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Wellbeing First Wellbeing Arranges Misrepresentation, Waste, and Mishandle Consistence Preparing Welcome… to our Consistence and Extortion, Waste, and Manhandle (FWA) instructional class for the greater part of our System Suppliers, Drug stores, Contracted Merchants and their representatives. Learning Goals
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Wellbeing First Health Plans Fraud, Waste, and Abuse Compliance Training

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Welcome… to our Compliance & Fraud, Waste, and Abuse (FWA) instructional class for the majority of our Network Providers, Pharmacies, Contracted Vendors and their workers.

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Learning Objectives At the end of this instructional meeting, you will: get comfortable with the CMS order for FWA preparing prerequisites. perceive illustrations of medicinal services FWA inside of your field. comprehend what HFHP is doing to recognize and forestall FWA know the fitting strides to report suspected medicinal services FWA.

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The CMS Mandate The Center for Medicare & Medicaid Services (CMS) last control entitled, “ Revisions to the Medicare Advantage and Part D Prescription Drug Contract Determinations, Appeals, and Intermediate Sanctions Processes,” distributed in December of 2007 , obliges Medicare Advantage (MA) associations to consolidate FWA preparing rules into their current consistence arrangements starting in arrangement year 2009.

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The CMS Mandate HFHP’s contracted elements, including system suppliers, drug stores, and sellers must get preparing to identify, redress, and avert Medicare misrepresentation. This preparation incorporates downstream people included in the organization or conveyance of the Medicare advantage as characterized under 42 CFR 423.504(b)(vi)(H).

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Combat Fraud This presentation was intended to assist you with turning into a dynamic member in the battle against misrepresentation in the social insurance industry by recognizing suspicious exercises identified with health advantages and physician recommended medication scope.

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By instructing ourselves on the most proficient method to distinguish and counteract false exercises, we can: sparing superfluous expenses that could build human services premiums ensuring Medicare reserves that are depended upon by millions

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Special Investigations Unit (SIU) HFHP has executed an interior FWA program otherwise called the Special Investigations Unit (SIU) which is housed inside of the Government Programs Department. To guarantee HFHP persistently conveys quality social insurance, it is vital that we defend the government stores depended to us by attempting to counteract medicinal services extortion. FWA

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SIU Regulatory Requirements Our wellbeing arrangement is needed by state and government laws to keep up a Special Investigations Unit. State Florida Statute: FS 626.9891â  Insurer hostile to misrepresentation investigative units; reporting prerequisites; punishments for rebelliousness Federal (Part C) 42 CFR §422.504, Contract procurements Federal (Part D) 42 CFR §423.505, Contract procurements

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SIU Program Our project is contained the accompanying components:  Detection  Prevention  Correction  Reporting  and most importantly…

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YOU! Wellbeing First partners, taking an interest suppliers, drug stores, and contracted elements all assume an imperative part in identifying Fraud, Waste, and Abuse connected with Medical and Pharmaceutical administrations.

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FWA Important Laws The False Claims Act (FCA) Prohibits intentionally introducing (or bringing on to be displayed) to the government a false or fake case for installment or regard. The Anti-Kickback Statute Section 1128B(b) of the Social Security Act (42 USC 13207b(b)) gives criminal punishments to people or elements that intentionally and persistently offer, pay, request, or get compensation keeping in mind the end goal to incite or reward business payable (or repayment) under the Medicare or other government human services programs. The Health Insurance Portability and Accountability Act (HIPAA) All part data must be done in consistence with HIPAA regulations and interior strategies to oversee and keep up satisfactory controls being used and treatment of part information.

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What is Fraud, Waste, and Abuse? Misrepresentation — When a shopper or social insurance supplier deliberately submits, or causes another person to submit false or deceiving data to acquire therapeutic treatment or installment for administrations. Waste — Actions by a person which causes the wellbeing arrangement to reliably pay for or approve pointless administrations. Medicinal services spending that can be disposed of without diminishing the nature of consideration. The demonstration itself is not intended to swindle the wellbeing. Misuse — Consistent lapses or uncalled for practices that outcomes in over the top, nonsensical and superfluous expense to the wellbeing arrangement. The demonstration is not intended to cheat the wellbeing arrangement.

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Health Care Fraud is a Crime Fraud is a wrongdoing when an individual deliberately submits, or causes another person to submit, false or deceiving data to get treatment or installment for administrations they are NOT qualified for.

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Who submits extortion? Anybody of the accompanying could possibly submit social insurance misrepresentation: Providers Members Pharmacies Pharmaceutical makers Employees of medicinal services elements

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Provider Fraud Examples Unbundling and/or upcoding; changing case structures or therapeutic documentation. Charging for administrations not rendered and/or supplies not gave. Endorsing medications without looking into a patient’s condition; superfluous medications could be exchanged. Composing a remedy for a higher amount than fitting to help part with minimizing their copayment.

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Employee or Patient Fraud Examples Stealing a solution cushion and composing their own medicines; resale of medications. Utilizing somebody else’s ID card to get secured medicinal services advantages. Adjusting a remedy to include more refills, build amounts, and so forth

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Pharmacy Fraud Examples ▪ Billing for everything endorsed except just recording a part, and not attributing the distinction back to the wellbeing arrangement. Deliberately charging for brand however administering non specific, or the wrong NDC code. Controlling figurings to keep recipients in the scope crevice or to push recipients into cataclysmic scope. Solution manufacturing or changing.

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Pharmaceutical Manufacturer Fraud Examples Offering affectations if the bought items are reimbursable by any of the government medicinal services programs. Advancing off-name drug utilization unlawfully through showcasing, monetary motivating forces, or other advancement crusades. Utilizing free examples illicitly by intentionally giving them to doctors who will charge the government social insurance programs for the specimens.

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Health Insurance Fraud Examples Violating the social insurance showcasing rules, for example, offering recipients a money installment as an actuation to select. Snare and switch advertising so as to valu: draw clients an item/benefit at an unfruitfully low value, then later uncover the item is not accessible but rather a substitute is. Installment for remedies composed by known perished or authorized doctor. Distorting or adulterating data outfitted to CMS.

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Difference Between Fraud and Abuse There is an almost negligible difference in the middle of extortion and misuse, in view of whether there is aim to hoodwink the social insurance industry. Extortion includes cognizant duplicity or distortion proposed to result in an unapproved therapeutic or drug store advantage. Misuse may be like misrepresentation aside from that it may not be plausible that the oppressive demonstrations were finished with a plan to bamboozle the back up plan. Will you demonstrate that the individual knew they were carrying out a wrongdoing? Assuming this is the case, it could be misrepresentation. If not, it’s in all probability misuse. In either case, you ought to report it.

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Red Flags Rule Under the new Red Flags Rule, certain associations including doctor workplaces, doctor\'s facilities and other social insurance associations, are obliged to be acquainted with notices signs that could show data fraud. These notice pointers help with minimizing the harms of data fraud inside of the social insurance field.

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Identity Theft: Red Flag Examples Address error Name disparity on distinguishing proof and protection data Personal data conflicting with data as of now on record Medical documentation is conflicting with restorative history as reported by the Patient denies accepting administrations that were charged to their protection bearer

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What is HFHP doing to offer assistance?  Special Investigations Unit (SIU) Housed inside HFHP to research conceivable FWA action.  Exclusions List Reviewed quarterly to guarantee the Health Plan is not leading business with a provider or element that has been avoided from taking an interest in a governmentally funded social insurance program.  Routine Auditing P ro-dynamic strides to guarantee the Health Plan is leading business in accordance with state and government rules.  Medicare Compliance Plan Establishes inside controls and screens the Health Plan’s behavior to lessen the danger of unlawful or inappropriate exercises.

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What Can You Do? On the off chance that you perceive exercises that may constitute human services misrepresentation, waste, or misuse submitted by a supplier, drug store, part, subcontractor, or worker, report these occurrences as fast as could be expected under the circumstances. You can help counteract potential fake exercises identified with the social insurance industry by reporting any suspicious demonstrations to our SIU division. It’s the correct thing to do!

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Why Should I Report?  Combating misrepresentation serves to brings down medicinal services costs and taxes.  CMS obliges us to report every single suspicious activitie.  Reporting could basically keep somebody from being defrauded by deceitful conduct and ensures the medicinal services\' trustworthiness industry.

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What If I’m Unsure? On the off chance that you think something is not right or dishonest, it’s basic that you

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