Overview

WorkAbilities serves clients whose service fees are paid with federal (Medicare/Medicaid) funds.  Because of this, we are now required to provide annual training to all staff:  “The Centers for Medicare & Medicaid Services (CMS) requires annual fraud, waste and abuse training for organizations providing health, prescription drug or administrative services to Medicare Advantage (MA) or Prescription Drug Plan (PDP) enrollees on behalf of a health plan.”

While much of this material will not seem applicable to you and/or WorkAbilities’ operations, the bottom line is this:  If you ever suspect financial fraud, waste or abuse of any kind here, you should report it immediately to the agency Compliance Officer who is the Quality Management Director, or call 1 800 MEDICARE.

Why Focus on Fraud, Waste and Abuse?

•	Scams alone cost the health care industry more than $100 billion annually
•	Fraud, waste and abuse programs save Medicare dollars and that benefits taxpayers, government, health plans and beneficiaries  
•	Detecting, correcting and preventing fraud, waste and abuse requires collaboration between:
•	You
•	Providers of services such as physicians, nurses and pharmacies
•	State and federal agencies
•	Beneficiaries

Fraud, Waste and Abuse Defined

•	Fraud: an intentional act of deception, misrepresentation or concealment in order to gain something of value. Examples include: 
•	billing for services that were never rendered
•	billing for services at a higher rate than is actually justified
•	deliberately misrepresenting services, resulting in unnecessary cost to the Medicare program, improper payments to providers or overpayments 
•	Waste: over-utilization of services (not caused by criminally negligent actions) and the misuse of resources
•	Abuse: excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss. Examples include: 
•	charging in excess for services or supplies
•	providing medically unnecessary services
•	billing for items or services that should not be paid for by Medicare 

Fraud, Waste and Abuse: Prescriber Examples

•	Illegal Payment Schemes
•	Prescriber is offered paid, solicits or receives unlawful payment to induce or reward the prescriber to write prescriptions for drugs or products.

•	Script Mills
•	Prescribers write prescriptions for drugs that are not medically necessary, often in mass quantities, and often for patients that are not theirs. These scripts are usually written, but not always, for controlled drugs for sale on the black market, and might include improper payments to the prescriber.
 
•	Theft of Prescriber’s Drug Enforcement Agency (DEA) Number or Prescription  Pad
•	Prescription pads and/or DEA numbers stolen from prescribers.  This information could illegally be used to write prescriptions for controlled substances or other medications.

Fraud, Waste and Abuse: Wholesaler Examples
•	Counterfeit, Impure Drugs through Black Market
•	Black Market includes fake, diluted, expired, illegally imported drugs, etc.
•	Diverters
•	Individuals who illegally gain control of discounted medicines and mark up the prices and move them to small wholesalers.
•	Inappropriate Documentation of Pricing Information
•	Submitting false or inaccurate pricing or rebate information.

Fraud, Waste and Abuse: Beneficiary Examples
•	Identify Theft
•	Using a member’s I.D. card that does not belong to that person to obtain prescriptions, services, equipment, supplies, doctor visits, and/or hospital stays. 

•	Doctor Shopping
•	Visiting a number of doctors to obtain multiple prescriptions for painkillers or other drugs. Might point to an underlying scheme (stockpiling or black market resale). 

Fraud, Waste and Abuse: Pharmaceutical Manufacturer Examples
•	Illegal Off-label Promotion
•	Promotion of off-label drug use

•	Illegal Usage of Free Samples
•	Providing free samples to prescribers knowing and expecting prescriber to bill Medicare for the sample
 
•	Kickbacks, Inducements, Other Illegal Payments
•	Inappropriate marketing or promotion of products reimbursable by federal health care programs
•	Inappropriate discounts or educational grants

Fraud, Waste and Abuse: Plan Sponsor Examples
•	Payments for Excluded Drugs
•	Receiving payment for drugs not covered by the Plan Sponsor’s formulary
•	Marketing Schemes
•	Offering beneficiaries a cash payment as an encouragement to enroll in a Medicare Plan
•	Unsolicited door-to-door marketing
•	Use of unlicensed agents
•	Enrollment of individual in a Medicare Plan without such individual’s knowledge or consent
•	Stating that a marketing agent/broker works for or is contracted with the Social Security Administration or CMS

Fraud, Waste and Abuse: 
Pharmacy Benefits Manager (PBM)/Pharmacy Examples 
•	Prescription Drug Switching
•	PBM receives a payment to switch a beneficiary from one drug to another or influence prescriber to switch patient to a different drug

•	Prescription Drug Splitting or Shorting
•	PBM mail order pharmacy intentionally provides less than the prescribed quantity, does not inform the patient or make arrangements to provide the balance and bills for the fully-prescribed amount
•	Splits prescription to receive additional dispensing fees

Fraud, Waste and Abuse:  Billing  Examples 
•	Inappropriate Billing Practices
•	Billing for services not provided 
•	Misrepresenting the service that was provided 
•	Billing for a higher level than the service actually delivered
•	Billing for non-covered services or prescriptions as covered items

Federal Fraud, Waste and Abuse Laws
•	False Claims Act: Prohibits any person from knowingly presenting or causing a fraudulent claim for payment.
•	Anti-Kickback Statute: Makes it a crime to knowingly and willfully offer, pay, solicit, or receive, directly or indirectly, anything of value to induce or reward referrals of items or services reimbursable by a Federal health care program.  
•	Self-Referral Prohibition Statute (Stark Law): Prohibits physicians from referring Medicare patients to an entity with which the physician or a physician’s immediate family member has a financial relationship — unless an exception applies. 

Reporting Potential Fraud, Waste and Abuse

Everyone has the right and responsibility to report possible fraud, waste or abuse. Report issues or concerns to WorkAbilities Compliance Officer, the Quality Management Director, or call 1-800-MEDICARE 
 
Remember:   You may report anonymously and retaliation is prohibited when you report a concern in good faith.

Fraud, Waste and Abuse Resources
Federal government websites are sources of information regarding detection, correction and prevention of fraud, waste and abuse:

Department of Health and Human Services Office of Inspector General: http://oig.hhs.gov/fraud.asp 
Centers for Medicare & Medicaid Services (CMS): http://www.cms.hhs.gov/MDFraudAbuseGenInfo/ 
CMS Information about the Physician Self Referral Law: www.cms.hhs.gov/PhysicianSelfReferral

Training:  All new employees will be trained on this during their orientation and annually therafter.

Note:  This is a condensed version of the “Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training” materials developed by the Minnesota Council of Health Plans.  The actual training materials run 20+ pages.  If you would like a copy of the actual training materials, please see Brent Williams.