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• Anytime you see the information button, click
on it for more information
• Click on the home button if you need to return
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• At the end of the training, take the quiz. Once you pass the quiz the answers will be submitted automatically-no need to do anything further.
A couple of things to note as you proceed through the class:
Marion County Health Department Presents: Fraud, Waste and Abuse Refresher
• If a screen does not proceed on its own you may need to click the next button located at the bottom of your screen
Hi June, I wanted to talk to you about our Fraud, Waste and Abuse policy
Oh good! I’ve been hearing about it and wanted to know more…
It is required by federal law that we have refreshers each year
You’re right Paul
What exactly do we mean by Fraud?
Fraud is…
The intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to oneself or someone else…NOT GOOD!
Let’s take a closer look at what is and isn’t Fraud
Examples of Fraud1. Billing for No Shows2. Misrepresenting a diagnosis in
order to justify the services3. Misrepresenting who, what, or
where the services occurred4. Duplicate billing and billing for
non-covered services5. Substituting Services6. Incorrect coding to generate
more revenue7. Overutilization
If slide does not advance automatically please manually click the next slide from the “Outline” to the left
The False Claims “Whistleblower” Employee protection Act
Laws Regulating Fraud
Deficit Reduction Act
False Claims Act (FCA)
HIPAA
The Anti-Kickback Statute
Physician Self-Referral (“Stark”) Statute
Administrative Remedies for False Claims and Statements
The False Claims “Whistleblower” Employee protection Act
Laws Regulating Fraud
Deficit Reduction Act
False Claims Act (FCA)
HIPAA
The Anti-Kickback Statute
Physician Self-Referral (“Stark”) Statute
Administrative Remedies for False Claims and Statements
…remember, every employee is protected from retribution for reporting Fraud, Waste or Abuse
It is especially important to…
The law about Whistleblower Protection sounds very important
…health care spending that can be eliminated without reducing quality of care That makes
sense…so what is Waste then?
Waste is…
Yes Paul. There are two types of Waste…
…and, “Inefficiency Waste” is redundancy, delays, and unnecessary process complexity
…“Quality Waste” is over, under or ineffective use
Zack and Angi are both correct
Tell her about Abuse
Abuse is…
…inconsistent practices that result in an unnecessary cost to Medicaid, Medicare or the MVBCN
Abuse can also be reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care
False Claims Act Under the False Claims Act (FCA), 31 U.S.C
3729-3733, those who knowingly submit, or cause another person or entity to submit false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim– The FCA applies to any health care entity
that receives more than $5 million in Medicaid funds • MCHD receives in excess of $5 million
annually Back
HIPAAThe Health Insurance Portability and Accountability Act (HIPAA), 45 CFR, Title II, 201-250, provides clear definition for Fraud & Abuse control programs, establishment of criminal and civil penalties and sanctions for noncompliance• Established the national Health Care Fraud and
Abuse Control Program (“HCFAC”) that coordinates Federal, state, and local law enforcement activities with respect to health care Fraud, Waste and Abuse. It created the offense of “health care Fraud” and established criminal penalties for violation.
• Penalties:• Fines• Imprisonment Back
Deficit Reduction ActThe Deficit Reduction Act (DRA), Public Law No. 109-171, 6032, passed in 2005, is designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries The Act requires compliance for continued participation in the programs. The development of policies and education relating to false claims, whistleblower protections and procedures for detecting and preventing Fraud & Abuse must be implemented
Back
The False Claims “Whistleblower” Employee protection Act
The False Claims Act Whistleblower Employee Protection Act, 31 U.S.C 3730(h), states that a company is prohibited from discharging, demoting, suspending, threatening, harassing or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer
• Every employee is protected with ZERO retribution for making referrals whether they are made anonymously or not
Back
The False Claims “Whistleblower” Employee protection Act
The False Claims Act Whistleblower Employee Protection Act, 31 U.S.C 3730(h), states that a company is prohibited from discharging, demoting, suspending, threatening, harassing or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer
• Every employee is protected with ZERO retribution for making referrals whether they are made anonymously or not
Back
Administrative Remedies for False Claims and Statements
Administrative Remedies for False Claims and Statements, 31 U.S.C Chapter 8, 3801, states that any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim
Back
The Anti-Kickback StatuteThe Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b), 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.
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 3 times the
amount of remuneration• Exclusion from Federal health care programs
Back
Physician Self-Referral (“Stark”) Statute
Back
The Physician Self-Referral, “Stark” Statute, 42 U.S.C. 1395nn, prohibits a physician, from making referrals for certain designated health services to an entity in which the physician, or a member of his/her family, has an ownership/investment interest or with which he/she has a compensation arrangement. Penalties for violation:
• Up to $15,000 for each claim submitted in violation of the law
• Up to $100,000 for each “scheme” that violates the law• Penalties of up to 3 times the amount claimed• Exclusion from Federal health care programs
MCHD has it’s own Anti-Fraud Strategy. Let’s take a closer look…
I suspect Fraud, now what do I do?
That’s a very important question, Ming.
Reporting Fraud Anonymous Hotline :1-877-706-4445 Email:
[email protected] Mail, submit or fax the Fraud, Waste
and Abuse Referral Form located on both the MCHD Internet and Intranet) to:
Mail: Marion County Health DeptAttn: FWA Compliance
Officer3180 Center St NESalem, OR 97301
Fax: (503) 364-6552
Back
Additional Contacts Medicaid Fraud Control Unit
(971) 673-1880
515 SW 5th Ave Suite 410
Portland, OR 97301
DHS Fraud Investigation Unit
(503) 378-6826
PO Box 14150
Salem, OR 97309
MCHD Compliance Officer
Remember: there is never a ‘bad’ referral and failure to report may result in disciplinary action.
Employee Rights and Responsibilities
Have the right to remain anonymous To the extent allowed by the law Protection from retaliation
Employees are obligated to report potential Fraud, Waste or Abuse
Failure to report could require MCHD to pay excessive fines and potentially be excluded from Federal health care programs
Back
MCHD Compliance OfficerDivision Director:
Roy Deede (503) 588-5405
His duties: Represent the Health Department on external
Fraud and Abuse Committees May act as the lead on internal or external
investigations of Fraud, Waste and Abuse
Back
Maintain appropriate and legible documentation
Understand which services are covered and which are not covered Don’t submit
duplicate claims
How do I make sure I stay in compliance?
Record start and stop times accurately
Avoid ‘up-coding’ or ‘down-coding’
Cooperate with any audits or reviews
Comply with State licensure regulations
As your supervisor, feel free to contact me if you have questions about Fraud, Waste or Abuse or reporting requirements. I’ll be glad to help!
YEAH!
YEAH! YEAH!
Together, we can eliminate Fraud, Waste and Abuse!
Quiz Instructions
1. You have just completed the Fraud, Waste, and Abuse training. To receive credit please complete the 10 question quiz by clicking on the link below.
2. It is very important that you enter your first and last name at the end of the quiz to receive credit.
3. Your results are electronically submitted. You do not need to print them .
Click HERE to proceed to the quiz