Where Do I Fit In?

As a person who provides health or administrative services to a Medicare Part C or Part D enrollee, you are either an employee of a:

• Sponsor;

• First-tier entity (Examples: Pharmacy Benefit Management (PBM), hospital or health care facility, provider group, doctor office, clinical laboratory, customer service provider, claims processing and adjudication company, a company that handles enrollment, disenrollment, and membership functions, and contracted sales agent);

• Downstream entity (Examples: pharmacies, doctor office, firms providing agent/broker services, marketing firms, and call centers); or

• Related entity (Examples: Entity with common ownership or control of a Sponsor, health promotion provider, or SilverSneakers®

 

 

 

Where Do I Fit In? (continued)

I am an employee of a Part C Plan Sponsor or an employee of a Part C Plan Sponsor’s first-tier or downstream entity

The Part C Plan Sponsor is a CMS Contractor. Part C Plan Sponsors may enter into contracts with FDRs. This stakeholder relationship shows examples of functions that relate to the Sponsor’s Medicare Part C contracts. First Tier and related entities of the Medicare Part C Plan Sponsor may contract with downstream entities to fulfill their contractual obligations to the Sponsor.

Examples of first tier entities may be independent practices, call centers, health services/hospital groups, fulfillment vendors, field marketing organizations, and credentialing organizations. If the first tier entity is an independent practice, then a provider could be a downstream entity. If the first tier entity is a health service/hospital group, then radiology, hospital, or mental health facilities may be the downstream entity. If the first tier entity is a field marketing organization, then agents may be the downstream entity. Downstream entities may contract with other downstream entities. Hospitals and mental health facilities may contract with providers.

 

I am an employee of a Part D Plan Sponsor or an employee of a Part D Plan Sponsor’s first-tier or downstream entity

The Part D Plan Sponsor is a CMS Contractor. Part D Plan Sponsors may enter into contracts with FDRs. This stakeholder relationship shows examples of functions that relate to the Sponsor’s Medicare Part D contracts. First Tier and related entities of the Part D Plan Sponsor may contract with downstream entities to fulfill their contractual obligations to the Sponsor.

Examples of first tier entities include call centers, PBMs, and field marketing organizations. If the first tier entity is a PBM, then the pharmacy, marketing firm, quality assurance firm, and claims processing firm could be downstream entities. If the first tier entity is a field marketing organization, then agents could be a downstream entity.

 

 

What Are Your Responsibilities?

You play a vital part in preventing, detecting, and reporting potential FWA, as well as Medicare non-compliance.

• FIRST, you must comply with all applicable statutory, regulatory, and other Medicare Part C or Part D requirements, including adopting and using an effective compliance program.

• SECOND, you have a duty to the Medicare Program to report any compliance concerns, and suspected or actual violations that you may be aware of.

• THIRD, you have a duty to follow your organization’s Code of Conduct that articulates your and your organization’s commitment to standards of conduct and ethical rules of behavior.

 

How Do You Prevent FWA?

• Look for suspicious activity;

• Conduct yourself in an ethical manner;

• Ensure accurate and timely data/billing;

• Ensure you coordinate with other payers;

• Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance; and

• Verify all information provided to you.

 

Stay Informed About Policies and Procedures

Familiarize yourself with your entity’s policies and procedures.

Every Sponsor and First-Tier, Downstream, or Related Entity (FDR) must have policies and procedures that address FWA. These procedures should help you detect, prevent, report, and correct FWA.

Standards of Conduct should describe the Sponsor’s expectations that:

• All employees conduct themselves in an ethical manner;

• Appropriate mechanisms are in place for anyone to report non-compliance and potential FWA; and

• Reported issues will be addressed and corrected.

Standards of Conduct communicate to employees and FDRs that compliance is everyone’s responsibility, from the top of the organization to the bottom.

 

 

Report FWA

Everyone must report suspected instances of FWA. Your Sponsor’s Code of Conduct should clearly state this obligation. Sponsors may not retaliate against you for making a good faith effort in reporting.

Do not be concerned about whether it is fraud, waste, or abuse. Just report any concerns to your compliance department or your Sponsor’s compliance department. Your Sponsor’s compliance department area will investigate and make the proper determination. Often, Sponsors have a Special Investigations Unit (SIU) dedicated to investigating FWA. They may also maintain an FWA Hotline.

 

Every Sponsor must have a mechanism for reporting potential FWA by employees and FDRs. Each Sponsor must accept anonymous reports and cannot retaliate against you for reporting. Review your organization’s materials for the ways to report FWA.

When in doubt, call your Compliance Department or FWA Hotline.

 

Reporting FWA Outside Your Organization

If warranted, Sponsors and FDRs must report potentially fraudulent conduct to Government authorities, such as the Office of Inspector General, the Department of Justice, or CMS.

Individuals or entities who wish to voluntarily disclose self-discovered potential fraud to OIG may do so under the Self-Disclosure Protocol (SDP). Self-disclosure gives providers the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.

Details to Include When Reporting FWA

When reporting suspected FWA, you should include:

• Contact information for the source of the information, suspects, and witnesses;

• Details of the alleged FWA;

• Identification of the specific Medicare rules allegedly violated; and

• The suspect’s history of compliance, education, training, and communication with your organization or other entities.

 

WHERE TO REPORT FWA

See the Reference Tab

HHS Office of Inspector General:

• Phone: 1-800-HHS-TIPS (1-800-447-8477) or TTY 1-800-377-4950

• Fax: 1-800-223-8164

• Email: HHSTips@oig.hhs.gov

• Online: https://forms.oig.hhs.gov/hotlineoperations

For Medicare Parts C and D:

• National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) at 1-877-7SafeRx (1-877-772-3379)

 

For all other Federal health care programs:

• CMS Hotline at 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048

 

 

Correction

Once fraud, waste, or abuse has been detected, it must be promptly corrected. Correcting the problem saves the Government money and ensures you are in compliance with CMS requirements.

Develop a plan to correct the issue. Consult your organization’s compliance officer to find out the process for the corrective action plan development. The actual plan is going to vary, depending on the specific circumstances. In general:

•Design the corrective action to correct the underlying problem that results in FWA program violations and to prevent future non-compliance;

•Tailor the corrective action to address the particular FWA, problem, or deficiency identified. Include timeframes for specification’s;

•Document corrective actions addressing non-compliance or FWA committed by a Sponsor’s employee or FDR’s employee and include consequences for failure to satisfactorily complete the corrective action; and

•Once started, continuously monitor corrective actions to ensure they are effective.

 

Corrective Action Examples

Corrective actions may include:

•Adopting new prepayment edits or document review requirements;

•Conducting mandated training;

•Providing educational materials;

•Revising policies or procedures;

•Sending warning letters;

•Taking disciplinary action, such as suspension of marketing, enrollment, or payment; or

•Terminating an employee or provider.

 

Indicators of Potential FWA

Now that you know about your role in preventing, reporting, and correcting FWA, let’s review some key indicators to help you recognize the signs of someone committing FWA.

The following pages present issues that may be potential FWA. Each page provides questions to ask yourself about different areas, depending on your role as an employee of a Sponsor, pharmacy, or other entity involved in the delivery of Medicare Parts C and D benefits to enrollees.

 

Key Indicators: Potential Beneficiary Issues

•Does the prescription, medical record, or laboratory test look altered or possibly forged?

•Does the beneficiary’s medical history support the services requested?

•Have you filled numerous identical prescriptions for this beneficiary, possibly from different doctors?

•Is the person receiving the medical service the actual beneficiary (identity theft)?

•Is the prescription appropriate based on the beneficiary’s other prescriptions?

 

Key Indicators: Potential Provider Issues

•Are the provider’s prescriptions appropriate for the member’s health condition (medically necessary)?

•Does the provider bill the Sponsor for services not provided?

•Does the provider write prescriptions for diverse drugs or primarily for controlled substances?

•Is the provider performing medically unnecessary services for the member?

•Is the provider prescribing a higher quantity than medically necessary for the condition?

•Is the provider’s diagnosis for the member supported in the medical record?

 

Key Indicators: Potential Pharmacy Issues

•Are drugs being diverted (drugs meant for nursing homes, hospice, and other entities being sent elsewhere)?

•Are the dispensed drugs expired, fake, diluted, or illegal?

•Are generic drugs provided when the prescription requires that brand drugs be dispensed?

•Are PBMs being billed for prescriptions that are not filled or picked up?

•Are proper provisions made if the entire prescription cannot be filled (no additional dispensing fees for split prescriptions)?

•Do you see prescriptions being altered (changing quantities or Dispense As Written)?

 

Key Indicators: Potential Wholesaler Issues

•Is the wholesaler distributing fake, diluted, expired, or illegally imported drugs?

•Is the wholesaler diverting drugs meant for nursing homes, hospices, and Acquired Immune Deficiency Syndrome (AIDS)clinics and then marking up the prices and sending to other smaller wholesalers or pharmacies

 

 

Key Indicators: Potential Manufacturer Issues

•Does the manufacturer promote off-label drug usage?

•Does the manufacturer provide samples, knowing that the samples will be billed to a Federal health care program?

 

Key Indicators: Potential Sponsor Issues

•Does the Sponsor encourage/support inappropriate risk adjustment submissions?

•Does the Sponsor lead the beneficiary to believe that the cost of benefits is one price, only for the beneficiary to find out that the actual cost is higher?

•Does the Sponsor offer cash inducements for beneficiaries to join the plan?

•Does the Sponsor use unlicensed agents?

 

Lesson 2 Summary

•As a person who provides health or administrative services to a Medicare Parts C or D enrollee, you play a vital role in preventing FWA. Conduct yourself ethically, stay informed of your organization’s policies and procedures, and keep an eye out for key indicators of potential FWA.

•Report potential FWA. Every Sponsor must have a mechanism for reporting potential FWA. Each Sponsor must be able to accept anonymous reports and cannot retaliate against you for reporting.

•Promptly correct identified FWA with an effective corrective action plan.

 

Lesson 2 Review

Now that you have completed Lesson 2, let’s do a quick knowledge check. The following questions do not contribute to your overall course score in the Post-Assessment.

 

 

Knowledge Check

Which of the following requires intent to obtain payment and the knowledge that the actions are wrong?

Select the correct answer.

○ A. Fraud

○ B. Abuse

○ C. Waste

CORRECT ANSWER  A

 

Knowledge Check

Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting Fraud, Waste, and Abuse (FWA)?

Select the correct answer.

○ A. Civil Monetary Penalties

○ B. Deportation

○ C. Exclusion from participation in all Federal health care programs

 

CORRECT ANSWER   B

 

Knowledge Check

A person comes to your pharmacy to drop off a prescription for a beneficiary who is a “regular” customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step?

Select the correct answer.

○A. Fill the prescription for 160

○B. Fill the prescription for 60

○C. Call the prescriber to verify the quantity

○D. Call the Sponsor’s compliance department

○E. Call law enforcement

 

CORRECT ANSWER   C

 

Knowledge Check

Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job you verify, through a certain process, that the data is accurate. Your immediate supervisor tells you to ignore the Sponsor’s process and to adjust/add risk diagnosis codes for certain individuals. What should you do?

Select the correct answer.

○A. Do what your immediate supervisor asked you to do and adjust/add risk diagnosis codes

○B. Report the incident to the compliance department (via compliance hotline or other mechanism)

○C. Discuss your concerns with your immediate supervisor

○D. Call law enforcement

 

CORRECT ANSWER   B

 

Knowledge Check

You are in charge of payment of claims submitted by providers. You notice a certain diagnostic provider (“Doe Diagnostics”) requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize that Doe Diagnostics’ claims far exceed any other provider that you reviewed. What should you do?

 

Select the correct answer.

○A. Call Doe Diagnostics and request additional information for the claims

○B. Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit (SIU), or other mechanism)

○C. Reject the claims

○D. Pay the claims

 

CORRECT ANSWER   B

 

Knowledge Check

You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?

Select the correct answer.

○A. Call local law enforcement

○B. Perform another review

○C. Contact your compliance department (via compliance hotline or other mechanism)

○D. Discuss your concerns with your supervisor

○E. Follow your pharmacy’s procedures

 

CORRECT ANSWER   E

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Payer Compliance Reporting Resources

Payer/Organization	Hotline	Online Reporting	Address
Your Direct PO/ PHO	PO Phone #		Compliance Official For your PO/ PHO
Medicare – HHS Office of Inspector General	800-447-8477   TTY: 800-337-4950	https://oig.hhs.gov/fraud/report-fraud/index.asp	U.S. Department of Health and Human Services Office of Inspector General ATTN: OIG HOTLINE OPERATIONS P.O. Box 23489 Washington, DC 20026
Medicare - Railroad	888-355-9165 Option 5
Medicaid – Michigan Department of Attorney General	800-242-2873 Medicaid Members: 800-222-8558	Email: MDHHS-OIG@michigan.gov   Online form: https://secure.ag.state.mi.us/complaints/medicaid.aspx	Department of Attorney General Health Care Fraud Division P.O. Box 30218 Lansing, MI 48909
Aetna	800-338-6361	Email: AetnaSIU@aetna.com
Blue Cross/Blue Shield PPO (BCBSM) Blue Care Network (BCN) Blue Cross Complete (BCC)	800-482-3787 Medicare – 888-650-8136	https://www.bcbsm.com/health-care-fraud/report-fraud/report-fraud-form.html	Blue Cross Blue Shield of Michigan Corporate & Financial Investigation Department MC 1825 600 E. Lafayette Detroit, MI 48226
CIGNA	800-667-7145	Email: specialinvestigations@cigna.com	Cigna Special Investigations 900 Cottage Grove Road W3SIU Hartford, CT 06152
CuraNet	877-746-2501
Health Alliance Plan (HAP) Alliance Health & Life Insurance Company	877-746-2501		HAP Compliance Department 2850 West Grand Boulevard Detroit, MI 48202
HAP Midwest Health Plan	877-746-2501		HAP Midwest Health Plan Midwest Information Privacy & Security Office 2850 W. Grand Blvd Detroit, MI 48202
Meridian Health Plan	844-667-3560	Email: FWA.mi@mhplan.com	Meridian Health Fraud, Waste and Abuse Department 1 Campus Martius, Suite 700 Detroit, MI 48226
Molina Health Care	866-606-3889	https://MolinaHealthcare.AlertLine.co​m
Priority Health – HMO & PPO	800-560-7013		Priority Health Compliance Officer 1231 East Beltline, NE, MS 3230 Grand Rapids, MI 49525