Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network 1APPENDICES A


Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES AINTRODUCTIONThe Combatting Medicare Parts C and D Fraud, Waste, and Abuse Training course is brought to you bythe Medicare Learning Network , a registered trademark of the U.S. Department of Health & HumanServices (HHS)3

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES AThis training document was current at the time it was published or uploaded onto the web. Medicarepolicy changes frequently so links to the source documents have been provided within the WBT for yourreference.This training document was prepared as a service to the public and is not intended to grant rights orimpose obligations. This document may contain references or links to statutes, regulations, or otherpolicy materials. The information provided is only intended to be a general summary. It is not intendedto take the place of either the written law or regulations. We encourage readers to review the specificstatutes, regulations, and other interpretive materials for a full and accurate statement of theircontents.This training module will assist Medicare Part C and D plan Sponsors employees, governing bodymembers, and their first-tier, downstream, and related entities (FDRs) in satisfying the annual Fraud,Waste, and Abuse (FWA) training requirements in the regulations and sub regulations at: 42 Code of Federal Regulations (CFR) Section 422.503(b)(4)(vi)(C);42 CFR Section 423.504(b)(4)(vi)(C);CMS-4159-F, Medicare Program Contract Year 2015 Policy and Technical Changes in theMedicare Advantage and the Medicare Prescription Drug Benefit Programs; andSection 50.3.2 of the Compliance Program Guidelines (Chapter 9 of the “Medicare PrescriptionDrug Benefit Manual” and Chapter 21 of the “Medicare Managed Care Manual”)Sponsors and their FDRs may use this module to satisfy the FWA training requirements. Sponsors andtheir FDRs are responsible for providing additional specialized or refresher training on issues posing FWArisks based on the employee’s job function or business setting.ACRONYMCFRFDRFWAWBT4TITLE TEXTCode of Federal RegulationsFirst Tier, Downstream, and Related EntityFraud, Waste, and AbuseWeb-Based Training

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES AWelcome to the Medicare Learning Network (MLN) – Your free Medicare education and informationresource!The MLN is home for the education, information, and resources for the health care professionalcommunity. The MLN provides access to the Centers for Medicare & Medicaid Services (CMS) programinformation you need, when you need it, so you can focus more on providing care for your patients.Servicing as the umbrella for a variety of CMS education and communication activities, the MLN offers:1. MLN Educational Products, including MLN Matters Articles;2. Web-Based Training (WBT) Courses (many offer Continuing Education credits);3. MLN Connects National Provider Calls;4. MLN Connects Provider Association Partnerships;5. MLN Connects Provider eNews; and6. Provider electronic mailing lists.The Medicare Learning Network , MLN Connects , and MLN Matters are registered trademarks of theU.S. Department of Health & Human Services (HHS).ACRONYMCMSMLNTITLE TEXTCenters for Medicare & Medicaid ServicesMedicare Learning NetworkHYPERLINK rk-MLN/MLNMatterArticlesLINKED TEXT/IMAGEMLN Educational Productshttps://learner.mlnlms.comWBT LN Connects NationalProvider CallsMLN Connects ProviderAssociation ion/Outreach/FFSProvPartProgMLN Connects nloads/MailingLists FactSheet.pdfProvider Electronic MailingLists5MLN Matters Articles

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES AWhy Do I Need Training?Every year billions of dollars are improperly spent because of FWA. It affects everyone - including you.This training will help you detect, correct, and prevent FWA. You are part of the solution.Combating FWA is everyone’s responsibility! As an individual who provides health or administrativeservices for Medicare enrollees, every action you take potentially affects Medicare enrollees, theMedicare Program, or the Medicare Trust Fund.Training Requirements: plan Employees, Governing Body Members, and FirstTier, Downstream, or Related Entity (FDR) employeesCertain training requirements apply to people involved in Medicare Parts C and D. All employees ofMedicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) (collectively referred toin this training document as “Sponsors”) must receive training for preventing, detecting, and correctingFWA.FWA training must occur within 90 days of initial hire and at least annually thereafter.Learn more about Medicare Part CMedicare Part C, or Medicare Advantage (MA), is a health plan choice available to Medicarebeneficiaries. MA is a program run by Medicare-approved private insurance companies. Thesecompanies arrange for, or directly provide, health care services to the beneficiaries who elect to enrollin an MA plan.MA plans must cover all services that Medicare covers with the exception of hospice care. MA plansprovide Part A and Part B benefits and may also include prescription drug coverage and othersupplemental benefits.Learn more about Medicare Part DMedicare Part D, the Prescription Drug Benefit, provides prescription drug coverage to all beneficiariesenrolled in Part A and/or Part B who elect to enroll in a Medicare Prescription Drug Plan (PDP) or an MAPrescription Drug (MA-PD) plan. Insurance companies or other companies approved by Medicareprovide prescription drug coverage to individuals who live in a plan’s service area.ACRONYMMA6TITLE TEXTMedicare Advantage

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES AFWA Training Requirements ExceptionThere is one exception to the FWA training and education requirement. FDRs will have met the FWAtraining and education requirements if they have met the FWA certification requirement through: Accreditation as a supplier of Durable Medicare Equipment, prosthetics, Orthotics, and SuppliesorEnrolled in Medicare A (hospital) or B (medical) ProgramIf you are unsure if this exception applies to you, please contact your management team for moreinformation.7

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES ACourse ContentThis training document consists of two lessons:1. What is FWA?2. Your Role in the Fight Against FWAAnyone who provides health or administrative services to Medicare enrollee must satisfy generalcompliance and FWA training requirements. You may use this document course to satisfy the FWArequirements.**Course Cues - This course uses cues at various times to provide additional information. The cues are hyperlinks,buttons, acronyms, pop-up windows, and printing cues.Course ObjectivesWhen you complete this course, you should be able to correctly: 8Recognize FWA in the Medicare Program;Identify the major laws and regulations pertaining to FWA;Recognize potential consequences and penalties associated with violations;Identify methods of preventing FWA;Identify how to report FWA; andRecognize how to correct FWA;

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES ALESSON 1: WHAT IS FWA?Lesson 1: Introduction and Learning ObjectivesThis lesson describes Fraud, Waste, and Abuse (FWA) and the laws that prohibit it. Upon completing thelesson, you should be able to correctly: Recognize FWA in the Medicare Program;Identify the major laws and regulations pertaining to FWA; andRecognize the potential consequences and penalties associated with violationsACRONYMFWATITLE TEXTFraud, Waste, and AbuseFraudFraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud anyhealth care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, orpromises, any of the money or property owned by, or under the custody or control of, any health carebenefit program.The Health Care Fraud Statute makes it a criminal offense to knowingly and willfully execute a scheme todefraud a health care benefit program. Health care fraud is punishable by imprisonment for up to 10years. It is also subject to criminal fines of up to 250,000.**In other words, fraud is intentionally submitting false information to the Government or a Government contractor toget money or a benefit.Waste and AbuseWaste includes overusing services, or other practices that, directly or indirectly, result in unnecessarycosts to the Medicare Program. Waste is generally not considered to be caused by criminally negligentactions but rather by the misuse of resources.Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the MedicareProgram. Abuse involves payment for items or services when there is not legal entitlement to thatpayment and the provider has not knowingly and/or intentionally misrepresented facts to obtainpayment.**For the definitions of fraud, waste, and abuse, refer to Chapter 21, Section 20 of the “Medicare Managed Care Manual”and9 Chapter 9 of the “Prescription Drug Benefit Manual” on the Centers for Medicare & Medicaid Services (CMS) website.

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network HYPERLINK onDrugCovContra/Downloads/Chapter9.pdfAPPENDICES ALINKED TEXT/IMAGEMedicare Managed CareManualPrescription Drug BenefitManualExamples of FWAExamples of actions that may constitute Medicare fraud include: Knowingly billing for services not furnished or supplies not provided, including billing Medicarefor appointments that the patient failed to keep; Billing for non-existent prescriptions; and Knowingly altering claim forms, medical records, or receipts to receive a higher payment.Examples of actions that may constitute Medicare waste include: Conducting excessive office visits or writing excessive prescriptions; Prescribing more medications than necessary for the treatment of a specific condition; and Ordering excessive laboratory tests.Examples of actions that may constitute Medicare abuse include: Billing for unnecessary medical services; Billing for brand name drugs when generics are dispensed; Charging excessively for services or supplies; and Misusing codes on a claim, such as upcoding or unbundling codes.Differences Among Fraud, Waste, and AbuseThere are differences among fraud, waste, and abuse. One of the primary differences is intent andknowledge. Fraud requires intent to obtain payment and the knowledge that the actions are wrong.Waste and abuse may involve obtaining an improper payment or creating an unnecessary cost to theMedicare Program, but does not require the same intent and knowledge.Understanding FWATo detect FWA, you need to know the law.The following screens provide high-level information about the following laws:10 Civil False Claims Act, Health Care Fraud Statute, and Criminal Fraud; Anti-Kickback Statute; Stark Statute (Physician Self-Referral Law); Exclusion; and Health Insurance Portability and Accountability Act (HIPAA).

Combatting Medicare Parts C and D Fraud, Waste, and AbuseMedicare Learning Network APPENDICES AFor details about the specific laws, such as safe harbor provisions, consult the applicable statute andregulations.Civil False Claims Act (FCA)The civil provisions of the FCA make a person liable to pay damages to the Government if he or sheknowingly: Conspires to violate the FCA;Carries out other acts to obtain property from the Government by misrepresentation;Knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay theGovernment;Makes or uses a false record or statement supporting a false claim; orPresents a false claim for payment or approvalFor more information, refer to 31United States Code (U.S.C.) Sections 3729-3733 on the Internet.**Damages and Penalties - Any person who knowingly submits false claims to the Government is liable for three times theGovernment’s damages caused by the violator plus a penalty. The Civil Monetary Penalty (CMP) may range from 5,500 to 11,000 for each false claim.EXAMPLE:A Medicare Part C plan in Florida: Hired an outside company to review medical records to find additional diagnosis codes thatcould be submitted to increase risk capitation payments from the Centers for Medicare&Medicaid Services (CMS);Was informed by the outside company that certain diagnosis codes pr