Fraud, Waste and Abuse Compliance
For some reason, it seems people think fraud, waste and abuse prevention compliance is difficult. While it is boring and it clearly has some scary ramifications when not followed, it’s actually very simple and fairly easy to implement. In this article, we will discuss why having a FWA prevention compliance program is important, things you can do to get started, examples of other people who thought they didn’t need to have all their FWA items in place and the issues they got into and some solutions to keep you from getting into hot water with Medicare and OIG.
Good news, if you are not billing Medicare Part B, C (Advantage) or D and now Medicaid, you don’t have to do FWA training or follow their rules. But chances are very good that you are in the 99.99% of pharmacies that have Medicare patients. Medicare patients are your bread and butter, and your state Medicaid program and several third party programs will require annual training and compliance with a host of different items, including Conflict of Interest and OIG and GSA Exclusion Verifications just to name a few. So to recap, if you want to participate in Medicare, Medicaid and most 3rd party Part D insurances, you will need to have an active FWA program in place.
So, what does a fraud, waste and abuse prevention compliance program look like? It will have 10 Policies & Procedures, a process to conduct monthly verification checks via the OIG-SAM Exclusion Verification Report (which by the way need to be retained for 10 years), annual Conflict of Interest certifications (COI), posting the CMS 10147 in your facility and training your staff on YOUR Policies & Procedures annually, not a canned training program that is unrelated to your program.
Super simple! Let’s pretend you forgot to do COI Certifications for the last two years, or you haven’t been running all employees, owners, 1099 or contract employees, BAA’s including assisted-living facilities and vendors whose products and services are billed to a federal health care plan (Medicare, Medicaid, Tri-care) through OIG-SAM Exclusion Verification and someone is on the Exclusion List, or maybe you did your annual trainings, but you never documented it. What’s the worst that could happen? Well, you have violated your Part D contract, and since PBM’s are the enforcers, they can take back all reimbursements to the date of the last time you did whatever it was that you were supposed to be doing. So, let’s say it was only for 1 month; can your facility survive if all Part D reimbursements were taken back for last month? Let’s be crazy and say you never did your annual training or you have an individual on the exclusion list since 2006. That’s right, they can take back ALL reimbursements up to 10 years! We like to say if it isn’t documented, it never happened; so make sure you have signed and dated documents!
There have been hundreds of cases where people blatantly committed fraud knowingly and willfully. Don’t do it. You will eventually get caught. This is one thing the government has gotten really good at!
- According to a Press Release from the DOJ July 25, 2018, an owner of a DME company pled guilty to defrauding D.C. Medicaid program of almost $9.5 million by willfully submitting false claims.
- According to a Press Release from the DOJ August 9, 2018, a pharmacist from Hattiesburg, MS, pled guilty to defrauding Tricare and other health care programs by mass producing and prescribing medically unnecessary compound medications that included kickbacks, bribes and fraud. Combined with other co-conspirators, it is estimated they were reimbursed over $243 million from these false claims.
- According to a Press Release from the DOJ May 2, 2018,a patient recruiter for Texas Tender Care was convicted in a $3.6 million home health care fraud scheme.
Don’t be like these people who were ignorant or just ignored the rules: (if the following are actual headlines/article titles, the capitalization of the first letter of each word can stand. If not, this section needs reviewed again with most capitalizations brought back to lower case)
- According to a January 23, 2017, article from the OIG: An Excluded and Unlicensed New Jersey Dentist Who Assumed Identity of Another Dentist Agrees to Settlement of $1.1 Million and 50-Year Exclusion to Resolve Civil Monetary Penalty Case
- According to OIG’s Civil Monetary Penalties and Affirmative Exclusions Report:
- On August 2, 2018, An Ohio Skilled Nursing Facility Settles Case Involving Excluded Individual for $45,735.42
- On August 2, 2018, A Maine Chiropractic Practice Settles Case Involving Excluded Individual Resulting in a $7,019 Fine
- On July 2, 2018, A Vermont Physician and Practice Settle Case Involving Excluded Individual, Registered Nurse, Resulting in a $61,142.96 Settlement
- On May 17, 2018, A Pennsylvania Home Health Company Settles Case Involving Excluded Individual Resulting in a $189,445.68 Settlement
List examples here of pharmacies having to give back reimbursements for failed to have documentation. ?EXAMPLES
If you want to follow the rules and ensure you get to keep all the moneys you collect but don’t have the time to create your own policies and procedures, or maybe you have a lot of employees, vendors and business associates to run through the OIG exclusion database, R.J. Hedges & Associates has a simple and easy solution for you. The R.J. Hedges Fraud, Waste and Abuse Prevention Program ensures you are in compliance with Medicare Parts B, C and D, Medicaid and third party payers. The program provides a platform that allows your monthly exclusion verification to be completed in seconds versus having to manually enter the data every month in the two different databases and consists of a series of policies and procedures including: Anti-Kickback, Conflict of Interest, False Claims Submission, OIG and GSA Exclusion Verifications, General Compliance, FWA Training and Whistleblower Protection.
If you already have a program in place and want to see how compliant you are with FWA rules and regulations, feel free to take our free FWA Assessment.
