Compliance Awareness

Training

2015

Overview of trainingThese training materials cover the following

topics:Compliance ProgramStandards of ConductHealth Insurance Portability and

Accountability ActFraud, Waste and AbuseFederal Rules governing health care

This training should not take more than 20 minutes to complete.

Introduction

This health plan is committed to conducting business ethically and with integrity, and to detecting and preventing fraud, waste and abuse through an effective compliance program. We are dedicated to working with our contracted organizations to ensure those goals are met as well as ensuring compliance with all applicable laws, regulations and requirements.

As a contractor with The Centers for Medicare and Medicaid Services (CMS) and Arizona Health Care Cost Containment System (AHCCCS), we are required to implement effective compliance training for our employees and contracted organizations to prevent, detect and correct: Fraud, Waste and Abuse Non-compliance with the program requirements of CMS and AHCCCS

If you are contracted with us to provide administrative or health care service functions related to our contract with a regulatory agency, you are considered a First Tier, Downstream or Related Entity (FDR) and are required to provide training to your employees. We are providing this training as a resource to our FDRs to meet the regulatory mandatory training requirement.

Introduction

If your organization has developed its own compliance training (including standards of conduct) and FWA training, you do not need to complete this training.

However:

Your organization is required to maintain records including: Materials used for training, Date training was provided, Methods training was provided, and Training logs identifying trained employees.

FDR Compliance Awareness Training Objectives

Gain a general understanding of the health plan’s Corporate Compliance Program, including:- Business ethics and compliance with all statutory and regulatory

program requirements- The Standards of Conduct and Ethics- An overview of the health plan’s Compliance Plan- Office of Inspector General’s (OIG) and General Service Administration’s (GSA) Exclusion List- FDRs responsibility to have policies and procedures regarding FWA- What happens when an incident is reported- Laws and regulations governing health care- Process for asking compliance questions or reporting potential non-

compliance

Definitions

Abuse: may directly or indirectly result in unnecessary costs of the Medicare or Medicaid program, improper payment for services which fail to meet professional recognized standards of care, or that are medically unnecessary.

Fraud: is an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person.

FDR: First tier entity, downstream entity, related entity (see individual definitions)

First tier entity: any party that enters into a written arrangement to provide administrative services or health care services for a member of the health plan.

Downstream entity: any party that enters into a written arrangement with persons or entities below the level of the arrangement between the health plan and first tier entity.

Related entity: any entity that is related to the health plan by common ownership or control and (1) performs some of the organization’s management functions under contract or delegation; (2) furnishes services to members under an oral or written agreement; or (3) Leases real property or sells materials to the health plan at a cost of more than $2,500 during a contract period.

Corporate Compliance Program

The purpose of the health plan’s compliance plan is to: (1) promote compliancewith applicable laws, regulations and federal healthcare program and contractrequirements; (2) prevent, detect and correct compliance violations and fraud, waste and abuse; (3) provide a framework for compliance oversight; and (4) state clear legal and ethical standards that promote principles of integrity and (5) further the mission of providing quality services to our members.

The Compliance Program applies to the Executive Management Committee, all health plan officers, employees and FDRs.

Benefits of a Compliance Program

Demonstrates commitment to honest and responsible conduct

Provides guidance to employees regarding regulations governing health care

Identifies and prevents criminal and unethical conduct

Encourages employees to report potential problems

Maintains confidentiality of member records

Compliance Program OverviewCore Elements

The health plan’s Compliance Program consists of policies and procedures covering the of seven core elements:

1. Written Policies and Procedures and Standards of Conduct which describe our commitment to comply with all federal and state regulations;

2. Compliance Officer, Compliance Committee and high level oversight who are responsible for identifying risks and trends related to non-compliance or fraud, waste and abuse and responsible for oversight of all aspects of the compliance program;

3. Training and Education which is provided to all employees including senior management, Board of Directors and FDRs;

4. Effective Lines of Communication which widely publicizes the methods for reporting program non-compliance and FWA;

Core elements (continued)

5. Enforcement of Standards through well-publicized disciplinary guidelines which emphasizes our commitment to appropriate corrective action for non-compliance with Standards of Conduct and other policies and procedures, up to and including termination;

6. Monitoring and Auditing for compliance risks which means we have processes in place to conduct internal monitoring and auditing to ensure compliance with policies, procedures, laws and regulations and external auditing of FDRs to evaluate the services provided and compliance with all contractual requirements; and

7. Procedures for prompt response to compliance issues which means we acknowledge issues as they arise, investigate them and correct them promptly to reduce the potential for reoccurrence.

Standards of Conduct

The health plan’s Standards of Conduct are an integral part of the Compliance Program and will assist employees and FDRs carrying out their activities within appropriate ethical and legal standards.

Employees are annually required to acknowledge that they have received and will

abide by the Standards of Conduct.

FDRs may have their own Standards of Conduct or use the health plan’s.

A copy of the health plan’s Standards of Conduct is available on the web under the Provider tab at:

www.phoenixhealthplan.com (AZ Medicaid)www.phoenixhealthplans.com (AZ Medicare)www.allegianadvantage.com (TX Medicare)www.harborhealthadvantage.com (MI Medicare)

Ethical Principles

Our standards of conduct and Compliance Program apply to all health plan employees, board of director, members, volunteers, contracted workers and FDRs

_______________________________________________________________Ethical Principles: Commitment to full compliance with all Federal Health care program

requirements policy and procedures regarding the health plan’s compliance program.

Health plan members and FDRs have a right to expect that the business of the health plan will be conducted ethically and competently by health plan employees.

Employees and FDRs shall perform this/her duties in good faith, in a manner that he/she reasonably believes to be in the best interest of the health plan and its members.

Employees and FDRs shall not engage, either directly or indirectly, in any corrupt business practice, including bribery, kickbacks or payoffs.

Prohibition of Excluded Parties

The health plan prohibits the employment or contracting with any individual or entity who have recently been convicted of a criminal offense related to health care or who have been debarred, excluded or otherwise is ineligible for participation in federal or state health care programs. The health plan uses the following databanks: OIG Cumulative Sanction Report (LEIE) GSA List of Parties Excluded from Federal Procurement and

Non-procurement Programs (SAM)

Confidentiality of Member Information

The health plan is committed to protecting the confidentiality of member information in all aspects of Health Insurance Portability and Accountability Act (HIPAA) and its associate regulations, Health Information Technology for Economic and Clinical Health Act (HITECH).

All member information maintained by the health plan is considered Protected Health Information (PHI).

Confidentiality of Member Information

HIPAA protects the privacy and security of PHI.

The Privacy Rule outlines specific protections or use and disclosure of PHI. It also grants rights specific to members.

The Security Rule outlines specific protections and safeguards of electronic PHI.

Confidentiality of Member Information

Remember!

PHI means all information whether written, verbal, recorded in a computer or by other means.

Only individuals with a “need to know” may access, use or disclose member information. This includes all activities related to treatment, payment or health care operations.

All PHI transmitted between the health plan and the FDR must be encrypted or sent by fax with a cover sheet containing no PHI.

Always verify a fax number before faxing and verify the fax was received.

Conflicts of Interest

The health plan requires its employees and FDRs to act honestly and ethically and not to have conflicts of interest with any line of business. A conflict of interest exists when a person’s private interest interferes in any way or even just appears to interfere with the health plan’s interests. Conflicts of interest also exist where an individual’s action or activities involve obtaining an improper person gain or advantage, or an adverse effect upon the health plan’s interest.If you are unsure if a conflict exists please see your supervisor, an Officer of the health plan, or the health plan Compliance Officer.

Examples of Non-Compliance with Regulatory Requirements

Not cooperating with CMS auditorUntimely submission of data to CMSViolating member privacyNon-compliance with contract deliverable

requirements

Fraud, Waste and Abuse

FDRs must implement policies and procedures that address fraud, waste and abuse. These policies and procedures shall address the following: What constitutes fraud, waste or abuse? What methods will be used to prevent and detect fraud, waste and abuse activities? How and who will investigate situations that are reported? How will employees report this information? How will employees be protected from retaliation should they report a potential issue? What corrective and/or disciplinary actions will be taken if fraud, waste or abuse occurs?

FDRs must report any potential fraud, waste or abuse

to the health plan.

What Happens when a Report is Filed

The report will be documented by the health plan.

The reported issue will be researched by the appropriate person to determine if fraud, abuse or other misconduct has occurred. This may include interviews, observation, audit, or other methods for determining the nature of the issue. (The identity of the person reporting the issue will remain confidential)

Preliminary assessment will be documented by the health plan .

If the issue is not related to a violation of state or federal regulations, fraud, abuse or other misconduct, it will be closed and no further action will be taken.

All instances of suspected violations of state or federal regulations, fraud, abuse or other misconduct will be handled by the Compliance Officer or his/her designee and reported to the appropriate regulatory authority.

Protections for FDR Employees Who Report Fraud, Waste or Abuse

FDR employees must report any potential fraud, waste or abuse that they know or think they know is occurring.

FDR employees who do make a report are not be retaliated against for making reports in good faith. Employees that are found to have made a report because they are disgruntled or other inappropriate motivation will not be afforded the same protections.

FDR employees are given the opportunity to report anonymously if they so choose.

FDR employees that retaliate against another employee that has made a good-faith report should be subject to corrective action up to and including termination.

Types of Fraud, Waste or Abuse

Marketing schemes: when the health plan or its FDR violates the Medicare marketing guidelines to improperly enroll members, i.e., unsolicited door-to-door marketing, use of unlicensed agents, enrollment of member without his/her knowledge or consent, requiring upfront premiums.

Payments for excluded drugs Forging or altering claims Kickbacks Falsifying credentials Falsification of eligibility information to obtain coverage or receive

services Double billing or billing for services that were not provided Submitting false data Doctor shopping by members

Indicators for Potential FWA

Does the prescription look altered or possibly forged? Is the diagnosis for the member supported by medical

records? Is the provider performing unnecessary services? Is the provider billing for a more expensive service than

was actually provided?Are generic drugs being provided when the plan is being

billed for brand drugs?Are members being enrolled who do not meet the eligibility

requirements? Is there illegal advertising or sales activity?Are inappropriate enrollment/disenrollment practices

occurring? Is the provider submitting a bill for services not provided or

for free services?

Healthcare Laws and Regulations

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.

Stark Law Compliance Tips

• Understand the Stark Law exceptions• Document financial relationships with referring physicians• Have systems to ensure properly structured payments• Beware of lease creep problems (i.e., ensure rent is fair market

value; collect rent per lease, track lease expenses)• Review productivity bonuses• Gifts and in-kind services can implicate Stark

Source: OIG HEAT Training Seminar, Denver, CO, May 2011

Anti-Kickback Statute – Compliance Tips

Use a Safe HarborIt’s a “one purpose” testFair market value for actual/necessary

services

Source: OIG HEAT Training Seminar, Denver, CO, May 2011

Penalties: Imposition of SanctionsCMS Civil Money penalties range from $10,000 to

$100,000 depending on the violation;CMS Suspension of enrollment of plan beneficiariesSuspension of payment to the plan by CMSSuspension of marketing activities of the plan by

CMSFor providers/violators: placement on the Exclusion

data base which will prevent you from receiving any payments by a federal health care program

For providers/violators: sanctions up to termination of contract

Reporting to Compliance

What types of items to report:Potential fraud, waste and abuse referralsProtected health information mishandlingNon-compliance with contract requirementsSanction noticesEthical violations

How to Report to Compliance

All suspected non-compliance issues, including fraud, waste and abuse, must be

reported to:Health Plan Compliance Officer at

phpcompliancereferrals@abrazohealth.com

Fax: 602-674-6634

OR

THE ETHICS ACTION LINE

1-800-838-4427Please remember your information remains confidential and

you may report anonymously

Thank you for completing the Compliance Awareness Training