AHIP TRAINING Medicare Fraud, Waste, and Abuse Training 2024/2025 Questions and Answers with complete solution

An Example of Health Plan Employee abuse - Maria Adams works for a Medicare plan. She uses the plan's email to send out information to enrollees of the plan promoting her husband's sports memorabilia business. (This activity would also be in violation of HIPPA privacy rules) AUDIT - **A methodical examination and review of data or processes with the purpose of verifying the data's accuracy or whether established processes are in place or are properly followed. Civil Monetary Penalties - The SS Act (which governs Medicare) authorizes civil monetary penalties when CMS or other federal authorities determine that an individual or entity has violated Medicare rules or regulations. **CMP's can be large--for instance, a health plan might be assessed $25,000 for each MA enrollee adversely impacted. Civil monetary penalties CMP's - Penalties that may be imposed for a variety of conduct including Medicare FWA. Different amts. of penalties and assessments may be authorized based on the type of violation and can range as high as $50,000 per violation. Example: Presenting a claim that a person knows or should know is for a service that was NOT provided as claimed or is false and fraudulent. CMS Anti-FWA requirements for Medicare plans - --Actively seek to prevent fraud, waste and abuse --Detect and investigate suspected FWA --Implement corrective action when instances of FWA are uncovered --Have a system in place 24 hrs per day for employees and subcontractors to voluntarily, and confidentially report suspected FWA or misconduct related to the MA and Part D programs CMS FWA training requirements for a Sponsor's Employees - **CMS requires Medicare plan sponsors to provide training in FWA to their employees involved in Medicare plan work. **This training must occur within 90 days of hire and annually thereafter.CMS FWA training requirements: Agents, Brokers and other Subcontractors Those required to take the training including, but not limited to: - --Insurance agents, brokers as well as employees of agencies and field marketing organizations that are performing services for Medicare plans --Employees of other vendors and subcontractors (such as claim processing firms) --Pharmacies and employees of Pharmacy benefit Managers CMS FWA training requirements: Agents, Brokers and other Subcontractors - **The FWA training must be received not only by Medicare plan sponsor employees but also by subcontractors and their employees who are under contract to provide health or administrative services. The EXCEPTIONS are limited to: ***accredited suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS) ***Healthcare providers who are enrolled in Medicare Part A/B Combating FWA: A Health Plan Priority - **Medicare plans also recognize the seriousness of FWA, which not only result in lost dollars but can jeopardize the quality of healthcare received by plan enrollees. **Health plans seek your help in combating FWA and this training is designed to help you recognize questionable activity and take steps to stop or prevent it. Defining Abuse: A Closer Look - CMS provides this definition: "Abuse involves payment for items or services when there is no legal entitlement to that payment and the health care provider has not knowingly and/or intentionally misrepresented facts to obtain payment." Defining Fraud: A Closer look - **According to the health care fraud criminal statute Healthcare fraud is: knowingly and willfully executing, or attempting to execute, a scheme or artifice, to defraud any healthcare 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 benefit program" **Healthcare fraud can result in civil and criminal penalties that include fines, monetary damages, and even imprisonment. **Additionally, there is a penalty of up to 20 years in prison or life in prison if the violation resulted in a person's death.Defining Waste: A Closer Look - CMS provides this definition in its compliance guidance for Medicare plans: "WASTE is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources. Distinguishing FWA - **It is often difficult to distinguish between abuse and FRAUD. This is because whether an action constitutes fraud or abuse depends on the specific facts and circumstances of the situation and the intent and prior knowledge of the individual committing the action. **It is also difficult to distinguish between waste and abuse because of their similarity and the dependence on the specific facts of an issue. **The good news is that you do NOT need to distinguish between FWA. **Report any activities that you suspect could be FWA. **Those who investigate the activity will determine which category it falls in. Example of Collusion - **Medicare fraud can involve several parties, including beneficiaries, providers, pharmacists, and organized crime. **Example: A physician write a series of Rx's, a Medicare beneficiary submits them to a pharmacy, and the beneficiary sells the prescribed drugs to a crime ring. The doctor and the beneficiary receive a cut from the crime ring. Example of Criminal Involvement Criminal Healthcare Fraud Statute: Section 1347 of Title 18 of the US code imposes criminal penalties for defrauding a healthcare benefit program or obtaining any money or property owned by or under the control of any healthcare benefit program. The penalties for violating this law are fines and up to 10 years in prison or longer if the action results in serious bodily injury to death. - **Medicare fraud can also be committed by person who are neither providers nor consumers of healthcare. Professional criminals or even organizations may be involved. **Health plan employees can monitor their claim systems and review claim records for unusual patterns. **The can conduct internal and external audits, which may involve other steps such as randomly testing claims to verify delivery of billed services and products.Example of Fraud Committed by a Medicare Part D beneficiary - Jacqueline Harris, a Medicare Part D enrollee, has a legitimate Rx form her doctor, but she alters it from 60 to 160 pills and sell the surplus to people she knows. Example of Fraud Committed by a Medicare Plan Employee - Connie Jones works in a Medicare Plan's enrollment department. She backdates enrollment effective dates received on the first or second of a month in order to allow the enrollment to begin a month earlier