AHIP TRAINING Medicare Fraud, Waste, and Abuse Training Questions and Answers with Verified Solutions

AHIP TRAINING Medicare Fraud, Waste, and Abuse Training Questions and Answers with Verified Solutions Medicare plan means A MA plan, MA-PD plan or PDP Subcontractor means **An individual or entity that provides services on behalf of a Medicare plan sponsor. This includes individuals and organizations with DIRECT relationship with the plan sponsor or individuals or organizations with INDIRECT relationship, such as an agent who has a contract with an agency or filed marketing organization that contract with a Medicare plan. FWA Training: A compliance program component **ALL Medicare plans are required to have robust programs to assure compliance by plan employees an subcontractors with all applicable laws, regulations and program guidance. **One required component of a compliance program is a FWA program to identify and address issues of compliance with FWA. **It is important to remember that ALL Medicare plan sponsor employees and subcontractors are responsible for complying with all relevant Medicare requirements, even if lack of compliance may not be viewed as FWA, FWA: Why participate in the training **Fraud, waste and abuse impacts everyone who receives or relies on healthcare in the US. **The purpose of this training is to help you detect, correct and prevent FWA and your help is needed. You are part of the solution! **As a subcontractor to or an employee of a Medicare plan, you are required to participate in FWA training. FWA: Combating: A federal priority **Important priority for the Federal Government. **CMS, the Federal agency responsible for administering these programs, takes its role in leading anti-fraud efforts very seriously and has issued strict requirements for those involved in providing MA and Medicare Part D coverage. **The office of Inspector General, a sister agency to CMS within the US Department of Health and Human Services , is also actively involved in anti-fraud efforts. Steps by Medicare plans to Combat FWA --The establishment and operation of special investigation units (SIU) or other existing departments that perform an internal investigation function --The analysis of claims data --Collaboration with law enforcement agencies --Adherence to rules set forth by CMS regarding efforts to identify and prevent fraud, waste and abuse. 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 **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 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 FWA Definitions and examples FRAUD is an intentional act of deception, misrepresentation, or concealment in order to gain something of value. Fraud often involves criminal behavior. ABUSE results in unwarranted payments from or costs to a Federal healthcare consumer, provider, or other person obtains money to which they are not entitled, but there is not the intent to deceive that is necessary for fraud to have occurred. Abuse often involves actions which are inconsistent with accepted medical and/or business practices. WASTE occurs when poor or inefficient practices result in unnecessar