Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/3.PPT (1/6/2012)
Fraud, Waste, and Abuse
2. Centers for Medicare and Medicaid Services (CMS)
– Chapter (9) — Fraud, Waste, and Abuse (FWA) requirements
• Elements of an “effective” compliance program
– Noticeable expansion of enforcement
• CMS regulations
• False Claims Act
• Increased penalties — Corporate Integrity Agreements (CIA) and civil monetary penalties
• Enrollment suspension
Why does our Board care? (continued)
4Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/4.PPT (1/6/2012)
Fraud, Waste, and Abuse
3. CMS’ Medicare Compliance Program audits
– Detect “print, post, and pray” programs
– Substantiate knowledgeable governing body
– Verify reasonable Board oversight of compliance program
Why does our Board care? (continued)
2/3/2012
3
5Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/5.PPT (1/6/2012)
Fraud, Waste, and Abuse
4. BlueCross BlueShield Association
– Revised licensure standards reflect revisions to USFSG
– Emphasis on compliance education and training for
Board members
Why does our Board care? (continued)
6Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/6.PPT (1/6/2012)
Fraud, Waste, and Abuse
5. Health and Human Services — program integrity
– Increased enforcement efforts and funding
– The Patient Protection and Affordable Care Act (PPACA) and
Health Care Reform contains many FWA-related sections
– Recovery critical for funding Health Care Reform
Why does our Board care? (continued)
2/3/2012
4
7Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/7.PPT (1/6/2012)
These ten individuals have allegedly defrauded taxpayers of more than $124 million.In all, we are seeking more than 170 fugitives on charges related to health care fraud and abuse.
$110 MILLION Miami, FL: These brothers submitted false and fraudulent
claims to Medicare, purportedly for HIV infusion therapy.
Charged with drug
possession, fraudulent
Internet marketing, and
child endangerment.
100’s of 1000’s OF $$False and fraudulent Durable
Medical Equipment (DME) claims
that were medically unnecessary.
4.3 MILLION (1.9 million in false claims)
Michigan: Dearborn Medical and Rehabilitation Center
(DMRC), an infusion therapy clinic.
17.1 MILLIONCalifornia: Home Health
Agency — Billed Medicare
for unlicensed nursing staff.
1.1 MILLIONCalifornia: Fraudulent DME
claims — motorized
wheelchairs, scooters, and
hospital beds
U.S. Department of Health and Human Services
Office of Inspector General (OIG)
8Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/8.PPT (1/6/2012)
Fraud, Waste, and Abuse
Comprehensive plan to detect, correct, and prevent FWA
• Written polices and procedures/standards of conduct
• Compliance officer and compliance committee
• Training and education
• Effective lines of communication
• Enforcement of standards/publicized disciplinary guidelines
• Monitoring and auditing
• Corrective action procedures
• Comprehensive fraud and abuse plan
What are the requirements?
2/3/2012
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9Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/9.PPT (1/6/2012)
Fraud, Waste, and Abuse
1. Policies and procedures/standards of conduct
– Compliance and Ethics Department — policies/procedures
– Operational areas — policies/procedures
– Code of Conduct
Specifications:
– Written, producible policies/procedures
– Up-to-date
– Comply with CMS regulations
How do we comply?
10Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/10.PPT (1/6/2012)
Fraud, Waste, and Abuse
2. Compliance officer and compliance committee
– Chief Compliance Officer
– Corporate Compliance Committee
– Medicare Compliance Committee
– Executive Compliance Committee
– Governance Committee of the Board
– Compliance and Ethics Department staff
How do we comply? (continued)
2/3/2012
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11Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/11.PPT (1/6/2012)
Fraud, Waste, and Abuse
3. Training and education
– Compliance and Ethics Department
• Members — new members and annual
– Specialized training in operational areas
– Training must include:
• Regulations that apply to their jobs
• How to report compliance and ethical concerns
• How to identify FWA
• Non-Retaliation policy
How do we comply? (continued)
12Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/12.PPT (1/6/2012)
Fraud, Waste, and Abuse
4. Effective lines of communication
– Employ various avenues to inform employees of:
• Reporting mechanisms (including anonymous options)
• Responsibility to report concerns
• Non-retaliation/confidentiality
How do we comply? (continued)
2/3/2012
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13Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/13.PPT (1/6/2012)
Fraud, Waste, and Abuse
5. Enforcement of standards/publicized disciplinary
guidelines
– Referral of Human Resources (HR)-related inquiries to the HR
department
– New management orientation
– Review of monthly compliance-related corrective action report
How do we comply? (continued)
14Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/14.PPT (1/6/2012)
Fraud, Waste, and Abuse
6. Monitoring and auditing
– Monitor over 600 high-risk or regulatory activities
– Review internal and external audit reports
– Require documentation of department-specific monitoring,
auditing, and quality checks throughout the company
7. Corrective action procedures (CAP)
– Oversee CAPs from external entities
– Identify, establish, and track internal CAPs
How do we comply? (continued)
2/3/2012
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15Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/15.PPT (1/6/2012)
Fraud, Waste, and Abuse
8. Comprehensive fraud and abuse plan
– Chapter 9 regulations
– Now applies to both Medicare Advantage and Part D programs
– “Shoulds” equal “Musts”
– Critical areas (Customer Service, Claims, Pharmacy Services,
Pharmacy Benefit Manager)
• Training
• Reporting
How do we comply? (continued)
16Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/16.PPT (1/6/2012)
Fraud, Waste, and Abuse
8. Comprehensive fraud and abuse plan (continued)
– Delegated entity oversight
• 2011 OIG work plan
• Regular compliance oversight (on-site reviews and audits, teleconferences, attestations, review of codes, FWA training, methods of reporting, etc.)
– Internal Delegated Oversight Committee
• Health Services and Vendor Management audits
• Compliance review of all quarterly audit reports
How do we comply? (continued)
2/3/2012
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17Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/17.PPT (1/6/2012)
Fraud, Waste, and Abuse
8. Comprehensive fraud and abuse plan (continued)
– Special Investigation Units (SIU)
• Unit dedicated to detecting FWA
• STARSentinelTM software detects aberrant behavior
• Internet and Intranet fraud hotline
How do we comply? (continued)
18Independent Licensee of the Blue Cross and Blue Shield Association
GR-P11-322/18.PPT (1/6/2012)
Fraud, Waste, and Abuse
8. Comprehensive fraud and abuse plan (continued)
– Capital BlueCross — Fraud and Abuse Committee
• Monthly meetings
• SIU, Compliance, and Legal representation
• Recoupment of all government programs’ monies
– Dominion Dental Services, Inc. — Quality Assurance Committee
• Quarterly meetings
• SIU, Compliance, and Legal representation
• Recoupment of all government programs’ monies
How do we comply? (continued)
2/3/2012
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Independent Licensee of the Blue Cross and Blue Shield Association
19GR-P11-322/19.PPT (1/6/2012)
Thank You