Medicare Advantage and Part D General Compliance Training Copyright © 2009 Highmark Inc.

Medicare AdvantageMedicare Advantage and Part D and Part D

General Compliance General Compliance TrainingTraining

Copyright © 2009 Highmark Inc.

Products Covered by this Products Covered by this TrainingTraining

Keystone Health Plan West Security Keystone Health Plan West Security BlueBlue

Highmark FreedomBlue PPO Highmark FreedomBlue PPO PennsylvaniaPennsylvania

Highmark FreedomBlue PFFS Highmark FreedomBlue PFFS PennsylvaniaPennsylvania

HHIC FreedomBlue PPO West VirginiaHHIC FreedomBlue PPO West Virginia HHIC FreedomBlue PFFS West VirginiaHHIC FreedomBlue PFFS West Virginia Highmark Senior Resources Blue RxHighmark Senior Resources Blue Rx


General Compliance TrainingGeneral Compliance Training

Why this training?Why this training? What will I learn?What will I learn? Fraud, waste, and abuse termsFraud, waste, and abuse terms Compliance and Fraud, waste, and Compliance and Fraud, waste, and

abuse lawabuse law Highmark’s expectations of Providers Highmark’s expectations of Providers

and their staffsand their staffs Examples of fraud, waste, and abuseExamples of fraud, waste, and abuse Where to ask questions or report Where to ask questions or report

potential fraud, waste and abuse potential fraud, waste and abuse violationsviolations


Why This Training?Why This Training?

CMS amended its Medicare Advantage (MA) andCMS amended its Medicare Advantage (MA) and

Part D regulations to clarify the obligations of Part D regulations to clarify the obligations of

MA organizations and Part D sponsors, such as MA organizations and Part D sponsors, such as

Highmark, to include general compliance and Highmark, to include general compliance and fraud, waste and abuse training in theirfraud, waste and abuse training in their

education plans for their providers and their education plans for their providers and their

providers’ employees, managers and directors.providers’ employees, managers and directors.


Terms You Should KnowTerms You Should Know

Theft by deception – The use of deception Theft by deception – The use of deception for unlawful gain or unjust advantage. for unlawful gain or unjust advantage.

Fraud – Using intentional deception or Fraud – Using intentional deception or misrepresentation for unlawful gain or misrepresentation for unlawful gain or unjust advantageunjust advantage

Waste – Using, consuming, spending, or Waste – Using, consuming, spending, or expending thoughtlessly or carelesslyexpending thoughtlessly or carelessly

Abuse - Using wrongly or improperlyAbuse - Using wrongly or improperly Conspiracy – An agreement between two or Conspiracy – An agreement between two or

more persons to perform together an more persons to perform together an illegal illegal wrongful or subversive act.wrongful or subversive act.


Terms You Should Know Terms You Should Know (Continued) (Continued)

Compliance Program – A program Compliance Program – A program to ensure that Highmark, its to ensure that Highmark, its employees and contractors employees and contractors comply with all applicable laws comply with all applicable laws and contractual requirements, and contractual requirements, including those regulating the including those regulating the Medicare Advantage and Part D Medicare Advantage and Part D programs and those prohibiting programs and those prohibiting waste, fraud and abuse.waste, fraud and abuse.


ExpectationsExpectations

Highmark’s expectations of our providers:Highmark’s expectations of our providers: Conduct business activities and interactions Conduct business activities and interactions

with our members ethically and with integrity.with our members ethically and with integrity. Conduct business activities in full compliance Conduct business activities in full compliance

with applicable statutory, regulatory and with applicable statutory, regulatory and Medicare Program requirements. Medicare Program requirements.

Maintain patient records that are accurate Maintain patient records that are accurate and complete and appropriately reflect and complete and appropriately reflect treatment.treatment.

Call the Highmark Integrity Office when you Call the Highmark Integrity Office when you have compliance questions or concerns about have compliance questions or concerns about potential fraud and abuse.potential fraud and abuse.


Compliance with the LawCompliance with the Law The activities of Highmark and each of its The activities of Highmark and each of its

contracting providers and their employees, contracting providers and their employees, managers and directors. must be carried out in managers and directors. must be carried out in accordance with applicable laws and related accordance with applicable laws and related Highmark policies and procedures.Highmark policies and procedures.

Federal and state laws may include matters such Federal and state laws may include matters such as, submission of data, record keeping, access to as, submission of data, record keeping, access to records, and privacy of protected health records, and privacy of protected health information.information.

Special provisions apply to government programs Special provisions apply to government programs such as Medicare Advantage and Part D.such as Medicare Advantage and Part D.

Violations of laws may subject you to individual Violations of laws may subject you to individual civil or criminal liability, as well as to civil or criminal liability, as well as to disciplinary action. disciplinary action.


Conflicts of Interest Conflicts of Interest Conflict of interest with Highmark and its Conflict of interest with Highmark and its

members should be avoided. members should be avoided. Conflicts of interest may arise when outside Conflicts of interest may arise when outside

personal interests, employment, or affiliations personal interests, employment, or affiliations influence or appear to influence business or influence or appear to influence business or medical practice decisions.medical practice decisions.

The self-referral law prohibits physicians from The self-referral law prohibits physicians from referring Medicare patients for certain referring Medicare patients for certain designated health services to an entity with designated health services to an entity with which the physician or a member of the which the physician or a member of the physician's immediate family has a financial physician's immediate family has a financial relationship--unless an exception applies. It also relationship--unless an exception applies. It also prohibits an entity from presenting or causing to prohibits an entity from presenting or causing to be presented under a Medicare Advantage plan a be presented under a Medicare Advantage plan a claim for a designated health service furnished claim for a designated health service furnished as a result of a prohibited referral. as a result of a prohibited referral.


Gifts, Gratuities and Entertainment

Providers and their employees may not offer any Providers and their employees may not offer any gift or entertainment that might be perceived to gift or entertainment that might be perceived to be primarily intended to gain favor or to be primarily intended to gain favor or to compromise a business or health care decision compromise a business or health care decision under a Federal health care program.under a Federal health care program. For example, providing gifts to Highmark For example, providing gifts to Highmark

employees in a position to influence decisions employees in a position to influence decisions about your participation is prohibited.about your participation is prohibited.

Offering gifts to Medicare beneficiaries may Offering gifts to Medicare beneficiaries may also violate the prohibition on beneficiary also violate the prohibition on beneficiary inducements.inducements.

Accepting gifts from pharmaceutical companies or Accepting gifts from pharmaceutical companies or device manufacturers that are intended to affect device manufacturers that are intended to affect the way you practice medicine is strongly the way you practice medicine is strongly discouraged.discouraged.


Compliance with Relevant Compliance with Relevant LawsLaws

Medicare Advantage organizations and Part Medicare Advantage organizations and Part D sponsors are paid in part using federal D sponsors are paid in part using federal Medicare funds. Therefore, Medicare Medicare funds. Therefore, Medicare Advantage plans, Part D sponsors and the Advantage plans, Part D sponsors and the providers and facilities that furnish services providers and facilities that furnish services to their members are subject to laws to their members are subject to laws applicable to individuals and entities applicable to individuals and entities receiving federal funds, including but not receiving federal funds, including but not limited to, the Age Discrimination Act, the limited to, the Age Discrimination Act, the American with Disabilities Act, applicable American with Disabilities Act, applicable provisions of criminal law and the False provisions of criminal law and the False Claims Act.Claims Act.


Fraud, Waste, and Abuse Fraud, Waste, and Abuse LawsLaws

The False Claims ActThe False Claims Act Prohibits knowingly presenting (or Prohibits knowingly presenting (or

causing to be presented) to the causing to be presented) to the Federal government a false or Federal government a false or fraudulent claim for payment or fraudulent claim for payment or approval.approval.

ProhibitsProhibits knowingly making, using, or knowingly making, using, or causing to be made or used, a false causing to be made or used, a false record or statement to get a false or record or statement to get a false or fraudulent claim paid or approved by fraudulent claim paid or approved by the Government.the Government.


The False Claims ActThe False Claims Act Applies to claims made to Medicare Applies to claims made to Medicare

Advantage Organizations and Part D Advantage Organizations and Part D SponsorsSponsors

Has been interpreted to mean that it Has been interpreted to mean that it is a potential violation of federal law is a potential violation of federal law if a provider makes little or no effort if a provider makes little or no effort to validate the truth and accuracy of to validate the truth and accuracy of his or her statements, his or her statements, representations, or claims or representations, or claims or otherwise acts in a reckless manner otherwise acts in a reckless manner as to the truth.as to the truth.



Anti-Kickback StatuteAnti-Kickback Statute Prohibits knowingly and willfully paying, offering, Prohibits knowingly and willfully paying, offering,

soliciting or receiving remuneration (anything of soliciting or receiving remuneration (anything of value) value)

to induce a referral of a patient for items or services for to induce a referral of a patient for items or services for which payment may be made, in whole or in part, under a which payment may be made, in whole or in part, under a Federal health care program; or Federal health care program; or

in return for purchasing, leasing, ordering, or arranging in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be good, facility, service, or item for which payment may be made in whole or in part under a Federal health care made in whole or in part under a Federal health care program. program.

There are certain exceptions specified in so-called There are certain exceptions specified in so-called “safe harbors” specified by law.“safe harbors” specified by law.



Prohibition on beneficiary Prohibition on beneficiary remunerationremuneration Prohibits offering or providing Prohibits offering or providing

anything of value to beneficiaries anything of value to beneficiaries to influence them to receive to influence them to receive services from particular providers.services from particular providers.


Other Payment Other Payment ProhibitionsProhibitions

Medicare Advantage Organizations and Part D Medicare Advantage Organizations and Part D Sponsors are generally prohibited by law from Sponsors are generally prohibited by law from paying:paying: Providers who have been excluded from participation Providers who have been excluded from participation

in a Federal Health Care Program such as Medicare, in a Federal Health Care Program such as Medicare, Medicaid or SCHIPMedicaid or SCHIP

Providers who have “opted out” of the Medicare Providers who have “opted out” of the Medicare ProgramProgram

except for providing emergency servicesexcept for providing emergency services Providers may not contract with, or employ, such Providers may not contract with, or employ, such

opted out or excluded individuals or entities to opted out or excluded individuals or entities to furnish services to members of Medicare furnish services to members of Medicare Advantage Organizations and Part D Sponsors Advantage Organizations and Part D Sponsors


Examples of Fraud, Waste Examples of Fraud, Waste and Abuseand Abuse

Professional ProviderProfessional Provider Misreporting/upgrading procedure codes to Misreporting/upgrading procedure codes to

receive a higher paymentreceive a higher payment Inappropriately altering a patient recordInappropriately altering a patient record Inappropriately prescribing drugsInappropriately prescribing drugs Submitting to Highmark encounter or Submitting to Highmark encounter or

diagnostic data that the Provider knows is diagnostic data that the Provider knows is incorrectincorrect

Performing or ordering inappropriate or Performing or ordering inappropriate or unnecessary procedures/tests. unnecessary procedures/tests.

Accepting remuneration in exchange for Accepting remuneration in exchange for prescribing particular drugsprescribing particular drugs



FacilityFacility Patient never receives his/her Patient never receives his/her

prescribed take home drugsprescribed take home drugs Billing for drugs never received by Billing for drugs never received by

the patientthe patient Reselling drugs not used by patientsReselling drugs not used by patients Drug diversionDrug diversion Billing for labs, procedures or Billing for labs, procedures or

services the patient did not receiveservices the patient did not receive



PharmacyPharmacy Submitting false claim for paymentSubmitting false claim for payment Altering prescriptions to receive higher Altering prescriptions to receive higher

paymentpayment Dispensing expired drugsDispensing expired drugs Collecting higher co-pays than allowed or Collecting higher co-pays than allowed or

charging more than the negotiated pricecharging more than the negotiated price Routinely waiving copaysRoutinely waiving copays Manipulating the amount of out-of-pocket Manipulating the amount of out-of-pocket

payments a beneficiary has madepayments a beneficiary has made Accepting illegal payments to convince Accepting illegal payments to convince

beneficiaries or physicians to switch drugsbeneficiaries or physicians to switch drugs



BeneficiaryBeneficiary Permitting another person to use Permitting another person to use

their Medicare ID number/cardtheir Medicare ID number/card Falsifying Coordination of Benefits Falsifying Coordination of Benefits

information to collect duplicate information to collect duplicate payments from multiple insurance payments from multiple insurance plansplans

Participating in schemes that Participating in schemes that involve conspiracy between a involve conspiracy between a provider/supplier and beneficiary. provider/supplier and beneficiary.


Consequences of Committing Consequences of Committing Fraud, Waste and Abuse Fraud, Waste and Abuse

Administrative Administrative Recoupment/RestitutionRecoupment/Restitution

Criminal and/or civil prosecutionCriminal and/or civil prosecution Fines/PenaltiesFines/Penalties ImprisonmentImprisonment Suspension/Loss of Provider LicenseSuspension/Loss of Provider License Exclusion from the Medicare Exclusion from the Medicare

programprogram


Identifying Possible Fraud, Identifying Possible Fraud, Waste and AbuseWaste and Abuse

You are a vital part of the effort You are a vital part of the effort to prevent, detect, and report to prevent, detect, and report possible fraud, waste and abuse possible fraud, waste and abuse issues. To do that you need to be issues. To do that you need to be able to identify various potential able to identify various potential misconduct that could rise to the misconduct that could rise to the level of fraud.level of fraud.


Read the following Read the following situations to better situations to better understand how to understand how to identify potential identify potential fraud, waste or fraud, waste or

abuse.abuse.



Professional Provider situations:Professional Provider situations: A practitioner knowingly misreported a A practitioner knowingly misreported a

procedure code for medication given to a procedure code for medication given to a patient. This misreported code resulted in patient. This misreported code resulted in higher payment to the provider/practitioner.higher payment to the provider/practitioner.

Patient records, claim forms, electronic Patient records, claim forms, electronic claim forms, show signs of alteration to claim forms, show signs of alteration to obtain higher payments.obtain higher payments.

““Double billing” – charging more than once Double billing” – charging more than once for the same service, for example by an for the same service, for example by an individual code then again as part of an individual code then again as part of an automated or bundled set of services. automated or bundled set of services.



FacilityFacility SituationsSituations Drug Diversion – Patients not Drug Diversion – Patients not

receiving medications (especially pain receiving medications (especially pain medications) due to staff substituting medications) due to staff substituting another substance for the medicationanother substance for the medication

Billing for supplies, medications, Billing for supplies, medications, procedures or lab services not procedures or lab services not provided to the patientprovided to the patient

Billing for a higher level care than Billing for a higher level care than the patient was receivingthe patient was receiving



Pharmacy Situations:Pharmacy Situations: The pharmacist offers to waive a The pharmacist offers to waive a

member’s co-pay if he agrees to use this member’s co-pay if he agrees to use this pharmacy for all his prescriptions.pharmacy for all his prescriptions.

A pharmacy employee bills the A pharmacy employee bills the insurance company for a narcotic using insurance company for a narcotic using the information from the pharmacy the information from the pharmacy database. The patient never received database. The patient never received the medication.the medication.

““Short Filling” – A pharmacy bills for Short Filling” – A pharmacy bills for more than the amount of medication more than the amount of medication dispensed.dispensed.



Beneficiary Situations:Beneficiary Situations: A member goes to a number of A member goes to a number of

different doctors for prescriptions for different doctors for prescriptions for the same controlled substancethe same controlled substance

A member gets a prescription from her A member gets a prescription from her physician allegedly for herself physician allegedly for herself intending that her husband will take it.intending that her husband will take it.

Letting someone use your Medicare Letting someone use your Medicare Number or ID card to obtain supplies, Number or ID card to obtain supplies, medications, procedures or lab services medications, procedures or lab services


Your InvolvementYour Involvement

Highmark engages in activities such as Highmark engages in activities such as auditing, monitoring and other oversight to auditing, monitoring and other oversight to identify compliance issues. However, we identify compliance issues. However, we need your assistance:need your assistance:

Facilities and Professional Providers: Facilities and Professional Providers: Establish a fraud, waste and abuse Establish a fraud, waste and abuse prevention policy. prevention policy.

Management: Educate Management: Educate coworkerscoworkers of the of the importance of fraud and abuse prevention.importance of fraud and abuse prevention.

All Individuals: Report any potential All Individuals: Report any potential incidents of fraud waste or abuse to incidents of fraud waste or abuse to Highmark.Highmark.


Policies Regarding Policies Regarding Inquiries and ReportsInquiries and Reports

All inquiries are confidential, subject to All inquiries are confidential, subject to limitations imposed by law. If an individual limitations imposed by law. If an individual is unwilling to identify himself or herself is unwilling to identify himself or herself despite this protection, they may make an despite this protection, they may make an anonymous report. If an individual does not anonymous report. If an individual does not identify himself or herself, we ask that he identify himself or herself, we ask that he or she provide some method of future or she provide some method of future contact. This will allow the internal contact. This will allow the internal investigator to ask follow up questions. investigator to ask follow up questions. Highmark policy prohibits retaliation Highmark policy prohibits retaliation against individuals who raise questions in against individuals who raise questions in good faith. good faith.


Where can a provider go to ask Where can a provider go to ask questions about potential waste questions about potential waste fraud and abuse?fraud and abuse?

Who should a provider or a member Who should a provider or a member of their staff report potential fraud of their staff report potential fraud waste or abuse to?waste or abuse to?

How to Obtain More Information How to Obtain More Information About, or Report Potential Fraud, About, or Report Potential Fraud,

Waste and AbuseWaste and Abuse


Contact InformationContact Information

For information and inquiries or to report potential For information and inquiries or to report potential misconduct contact The Highmark Integrity officemisconduct contact The Highmark Integrity office Toll –Free hotline available 24-Hour a day/ 7 days a week Toll –Free hotline available 24-Hour a day/ 7 days a week

1 (800) 985-10561 (800) 985-1056

Confidential U.S. Post Office BoxConfidential U.S. Post Office Box:: Highmark Inc.Highmark Inc. Integrity OfficeIntegrity Office P. O. Box 150P. O. Box 150 Enola, PA 17025Enola, PA 17025

Confidential FaxConfidential Fax Camp Hill Fax: (717) 302-3650 Camp Hill Fax: (717) 302-3650 Pittsburgh Fax: (412) 544-2475Pittsburgh Fax: (412) 544-2475 E-Mail: E-Mail: [email protected]@highmark.com


Follow-upFollow-up For any credible report of potential waste, For any credible report of potential waste,

fraud and/or abuse, Highmark will undertake a fraud and/or abuse, Highmark will undertake a reasonable investigation and may refer the reasonable investigation and may refer the issue, as appropriate, to a MEDIC, CMS or law issue, as appropriate, to a MEDIC, CMS or law enforcement.enforcement.

The MEDIC (The MEDIC (((Medicare Drug Integrity Medicare Drug Integrity Contractor) is an organization assigned by Contractor) is an organization assigned by CMS to manage anti-fraud and abuse efforts in CMS to manage anti-fraud and abuse efforts in the Part D program. The MEDIC will further the Part D program. The MEDIC will further investigate referrals from Part D Sponsors, investigate referrals from Part D Sponsors, develop the investigations, and make referrals develop the investigations, and make referrals to appropriate law enforcement agencies or to appropriate law enforcement agencies or other outside entities when necessaryother outside entities when necessary


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