2/3/2012

1

Independent Licensee of the Blue Cross and Blue Shield Association

1GR-P11-322/1.PPT (1/6/2012)

Fraud, Waste, and AbuseThe Whys, the Whats, and the Hows

February 13, 2012

2Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/2.PPT (1/6/2012)

Fraud, Waste, and Abuse

1. United States Federal Sentencing Guidelines (USFSG)

– Focus on ethical behavior

– Focus on Board engagement

– Require Board understanding of the elements of an effective

compliance program

Why does our Board care?

2/3/2012

2

3Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/3.PPT (1/6/2012)

Fraud, Waste, and Abuse

2. Centers for Medicare and Medicaid Services (CMS)

– Chapter (9) — Fraud, Waste, and Abuse (FWA) requirements

• Elements of an “effective” compliance program

– Noticeable expansion of enforcement

• CMS regulations

• False Claims Act

• Increased penalties — Corporate Integrity Agreements (CIA) and civil monetary penalties

• Enrollment suspension

Why does our Board care? (continued)

4Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/4.PPT (1/6/2012)

Fraud, Waste, and Abuse

3. CMS’ Medicare Compliance Program audits

– Detect “print, post, and pray” programs

– Substantiate knowledgeable governing body

– Verify reasonable Board oversight of compliance program

Why does our Board care? (continued)

2/3/2012

3

5Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/5.PPT (1/6/2012)

Fraud, Waste, and Abuse

4. BlueCross BlueShield Association

– Revised licensure standards reflect revisions to USFSG

– Emphasis on compliance education and training for

Board members

Why does our Board care? (continued)

6Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/6.PPT (1/6/2012)

Fraud, Waste, and Abuse

5. Health and Human Services — program integrity

– Increased enforcement efforts and funding

– The Patient Protection and Affordable Care Act (PPACA) and

Health Care Reform contains many FWA-related sections

– Recovery critical for funding Health Care Reform

Why does our Board care? (continued)

2/3/2012

4

7Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/7.PPT (1/6/2012)

These ten individuals have allegedly defrauded taxpayers of more than $124 million.In all, we are seeking more than 170 fugitives on charges related to health care fraud and abuse.

$110 MILLION Miami, FL: These brothers submitted false and fraudulent

claims to Medicare, purportedly for HIV infusion therapy.

Charged with drug

possession, fraudulent

Internet marketing, and

child endangerment.

100’s of 1000’s OF $$False and fraudulent Durable

Medical Equipment (DME) claims

that were medically unnecessary.

4.3 MILLION (1.9 million in false claims)

Michigan: Dearborn Medical and Rehabilitation Center

(DMRC), an infusion therapy clinic.

17.1 MILLIONCalifornia: Home Health

Agency — Billed Medicare

for unlicensed nursing staff.

1.1 MILLIONCalifornia: Fraudulent DME

claims — motorized

wheelchairs, scooters, and

hospital beds

U.S. Department of Health and Human Services

Office of Inspector General (OIG)

8Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/8.PPT (1/6/2012)

Fraud, Waste, and Abuse

Comprehensive plan to detect, correct, and prevent FWA

• Written polices and procedures/standards of conduct

• Compliance officer and compliance committee

• Training and education

• Effective lines of communication

• Enforcement of standards/publicized disciplinary guidelines

• Monitoring and auditing

• Corrective action procedures

• Comprehensive fraud and abuse plan

What are the requirements?

2/3/2012

5

9Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/9.PPT (1/6/2012)

Fraud, Waste, and Abuse

1. Policies and procedures/standards of conduct

– Compliance and Ethics Department — policies/procedures

– Operational areas — policies/procedures

– Code of Conduct

Specifications:

– Written, producible policies/procedures

– Up-to-date

– Comply with CMS regulations

How do we comply?

10Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/10.PPT (1/6/2012)

Fraud, Waste, and Abuse

2. Compliance officer and compliance committee

– Chief Compliance Officer

– Corporate Compliance Committee

– Medicare Compliance Committee

– Executive Compliance Committee

– Governance Committee of the Board

– Compliance and Ethics Department staff

How do we comply? (continued)

2/3/2012

6

11Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/11.PPT (1/6/2012)

Fraud, Waste, and Abuse

3. Training and education

– Compliance and Ethics Department

• Members — new members and annual

– Specialized training in operational areas

– Training must include:

• Regulations that apply to their jobs

• How to report compliance and ethical concerns

• How to identify FWA

• Non-Retaliation policy

How do we comply? (continued)

12Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/12.PPT (1/6/2012)

Fraud, Waste, and Abuse

4. Effective lines of communication

– Employ various avenues to inform employees of:

• Reporting mechanisms (including anonymous options)

• Responsibility to report concerns

• Non-retaliation/confidentiality

How do we comply? (continued)

2/3/2012

7

13Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/13.PPT (1/6/2012)

Fraud, Waste, and Abuse

5. Enforcement of standards/publicized disciplinary

guidelines

– Referral of Human Resources (HR)-related inquiries to the HR

department

– New management orientation

– Review of monthly compliance-related corrective action report

How do we comply? (continued)

14Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/14.PPT (1/6/2012)

Fraud, Waste, and Abuse

6. Monitoring and auditing

– Monitor over 600 high-risk or regulatory activities

– Review internal and external audit reports

– Require documentation of department-specific monitoring,

auditing, and quality checks throughout the company

7. Corrective action procedures (CAP)

– Oversee CAPs from external entities

– Identify, establish, and track internal CAPs

How do we comply? (continued)

2/3/2012

8

15Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/15.PPT (1/6/2012)

Fraud, Waste, and Abuse

8. Comprehensive fraud and abuse plan

– Chapter 9 regulations

– Now applies to both Medicare Advantage and Part D programs

– “Shoulds” equal “Musts”

– Critical areas (Customer Service, Claims, Pharmacy Services,

Pharmacy Benefit Manager)

• Training

• Reporting

How do we comply? (continued)

16Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/16.PPT (1/6/2012)

Fraud, Waste, and Abuse

8. Comprehensive fraud and abuse plan (continued)

– Delegated entity oversight

• 2011 OIG work plan

• Regular compliance oversight (on-site reviews and audits, teleconferences, attestations, review of codes, FWA training, methods of reporting, etc.)

– Internal Delegated Oversight Committee

• Health Services and Vendor Management audits

• Compliance review of all quarterly audit reports

How do we comply? (continued)

2/3/2012

9

17Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/17.PPT (1/6/2012)

Fraud, Waste, and Abuse

8. Comprehensive fraud and abuse plan (continued)

– Special Investigation Units (SIU)

• Unit dedicated to detecting FWA

• STARSentinelTM software detects aberrant behavior

• Internet and Intranet fraud hotline

How do we comply? (continued)

18Independent Licensee of the Blue Cross and Blue Shield Association

GR-P11-322/18.PPT (1/6/2012)

Fraud, Waste, and Abuse

8. Comprehensive fraud and abuse plan (continued)

– Capital BlueCross — Fraud and Abuse Committee

• Monthly meetings

• SIU, Compliance, and Legal representation

• Recoupment of all government programs’ monies

– Dominion Dental Services, Inc. — Quality Assurance Committee

• Quarterly meetings

• SIU, Compliance, and Legal representation

• Recoupment of all government programs’ monies

How do we comply? (continued)

2/3/2012

10

Independent Licensee of the Blue Cross and Blue Shield Association

19GR-P11-322/19.PPT (1/6/2012)

Thank You