AHIP TRAINING Medicare Fraud, Waste,
and Abuse Training
1. An Example of Health Plan Employee abuse - ANS-Maria Adams works for a Medicare
plan. She makes use of the plan's email to ship out data to enrollees of the plan selling
her husband's sports memorabilia commercial enterprise. (This pastime might
additionally be in violation of HIPPA privacy policies)
2. AUDIT - ANS-**A methodical examination and evaluate of records or tactics with the
reason of verifying the statistics's accuracy or whether or not set up methods are in
region or are properly accompanied.
3. Civil Monetary Penalties - ANS-The SS Act (which governs Medicare) authorizes civil
financial penalties while CMS or different federal government decide that an person or
entity has violated Medicare policies or guidelines.
4. **CMP's can be large--as an example, a health plan is probably assessed $25,000 for
each MA enrollee adversely impacted.
5. Civil monetary penalties CMP's - ANS-Penalties that may be imposed for a spread of
behavior together with Medicare FWA. Different amts. Of penalties and assessments can
be authorized primarily based at the kind of violation and can range as excessive as
$50,000 in step with violation.
6. Example: Presenting a claim that someone knows or need to understand is for a carrier
that was NOT provided as claimed or is false and fraudulent.
7. CMS Anti-FWA necessities for Medicare plans - ANS---Actively searching for to prevent
fraud, waste and abuse
8. --Detect and investigate suspected FWA
9. --Implement corrective action whilst times of FWA are exposed
10. --Have a gadget in vicinity 24 hrs consistent with day for employees and subcontractors
to voluntarily, and confidentially document suspected FWA or misconduct associated
with the MA and Part D applications
11. CMS FWA schooling requirements for a Sponsor's Employees - ANS-**CMS calls for
Medicare plan sponsors to offer training in FWA to their personnel worried in Medicare
plan paintings.
12. **This training must arise within 90 days of hire and annually thereafter.
13. CMS FWA education requirements: Agents, Brokers and other Subcontractors
14. Those required to take the training including, however not restrained to: -
ANS---Insurance sellers, brokers as well as personnel of agencies and subject
advertising businesses that are acting services for Medicare plans
15. --Employees of different companies and subcontractors (consisting of declare
processing corporations)
16. --Pharmacies and employees of Pharmacy gain Managers
, 17. CMS FWA training requirements: Agents, Brokers and other Subcontractors -
ANS-**The FWA education have to be obtained no longer simplest by way of Medicare
plan sponsor personnel but additionally by means of subcontractors and their personnel
who're beneath agreement to provide fitness or administrative services. The
EXCEPTIONS are restrained to:
18. ***accredited providers of DME, prosthetics, orthotics, and substances (DMEPOS)
19. ***Healthcare vendors who're enrolled in Medicare Part A/B
20. Combating FWA: A Health Plan Priority - ANS-**Medicare plans also understand the
seriousness of FWA, which now not handiest bring about lost dollars however can
jeopardize the quality of healthcare obtained by way of plan enrollees.
21. **Health plans seek your help in combating FWA and this schooling is designed to help
you understand questionable interest and take steps to prevent or save you it.
22. Defining Abuse: A Closer Look - ANS-CMS provides this definition: "Abuse includes
price for gadgets or offerings whilst there may be no criminal entitlement to that payment
and the fitness care company has now not knowingly and/or intentionally misrepresented
statistics to obtain payment."
23. Defining Fraud: A Closer look - ANS-**According to the fitness care fraud crook statute
Healthcare fraud is: knowingly and willfully executing, or trying to execute, a scheme or
artifice, to defraud any healthcare advantage program or to reap, through fake or
fraudulent pretenses, representations, or promises, any of the money or assets owned
by way of, or beneath the custody or control of, any health benefit program"
24. **Healthcare fraud can result in civil and criminal consequences that consist of fines,
economic damages, and even imprisonment.
25. **Additionally, there's a penalty of up to 20 years in jail or life in prison if the violation
ended in someone's death.
26. Defining Waste: A Closer Look - ANS-CMS offers this definition in its compliance
steerage for Medicare plans: "WASTE is the overutilization of services, or different
practices that, directly or not directly, bring about unnecessary charges to the Medicare
software. Waste is generally no longer taken into consideration to be caused by
criminally negligent actions, however as a substitute the misuse of assets.
27. Distinguishing FWA - ANS-**It is often hard to differentiate between abuse and FRAUD.
This is because whether or not an motion constitutes fraud or abuse relies upon on the
precise records and occasions of the scenario and the rationale and previous
understanding of the individual committing the action.
28. **It is also difficult to differentiate among waste and abuse because of their similarity and
the dependence on the precise facts of an problem.
29. **The true information is which you do NOT want to differentiate between FWA.
30. **Report any activities that you suspect might be FWA.
31. **Those who investigate the hobby will decide which class it falls in.
32. Example of Collusion - ANS-**Medicare fraud can involve numerous events, which
includes beneficiaries, companies, pharmacists, and organized crime.
33. **Example: A medical doctor write a series of Rx's, a Medicare beneficiary submits them
to a pharmacy, and the beneficiary sells the prescribed drugs to against the law ring. The
physician and the beneficiary get hold of a cut from the crime ring.
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