VIVA Health Provider Compliance and Fraud Waste and

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VIVA Health Provider Compliance and Fraud, Waste and Abuse (FWA) Training

VIVA Health Provider Compliance and Fraud, Waste and Abuse (FWA) Training

Why We Do Compliance Training? n Improve n Define expected conduct n Provide n

Why We Do Compliance Training? n Improve n Define expected conduct n Provide n Assist n CMS guidance on making right decisions in compliance with laws and regulations n Quickly n Avoid services for our members identify and resolve compliance concerns legal and financial penalties requirement 2

New Regulatory Requirements n CMS requires Medicare Advantage (MA) plan sponsors to provide Compliance

New Regulatory Requirements n CMS requires Medicare Advantage (MA) plan sponsors to provide Compliance Training n MA plans are required to extend training to entities with whom they contract to provide Medicare benefits or services w 42 cfr 422. 503 w 42 cfr 423. 504 3

VIVA Health’s Compliance Mission n To direct our business in an ethical manner and

VIVA Health’s Compliance Mission n To direct our business in an ethical manner and in accordance with existing state and Federal laws and regulations n To promptly and effectively implement regulatory requirements n To foster open/honest communications and cooperative relationships between VIVA Health and our Providers n To integrate Compliance as an essential part of daily operations 4

VIVA Health’s Code of Conduct n. Be honest n. Know n. Ask the rules

VIVA Health’s Code of Conduct n. Be honest n. Know n. Ask the rules questions n. Don’t be afraid to ask for help n. Admit mistakes n. Report concerns 5

Provider Responsibilities VIVA Health Provider Responsibilities: n Follow the guidelines specified in this training

Provider Responsibilities VIVA Health Provider Responsibilities: n Follow the guidelines specified in this training material, your contract, and the VIVA Health Provider Manual n Comply with Federal and state licensing requirements n Report any suspected violations of laws, regulations, or our Code of Conduct 6

Provider Responsibilities VIVA Health Provider Responsibilities: n Support VIVA Health’s efforts to prevent, detect

Provider Responsibilities VIVA Health Provider Responsibilities: n Support VIVA Health’s efforts to prevent, detect and eliminate fraud, waste, and abuse (FWA) n Cooperate with VIVA Health’s investigations into suspected violations n Implement internal policies and procedures to prevent, detect and eliminate FWA 7

Fraud, Waste and Abuse n FWA - National problem that affects all of us,

Fraud, Waste and Abuse n FWA - National problem that affects all of us, directly or indirectly n Billions n FWA of dollars are lost to FWA each year drives up healthcare costs and premiums n We are all responsible for preventing, detecting and eliminating FWA 8

FWA - Definitions n Fraud - misrepresenting information that could benefit you or another

FWA - Definitions n Fraud - misrepresenting information that could benefit you or another person n Waste - performing functions in a manner that requires more resources than are necessary n Abuse - providing products or services that are inconsistent with accepted practices or are clearly not reasonable or necessary 9

Examples of FWA n Fraud - submitting false claims for healthcare services that were

Examples of FWA n Fraud - submitting false claims for healthcare services that were not provided or filing a claim for a more complicated service than the service performed* n Waste - unnecessary spending or use of supplies, technology, resources* n Abuse - billing for services/supplies that are not medically necessary or providing care that is not consistent with accepted medical practices* * This is a limited set of examples 10

Anti-Kickback Laws n Anti-Kickback Statute and Stark Law are Federal laws n Prohibit someone

Anti-Kickback Laws n Anti-Kickback Statute and Stark Law are Federal laws n Prohibit someone from knowingly or willfully offering, paying or receiving anything of value for a referral n Examples of prohibited activities include: w Waiving a copay or deductible for reasons other than real financial hardship (or allowable exceptions) w Accepting payment that is different from fair market value as a means to obtain more business w Demanding or requesting a kickback (e. g. gifts, cash, write-offs, or free supplies for referring patients to specific providers) n Failure to comply can result in fines, jail and/or exclusion from Medicare, Medicaid and/or State Health Programs 11

False Claims Act n False Claims Act (FCA) is Federal law n Prohibits knowingly

False Claims Act n False Claims Act (FCA) is Federal law n Prohibits knowingly submitting false, fictitious, or fraudulent claims to obtain payment from Federal or state programs n Knowingly and/or willfully making a false statement about a claim is a Federal Felony n Penalties can result in significant fines, jail time and/or exclusion from participation in Federal and state programs 12

Monitoring and Auditing n Everyone is obligated to monitor compliance activities through normal daily

Monitoring and Auditing n Everyone is obligated to monitor compliance activities through normal daily operations n Any instance of FWA related to your VIVA Health contract must be reported immediately n VIVA Health will review claims and other data submitted by each provider as an internal monitoring and auditing control 13

Compliance and FWA Best Practices n Develop a compliance program n Monitor claims for

Compliance and FWA Best Practices n Develop a compliance program n Monitor claims for accuracy—ensure coding reflects services provided n Monitor medical records—ensure documentation supports services rendered n Perform regular internal audits 14

Compliance and FWA Best Practices n Establish effective lines of communication with colleagues and

Compliance and FWA Best Practices n Establish effective lines of communication with colleagues and staff members n Ask about potential compliance issues in exit interviews n Take action if you identify a problem n Remember you are ultimately responsible for claims bearing your name, regardless of whether you submitted the claim 15

Criminal Activity (Self Disclosure) n Felony convictions or other criminal activity (other than minor

Criminal Activity (Self Disclosure) n Felony convictions or other criminal activity (other than minor traffic violations) occurring prior to or during your contract with VIVA Health must be self-disclosed to VIVA Health n Evidence of criminal activity will be reviewed during the initial and re-credentialing processes and at other times as deemed appropriate 16

Debarment or Exclusion n Debarred or excluded individuals/entities: w Participated or engaged in certain

Debarment or Exclusion n Debarred or excluded individuals/entities: w Participated or engaged in certain impermissible, inappropriate or illegal conducts w Recorded with the Office of Inspector General (OIG) and/or General Service Administration (GSA) w Cannot be employed or contracted by VIVA Health w Cannot be paid through a Federal or state health program for services or products furnished, prescribed, or ordered 17

Debarment or Exclusion n VIVA Health reviews the OIG and GSA lists at the

Debarment or Exclusion n VIVA Health reviews the OIG and GSA lists at the following: w Initial credentialing w Re-credentialing w Monthly n VIVA Health contractors are required to selfdisclose any information concerning debarment, exclusion or any other activities that prevent you from working directly or indirectly with Medicare, Medicaid or Federal health programs 18

Confidential Information n Compliance with HIPAA regulations is mandatory and the confidentiality of records,

Confidential Information n Compliance with HIPAA regulations is mandatory and the confidentiality of records, documents and business practices must be maintained n Protected Health Information (PHI) and other member information must be appropriately safeguarded t This includes paper, e-mail, electronic records, and oral communication n PHI should only be shared if the disclosure is specifically allowed by HIPAA 19

Records n CMS regulations require records be kept for at least ten (10) years

Records n CMS regulations require records be kept for at least ten (10) years n Records and documents must never be falsified 20

Get Assistance or Report a Potential Violation To ask a question or report a

Get Assistance or Report a Potential Violation To ask a question or report a potential violation contact any or all of the following: n. VIVA t t t n. OIG t Health Customer Service 205 -558 -7474 800 -294 -7780 VIVA Health Attn: Compliance Officer 1222 14 th Avenue South Birmingham, AL 35205 Hotline 800 -447 -8477 n. MEDIC t Contractors See next slide * Use the method that makes you the most comfortable. 21

Get Assistance or Report a Potential Violation n MEDIC w FWA issues s Health

Get Assistance or Report a Potential Violation n MEDIC w FWA issues s Health Integrity Attn: MEDIC 9240 Centreville Road Easton, MD 21601 877 -7 Safe. Rx (877 -772 -3379) w Compliance Issues s Safe. Guard Services (SGS) MEDIC 225 Grandview Avenue Mailstop F 10 Camp Hill, PA 17011 717 -975 -4442 (fax) 22

Whistleblower Protection Whistleblower: An employee, former employee, or member of an organization who reports

Whistleblower Protection Whistleblower: An employee, former employee, or member of an organization who reports misconduct to people or entities that have the power to take corrective action n False Claims Act allows individuals to: w Report fraud anonymously w Sue an organization on behalf of the government and collect a portion of any resulting settlement n Employers cannot threaten or retaliate against whistleblowers. 23

Compliance Investigations n VIVA Health investigates every report n Your identity can remain anonymous

Compliance Investigations n VIVA Health investigates every report n Your identity can remain anonymous (unless required by law) n No retribution for reports made in good faith 24

Corrective Action n When an investigation confirms a violation, Corrective Action will be initiated

Corrective Action n When an investigation confirms a violation, Corrective Action will be initiated n Corrective action may include, but is not limited to: w Mandatory retraining w Required regulatory agency reporting w Contract suspension and/or contract termination 25

CMS Administrative Sanctions n Denial or revocation of Medicare provider number application n Suspension

CMS Administrative Sanctions n Denial or revocation of Medicare provider number application n Suspension of provider payments n Addition to the OIG List of Excluded Individuals/Entities (LEIE) n License suspension or revocation 26

CMPs, Litigation and Settlements n Social Security Act authorizes the imposition of civil monetary

CMPs, Litigation and Settlements n Social Security Act authorizes the imposition of civil monetary penalties (CMPs) when individuals or entities violate Medicare rules and regulations w Typically, penalties involve assessments of significant damages such as CMPs up to $25, 000 for each Medicare Advantage enrollee adversely affected n United States Attorney's Office may file a civil suit or settle a case out of court w The civil suit or settlement may include a Corporate Integrity Agreement (CIA) s A CIA requires the individual or entity to accomplish specific goals (e. g. , educational plan, corrective action plan, reorganization) and be subject to periodic audits by the federal government 27

Summary n The material and policies set forth in this training material, the VIVA

Summary n The material and policies set forth in this training material, the VIVA Health Provider Manual, and your VIVA Health contract are mandatory n Ethical and compliant behavior can never be sacrificed in the pursuit of business objectives n VIVA Health is committed to the highest standards of ethics and compliance n You are responsible for your conduct and the conduct of your employees and vendors 28

FWA Resources n Department of Health and Human Services Office of Inspector General: w

FWA Resources n Department of Health and Human Services Office of Inspector General: w http: //oig. hhs. gov/fraud/hotline/ n Centers for Medicare and Medicaid Services (CMS): w http: //www. cms. hhs. gov/Fraud. Abusefor. Profs/ n CMS Information about the Physician Self Referral Law: w www. cms. hhs. gov/Physician. Self. Referral n CMS’ Prescription Drug Benefit Manual w http: //www. cms. hhs. gov/Prescription. Drug. Cov. Contra/Downlo ads/PDBManual_Chapter 9_FWA. pdf n Medicare Learning Network (MLN) Fraud & Abuse Job Aid w http: //www. cms. hhs. gov/MLNProducts/downloads/081606_M edicare_Fraud_and_Abuse_brochure. pdf 29

Conclusion Thank you for your cooperation and compliance n For more information on any

Conclusion Thank you for your cooperation and compliance n For more information on any of these topics: w See the VIVA Health Provider Manual w Contact the VIVA Health Compliance Department s 205 -558 -7606 s [email protected] edu s 205 -558 -7544 s [email protected] edu 30