1 Medicare Compliance and Fraud, Waste and Abuse (FWA) Training
12/11/2013
Slide 2
FRAUD, WASTE AND ABUSE (FWA) EXECPTION-NOTICE There is one
exception to the FWA training and education requirement.
Regulations effective June 7, 2010 implemented a deeming exception
which exempts FDRs who are enrolled in Medicare Parts A or B from
annual FWA training and education. Therefore, if an entity or an
individual is enrolled in Medicare Parts A or B, the FWA training
and education requirement has already been satisfied. If you are
unsure if this deeming exception applies to you please contact an
IEHP Compliance Manager at [email protected] for more
information. [email protected] 2
Slide 3
3 Overview & Objectives What: Compliance, Fraud, Waste,
& Abuse (FWA) program requirements Inform you about what you
need to be aware of and implement into your practices Meet the
regulatory requirements for training and education Provide
information on laws pertaining to fraud, waste, and abuse Why:
Compliance programs help raise awareness and provide mechanisms to
detect, prevent, and correct FWA Provide information on how to
report fraud, waste, and abuse You must report non compliance and
suspected or known FWA activities to a compliance officer or
compliance department representative How: Training and education
You must demonstrate training through completion of this training
or an equivalent training You must be able to ensure that training
was completed for each of your staff and that you have a process
for new hires. Training to be completed by 12/31/2013
Slide 4
Why Do I Need Training? Every year millions of dollars are
improperly spent because of fraud, waste, and abuse. It affects
everyone, including YOU. This training will help you detect,
correct, and prevent fraud, waste, and abuse. YOU are part of the
solution. 4
Slide 5
Where Do I Fit In? As a First Tier, Downstream, or Related
Entity (FDR) who provides health or administrative services to a
Part C or Part D IEHP Member You are required to comply with all
applicable statutory, regulatory, and other Part C or Part D
requirements, including adopting and implementing an effective
compliance program You have a duty to the Medicare Program to
report any violations of laws of which you may be aware You have a
duty to follow your organizations Code of Conduct that articulates
your and your organization's commitment to standards of conduct and
ethical rule of behavior. 5
Slide 6
Requirements The Social Security Act and CMS regulations and
guidance govern the Medicare program, including parts C and D. Part
C and Part D sponsors must have an effective compliance program
which includes measure to prevent, detect and correct Medicare
non-compliance as well as measures to prevent, detect and correct
fraud, waste, and abuse. IEHP must have an effective training
program for employees, managers, and directors, as well as their
first tier, downstream, and related entities. (42 C.F.R. 422.503
and 42 C.F.R. 423.504 6
Slide 7
An Effective Compliance Program Must at a minimum, include the
7 core compliance program requirements Written compliance policies,
procedures, and standards of conduct A Compliance Officer,
Compliance Committee, and High Level Oversight Effective training
and education Effective lines of communication Well publicized
disciplinary standards Effective system for routine monitoring and
identification of compliance risks Procedures and system for prompt
response to compliance issues 7
Slide 8
DETECTION 8
Slide 9
UNDERSTANDING FRUAD, WASTE, AND ABUSE In order to detect fraud,
waste, and abuse you need to know the Law CRIMINAL FRAUD: Knowingly
and willfully executing, or attempting to execute, a scheme or
artifice to defraud any health care benefit program; or to obtain,
by means of false or fraudulent pretenses, representations, or
promises, any of the money or property owned by, or under the
custody or control of, any health care benefit program. 18 United
States Code 1347 9
Slide 10
Waste and Abuse WASTE: Overutilization of services or other
practices that directly or indirectly result in unnecessary costs
to the Medicare Program. Abuse: Includes actions that may directly
or indirectly result in unnecessary costs to the Medicare Program.
10
Slide 11
Differences Between Fraud, Waste, and Abuse Criminal Fraud:
Intentionally submitting false information to the government or a
government contractor in order to get money or a benefit. Person
has intent to obtain payment or benefit and the knowledge that
their actions are wrong. Waste and Abuse: May involve obtaining an
improper payment, but does not require the same intent and
knowledge. 11
Slide 12
12 Examples of Fraud Examples of Abuse Examples of Waste
Billing for services not furnished Billing for services at a higher
rate than is actually justified Soliciting, offering or receiving a
kickback, bribe or rebate Deliberately misrepresenting services,
resulting in unnecessary cost, improper payments or overpayment
Violations of the physician self- referral (Stark) prohibition
Source: 1. Medicare Physician Guide: A Resource for Residents,
Practicing Physicians, & Other Health Care Professionals, 10 th
Edition (10/08) Charging in excess for services or supplies
Providing medically unnecessary services Providing services that do
not meet professionally recognized standards Billing Medicare based
on a higher fee schedule than is used for patients not on Medicare
Source: 2. CMS Medicare Fraud and Abuse Web-based Training (April
2007) Over-utilization of services Misuse of resources Quick
Reference Chart
Slide 13
REPORTING 13
Slide 14
Reporting Fraud, Waste, and Abuse Do not be concerned about
proving whether it is fraud, waste, or abuse. You do not have to
prove FWA to report it, you only need to suspect it to report it!
Report any concerns to your Compliance Department or the IEHP
Compliance Department. IEHPs Compliance Department will investigate
and make the proper determination. 14
Slide 15
Required Reporting Violations of the code of conduct, ethics or
any fraud, waste or abuse must be reported. Not reporting fraud or
suspected fraud can make you a party to a case by allowing the
fraud to continue. Everyone is required to report suspected
instances of fraud, waste, and abuse which is clearly stated in the
IEHP Code of Conduct Your organization must have internal
mechanisms for reporting compliance & FWA concerns (i.e., your
Compliance Officer or a Compliance Hotline) IEHP may not retaliate
against you for making a good faith effort in reporting. Fraud or
suspected fraud may be reported anonymously to IEHP, your internal
reporting mechanisms, or MEDICS at 1-800-MEDICARE Refer to the
following slide regarding IEHP compliance reporting options 15
Slide 16
16 Health Plan Hotline Information IEHP Compliance Hotline
866-355-9038 IEHP Compliance Department Email [email protected][email protected] IEHP Compliance Department Fax # 909-890-2973
Mailing Address Compliance Officer IEHP P.O. Box 1800 Rancho
Cucamonga, CA 91729-1800 Required Reporting (continued)
Slide 17
Everyone has the right and responsibility to report possible
fraud, waste, or abuse. REMEMBER: You may report anonymously and
retaliation is prohibited when you report a concern in good faith.
WHEN IN DOUBT: Call IEHP fraud, waste, and abuse Hotline or the
Compliance Department IEHP Compliance Hotline 866-355-9038 17
Slide 18
Types of FWA Medicare Advantage Organization (MAO) or Part D
Plan (PDP) Fraud Member Fraud Provider Fraud Pharmacy Fraud Each
carries a set of implications that we need to be aware of as part
of our daily activities to help prevent FWA 18
Slide 19
MAO / PDP PLAN FWA (examples) Failure to Provide Medically
Necessary Services Medically necessary items or services fail to be
provided which the organization is required to provide (under law
or under the contract) to a Part C or Part D plan enrollee, and
that failure adversely affects (or is likely to affect) the
enrollee. Inappropriate Enrollment / Disenrollment Improperly
reporting enrollment and disenrollment data to CMS to inflate
prospective payments. For example, Sponsor fails to effect timely
disenrollment of beneficiary from CMS systems upon beneficiarys
request. 19
Slide 20
MAO / PDP PLAN FWA (examples continued) Marketing Schemes
Offering beneficiaries a cash payment as an encouragement to enroll
in a Plan. Gifts that are above the CMS allowed $15 exemption,
gifts convertible to cash, or meals (anything beyond the light
snacks that guidance allows) Unsolicited door-to-door marketing.
Use of unlicensed agents, where required by state law. Enrollment
of individual in a Medicare Plan without knowledge or consent.
Stating that a marketing agent / broker works for or is contracted
with the Social Security Administration or CMS Formulary or
Coverage Decisions Making inappropriate formulary decisions or
coverage decisions based on inducements. Delaying access to
necessary covered drugs. 20
Slide 21
Beneficiary (Member) FWA (examples) The following are examples
of fraud by Medicare beneficiaries (members): Identity Theft Using
a different members I.D. card to obtain prescriptions, services,
equipment, supplies, doctor visits, and / or hospital stays.
Individuals who loan their I.D. card face significant risks to care
(i.e., wrong blood type in their medical record) Doctor Shopping
Visiting several different doctors to obtain multiple prescriptions
for painkillers or other drugs might point to an underlying scheme
(stockpiling or black market resale). Improper Coordination of
Benefits Beneficiary fails to disclose multiple coverage policies,
or leverages various coverage policies to game the system.
Prescription Fraud Resale of Drugs on Black Market. Falsely
reporting loss or theft of drugs or feigns illness to obtain drugs
for resale on the black market. Falsifying or modifying a
prescription. 21
Slide 22
22 Provider FWA (examples) Kickbacks: Soliciting, offering, or
receiving a kickback, bribe, or rebate For example, paying for a
referral of patients in exchange for the ordering of diagnostic
tests and other services or medical equipment. Inducements: Such as
copay waivers or free services to retain patients Caution required
when dispensing free medications from pharmacy companies. Should
have consistent policies reviewed by legal. False Claims: Billing
for services not rendered or supplies not provided For example,
billing for appointments the patient failed to keep. Billing for a
gang visit in which a physician visits a nursing home and bills for
20 nursing home visits without furnishing any specific service to
individual patients. Double billing: Such as billing both Medicare
and the beneficiary, or billing both Medicare and another
insurer.
Slide 23
23 Provider FWA (examples continued) Date of Service:
Misrepresenting the date services were rendered. Identity:
Misrepresenting the identity of the individual who received the
services. Rendering Provider: Misrepresenting who rendered the
service. Such as billing for an office visit when the only services
were an injection by a medical assistant. False Coding or Services:
Billing for a covered item or service when the actual item or
service provided was a non-covered item or service. Unnecessary
Care: Providing unnecessary procedures or prescribing unnecessary
drugs. This includes appropriate review that patients meet the
Certification of Medical Necessity requirements
Slide 24
24 Provider FWA (examples continued) Altering Medical Records:
Erroneous or false or late entries in the medical record. Late
entry in the record, such as an addendum must be entered
sequentially in the record according to coding rules Delay in Care:
Delay in authorizing or providing access to medically necessary
care. Physician office errors in non-timely submission of auth
requests can result in delay in care. Patient Dumping: Encouraging
disenrollment for high cost patients to defer costs and care to
original Medicare when in a capitated model.
Slide 25
25 Provider Prescription Drug FWA (examples) Over Prescribing:
Over-prescription or false prescription of narcotics Selling
Prescriptions: Participating in illegal remuneration schemes, such
as selling prescriptions. Inducements: Prescribing medications
based on illegal inducements, rather than the clinical needs of the
patient. Such as pharmacy manufacturer incentives or discounted
services Not Medically Necessary: Writing prescriptions for drugs
that are not medically necessary, often in mass quantities, and
often for individuals that are not patients of a provider.
Slide 26
26 Provider Prescription Drug FWA (examples continued) Theft
Identity Fraud: Theft of a prescribers Drug Enforcement Agency
(DEA) number, prescription pad, or e-prescribing log-in
information. Falsifying Justification: Falsifying information in
order to justify coverage, such as ruling out lower cost generics
Dilution or Illegal Importation: Diluted substances or substituted
provider administered drugs that may be either less than effective
or contraindicated or illegal importation of drugs used or sold as
covered drugs.
Slide 27
27 Pharmacists FWA (examples) False Billing: Billing for
prescriptions that are never picked up. Billing for a brand name
when generics are dispensed. Billing for non-covered prescriptions
as covered items. Splitting prescriptions: For example, by
splitting a 30-day prescription into 4 7-day prescriptions to get
additional copayments and dispensing fees. Steering &
Kickbacks: Engaging in unlawful remuneration, such as remuneration
for steering a beneficiary toward a certain plan or drug, or for
formulary placement. Overcharging: Failing to offer negotiated
prices. Collecting higher copays than specified. Short Fills:
Prescription drug shorting: Provides less than the prescribed
quantity and bills for the fully-prescribed amount.
Slide 28
28 Pharmacists FWA (examples continued) Bait and switch
pricing: When a beneficiary is led to believe that a drug will cost
one price, but at the point of sale, the beneficiary is charged a
higher amount. Forging and altering prescriptions: Modification to
scripts or dosage Modifications to allowable refills Expired Drugs
or Tainted Drugs: Dispensing drugs that are expired or have not
been stored or handled in accordance with manufacturer and FDA
requirements. Manipulating the True Out-of-Pocket cost: When a
pharmacy falsely pushes a beneficiary through the coverage gap,
into catastrophic coverage before they are eligible, or keeps a
beneficiary in the coverage gap so that catastrophic coverage never
occurs.
Slide 29
29 Pharmaceutical Wholesaler FWA (examples) Counterfeit Drugs:
Counterfeit and adulterated drugs through black and grey market
purchases. This includes but is not limited to fake, diluted,
expired, and illegally imported drugs. Diverters: Brokers who
illegally gain control of discounted medicines intended for places
such as nursing homes, hospices and AIDS clinics. Diverters take
the discounted drugs, mark up the prices, and rapidly move them to
small wholesalers. In some cases, the pharmaceuticals may be marked
up six times before being sold to the consumer. Inappropriate
documentation of pricing information: Submitting false or
inaccurate pricing or rebate information to, or that may be used by
any, Federal health care program.
Slide 30
30 Pharmaceutical Manufacturer FWA (examples) Kickbacks,
inducements, and other illegal remuneration: Inappropriate
marketing and/or promotion of products. Inducements offered if the
purchased products are reimbursable by any of the federal health
care programs such as discounts, inappropriate product support
services, educational grants, research funding, etc. Records
Management: Lack of integrity of data to establish payment and/or
determine reimbursement, such as missing or inappropriate
documentation of pricing information. Formulary and formulary
support activities: Inappropriate relationships with Pharmacy &
Therapeutic Services Committee Members. Payments to PBMs for
formulary placement.
Slide 31
31 Pharmaceutical Manufacturer FWA (examples continued)
Inappropriate relationships with physicians: Switching
arrangements, when manufacturers offer physicians cash payments or
other benefits each time a patients prescription is changed to the
manufacturers product from a competing product. Incentives offered
to physicians to prescribe medically unnecessary drugs. Improper
entertainment or incentives offered by sales agents. Off Label Use:
Illegal promotion of off-label drug usage. Billing for Free
Samples: Illegal usage of free samples to physicians knowing and
expecting those physicians to bill the federal health care programs
for the samples.
Slide 32
PREVENTION IS KEY 32
Slide 33
PREVENTION Make sure you are up-to-date with laws, regulations,
policies Ensure you coordinate with other payers. Ensure
data/billing is both accurate and timely Verify information
provided to you Be on the lookout for suspicious activity 33
Slide 34
POLICY AND PROCEDURES Per contractual agreements, every
sponsor, first tier, downstream, and related entity must have
policies and procedures in place to address fraud, waste, and
abuse. These procedures should assist you in detecting, correcting,
and preventing fraud, waste, and abuse. Make sure you are familiar
with your entitys policies and procedures. 34
Slide 35
Distribution of Compliance Policies & Procedures and
Standards of Conduct The distribution of compliance policies,
procedures and Standards of Conduct is essential to effectiveness.
CMS expects Sponsors to ensure that its employees and employees of
FDRs, as a condition of employment, read and agree to comply with
all written compliance policies, procedures and Standards of
Conduct within 90 days of the date of hire, when there are updates
to the polices and procedures, and annually thereafter. IEHP shall
demonstrate to CMS that all employees and employees of FDRs meet
these requirements through the distribution of training materials
and tracking of attestation documentation. 35
Slide 36
36 Best Practices for Preventing FWA Develop an effective
compliance program tailored to your organization Perform regular
internal audits & monitoring against regulatory standards
Review for outliers / deviations from the norm Confirm UM
decisions, coding and claims are timely / accurate. Confirm prompt
refunds of overpayments (within 60 days) Ensure effective training
& education is occurring, minimally for: New hires within 90
days and annually for all Staff Confirm training occurs on HIPAA
Privacy and breach reporting Provide training updates and policy
updates when regulations change Provide refresher training on
policies as part of any Corrective Action Plan
Slide 37
37 Best Practices for Preventing FWA Establish effective lines
of communication with colleagues and staff members. Ensure ALL
staff are aware of how to report potential/actual FWA or compliance
concerns Take action! If you identify a FWA issue you must report
it. Ask about potential compliance issues during exit interviews
Remember: The Provider, Hospital, IPA and the MAO or PDP plan are
each ultimately responsible for all claims and encounters that are
submitted for payment with your name on the claim.
Slide 38
Web FWA Resources ResourceLink Department of Health and Human
Services Office of Inspector General:
http://oig.hhs.gov/fraud/hotline/ Centers for Medicare and Medicaid
Services (CMS): http://www.cms.hhs.gov/FraudAbuseforProfs/ CMS
Information about the Physician Self Referral Law:
www.cms.hhs.gov/PhysicianSelfReferral CMS Prescription Drug Benefit
Manualhttp://www.cms.hhs.gov/PrescriptionDrugCovContr
a/Downloads/PDBManual_Chapter9_FWA.pdf Medicare Learning Network
(MLN) Fraud & Abuse Job Aid https://www.cms.gov/Outreach-and-
Education/Training/NationalMedicareTrainingProgr
am/Training-Library-Items/CMS1248271.html 38 Federal government web
sites are sources of information regarding detection, correction,
and prevention of fraud, waste, and abuse:
Slide 39
CORRECTION 39
Slide 40
Correction Identified fraud, waste, or abuse must be promptly
corrected. Correcting the problem saves the government money and
ensures you are in compliance with CMS requirements. 40
Slide 41
How Do I Correct Issues? Once issues have been identified, a
plan to correct them needs to be developed. Consult your Compliance
Officer or the IEHP Compliance Officer to find out the process for
corrective action plan (CAP) development. The actual CAP is going
to vary, depending on the specific circumstances. 41
Slide 42
LAWS YOU NEED TO KNOW ABOUT 42
Slide 43
Civil Fraud Civil Fraud Claims Act Prohibits: Presenting a
false claim for payment or approval; Making or using a false record
or statement in support of a false claim; Conspiring to violate the
False Claims Act; Falsely certifying the type/amount of property to
be used by the Government; Certifying receipt of property without
knowing if its true; Buying property from an unauthorized
Government officer; and Knowingly concealing or knowingly and
improperly avoiding or decreasing an obligation to pay the
Government. 31 United States Code 3729-3733 43
Slide 44
Laws The following slides provide very high level information
about specific laws. For details about the specific laws, such as
safe harbor provisions, consult the applicable statute and
regulations concerning the law. 44
Slide 45
Physician Self-Referral Prohibition Statute (Stark Law) The
Physician Self-Referral Prohibition Statute, commonly referred to
as the Stark Law, prohibits: A physician from making a referral for
certain designated health services to an entity in which the
physician (or a member of his or her family) has an
ownership/investment interest or with which he or she has a
compensation arrangement (exceptions apply). Stark Statute Damages
and Penalties Medicare claims tainted by an arrangement that does
not comply with Stark are not payable. Penalties may include up to
a $15,000 fine for each service provided or up to a $100,000 fine
for entering into an arrangement or scheme. 42 United States Code
1395nn 45
Slide 46
Anti-Kickback Statute Prohibits: Knowingly and willfully
soliciting, receiving, offering or paying remuneration (including
any kickback, bribe, or rebate) for referrals for services that are
paid in whole or in part under a federal health care program (which
includes the Medicare program). 42 United States Code 1320a-7b(b)
46
Slide 47
Health Insurance Portability and Accountability Act (HIPAA)
Health Insurance Portability and Accountability Act of 1996 (P.L.
104-191) Created greater access to health care insurance,
protection of privacy of health care data, and promoted
standardization and efficiency in the health care industry.
Safeguards to prevent unauthorized access to protected health care
information. As an individual who has access to protected health
care information, you are responsible for adhering to HIPAA.
47
Slide 48
Remember to Protect Confidentiality Carefully handle all data
that can identify the member: This includes any of the elements
noted below: Social Security, Medicare ID (HICN), or Health Plan
Member I.D. number Member Name, Address, Phone, Date of Birth
Medical Record Number / Patient Account Number Review your internal
HIPAA training. Review your internal policies and practices for
reporting of any security and privacy breach to your respective
HIPAA security or privacy officer. Reporting MUST be done
immediately if you become aware of or suspect a breach may have
occurred. 48
Slide 49
49 Entities / Individuals Excluded from Medicare or Government
Programs Compliance programs must carefully monitor to ensure
payments go to proper entities. This includes payments to
employees, providers, contractors and subcontractors. Medicare
Advantage Organizations, Part D Sponsors and contracted entities
are required to review the Department of Health and Human Services
(DHHS) OIG List of Excluded Individuals and Entities (LEIE) and the
General Services Administration (GSA) System for Award Management
(SAM) prior to the hiring or contracting of any new employee,
temporary employee, volunteer, consultant, governing body member,
or FDR, and monthly thereafter to ensure that none of these persons
or entities are excluded or become excluded from participation in
federal programs. OIG List of Excluded Individuals/Entities (LEIE):
http://exclusions.oig.hhs.gov/search.html
http://exclusions.oig.hhs.gov/search.html GSA System for Award
Management (SAM): https://www.sam.govhttps://www.sam.gov
Slide 50
Exclusion No Federal Health Care Program payment may be made
for any item or service furnished, ordered, or prescribed by an
individual or entity excluded by the Office of Inspector General.
42 U.S.C. 1395(e)(1) 42 C.F.R. 1001.1901 50
Slide 51
CONSEQUENCES 51
Slide 52
Consequences of Committing Fraud, Waste, and Abuse The
following are potential penalties. The actual consequence depends
on the violation. Civil Money Penalties Criminal Conviction/Fines
Civil Prosecution Imprisonment Loss of Provider License Exclusion
from Federal Health Care programs 52
Slide 53
Penalties and Consequences of FWA Repayment / Restitution is
just the start False Claims Act : $5,500 up to $11,000 per claim
plus up to triple the amount of the claim in damages Criminal
and/or civil prosecution & imprisonment Suspension/loss of
provider license / Medicare Provider number Exclusion from the
Medicare program / Government Contracts Anti-Kickback Statute
Penalties Fine of up to $25,000 Imprisonment up to five (5) years
Or both, fine and imprisonment 53
Slide 54
Penalties and Consequences of FWA (continued) Criminal Fraud
penalties If convicted, the individual may be fined, imprisoned, or
both. If the violations resulted in death, the individual may be
imprisoned for any term of years or life 18 United States Code 1347
HIPAA Privacy and Security Breaches Payment for credit monitoring
and restoration services Various State and Federal Monetary
penalties Health Information Technology for Economic and Clinical
Health (HITECH) Act Penalties Penalties up to $1.5 Million for all
violations of an identical provision (Note: the Patient Protection
and Affordable Care Act (PPACA) may provide for increased penalties
and restitution amounts) 54
Slide 55
CASE SCENARIOS 55
Slide 56
Scenario #1 A person comes to your pharmacy to drop off a
prescription for a beneficiary who is a regular customer. The
prescription is for a controlled substance with a quantity of 160.
This beneficiary normally receives a quantity of 60, not 160. You
review the prescription and have concerns about possible forgery.
What is your next step? 56
Slide 57
Scenario #1 (continued) A. Fill the prescription for 160 B.
Fill the prescription for 60 C. Call the prescriber to verify
quantity D. Call IEHP compliance department E. Call law enforcement
57
Slide 58
Scenario #1 Answer Answer: C Call the prescriber to verify that
the quantity should be 60 and not 160. Your next step should be to
immediately call the IEHP Compliance Hotline. IEHP Compliance
Department will provide the next course of action. IEHP Compliance
Hotline 866-355-9038 58
Slide 59
Scenario #2 Your job is to submit risk diagnosis to CMS for
purposes of payment. As part of this job you are to verify, through
a certain process, that the data is accurate. Your immediate
supervisor tells you to ignore the sponsors process and to
adjust/add risk diagnosis codes for certain individuals. What do
you do? 59
Slide 60
Scenario #2 (continued) A. Do what is asked of you by your
immediate supervisor B. Report the incident to the compliance
department (via compliance hotline or other mechanism) C. Discuss
concerns with immediate supervisor D. Contact law enforcement
60
Slide 61
Scenario #2 Answer Answer: B Report the incident to the
compliance department (via compliance hotline or other mechanism)
The compliance department is responsible for investigating and
taking appropriate action. Your sponsor/supervisor may NOT
intimidate or take retaliatory action against you for good faith
reporting concerning a potential compliance, fraud, waste, or abuse
issue. 61
Slide 62
Scenario #3 You are in charge of payment of claims submitted
from providers. You notice a certain diagnostic provider (Doe
Diagnostics) has requested a substantial payment for a large number
of members. Many of these claims are for a certain procedure. You
review the same type of procedure for other diagnostic providers
and realize that Doe Diagnostics claims far exceed any other
provider that you reviewed. What do you do? 62
Slide 63
Scenario #3 (continued) A. Call Doe Diagnostics and request
additional information for the claims B. Consult with your
immediate supervisor for next steps C.Contact the compliance
department D.Reject the claims E. Pay the claims 63
Slide 64
Scenario #3 Answer Answers B or C Consult with your immediate
supervisor for next steps or Contact the compliance department
Either of these answers would be acceptable. You do not want to
contact the provider. This may jeopardize an investigation. Nor do
you want to pay or reject the claims until further discussions with
your supervisor or the compliance department have occurred,
including whether additional documentation is necessary. 64
Slide 65
Scenario #4 You are performing a regular inventory of the
controlled substances in the pharmacy. You discover a minor
inventory discrepancy. What should you do? 65
Slide 66
Scenario #4 (continued) A.Call the local law enforcement
B.Perform another review C.Contact your compliance department
D.Discuss your concerns with your supervisor E. Follow your
pharmacys procedures 66
Slide 67
Scenario #4 Answer Answer E Follow your pharmacys procedures
Since this is a minor discrepancy in the inventory you are not
required to notify the DEA. You should follow your pharmacys
procedures to determine the next steps. 67
Slide 68
68 Thank you for participating and expanding compliance program
effectiveness by ensuring you and your organization incorporate the
information into your individual compliance program and business
practices.