Community Health Group Compliance Training. Presented by Mike Scarano, esq. Foley & Lardner

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1 Community Health Group Compliance Training Presented by Mike Scarano, esq. Foley & Lardner

2 Overview & Objectives What: Compliance, Fraud Waste & Abuse (FWA), Ethics Programs Requirements. Language Assistance Program Requirements. Why: An effective Compliance Programs helps raise awareness and provides mechanisms to detect, prevent, and correct all non-compliance events. How: Through training and education. Who: First Tier, Downstream and Related Entities.

3 Compliance Program As a health care service plan in California, CHG is required by Health and Safety Code section 1348(e) to implement an Antifraud Plan. As of January 1, 2011, Federal Regulations require Managed Care Plans to not just have a compliance program, but also to make sure it is an effective program designated to deter FWA. This includes compliance training requirements annually to all employees.

4 Compliance Program HIPAA Breach Notification Requirement: Requires notification to affected individuals, the Department of Health and Human Services and, in some cases, the media, in the event of a breach of unsecured protected health information.

5 Training Requirements Compliance training is required for all new hires and annually thereafter. Health Plan Staff that work with Medicare Advantage or Part D programs. Contracted Providers. Pharmacy Benefit Managers (MedImpact Healthcare Systems). Independent Physician Associations / Medical Groups.

6 CHG s Antifraud Provider Training

7 Seven Key Compliance Plan Elements 1. Written Standards of Conduct. 2. Designation of a Compliance Officer and Compliance Committee. 3. Effective Compliance Training. 4. Effective Lines of Communication. 5. Internal Monitoring and Auditing. 6. Disciplinary Mechanisms. 7. Procedures for responding to Detected Offenses / Corrective Action.

8 Structure of CHG s Compliance Program Ultimate Authority The Board CEO Norma Diaz Compliance Officer Ann Warren Compliance Committee Policies and Procedures Education and Training Reporting Mechanism Audits and Investigations Discipline and other remedial measures

9 Reasons to Implement a Compliance Plan Demonstrates the organization has a strong commitment to honesty and responsible corporate integrity. Helps an organization fulfill its legal duty to the government. Compliance programs are cost effective. Provides guidance and procedures to promptly correct misconduct.

10 Types of FWA Managed Care Organization Fraud Member Fraud Provider Fraud Pharmacy Fraud

11 Plans Examples of FWA Failure to Provide Medically Necessary Services. Inappropriate Enrollment/Disenrollment. Marketing Schemes. Formulary or Coverage Decisions.

12 Examples of Beneficiary (Member) FWA The following are examples of fraud by Medicare beneficiaries (members): Identity Theft. Doctor Shopping. Prescription Fraud.

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14 Examples of Provider FWA Rendering Provider: Misrepresenting who rendered the service. False Coding or Services: Billing for a covered item or service when the actual item or service provided was a non-covered item or service. Unnecessary Care: Providing unnecessary procedures or prescribing unnecessary drugs. Altering Medical Records: Erroneous, false, or late entries in the medical record.

15 Major Insurance Fraud Bust Undercover Grandma

16 Prescription Fraud. In 2011, the Office of Inspector General (OIG) arrested two Brooklyn pharmacists for defrauding Medicare for more than $3 billion by billing for prescription that were never filled or dispensed.

17 Penalties and Consequences of FWA Repayment / Restitution is just the start False Claims Act: $5,500 and up to $11,000 per claim plus up to triple the amount of the claim in damages. Anti-Kickback: Medicare Advantage Organization - enrollment freeze and sanctions under CMS authority, up to $25,000 per beneficiary impacted anti-kickback violation. Providers: up to five years in prison and fines of up to $25,000. If a patient suffers bodily injury as a result of any kickback scheme, such as unnecessary procedures, the prison sentence may be 20+ years.

18 Most Abused Drugs Cocaine Marijuana Heroin Non-specific benzodiazepines Alprazolam (xanax) Hydrocodone (vicodin, Loercet, Lortab) Oxycodone Amphetamines Methamphetamine Clonazepam Methadone Diazepam Lorezepam Clarisoprodol Trazodone Parxetine Zolpidem Sertraline Non-specific barbituates

19 Why are prescriptions so appealing? They can be obtained with a physician s prescription Clean obtained in a Safe environment Perception of legality Not as bad as illicit drugs Easy to obtain Accidental addicts Celebrities

20 Prescription Drug Abuse Epidemic

21 Centers for Disease Control and Prevention Source: CDC Vital Signs 11/2011

22 What do we do with our prescriptions?

23 Keep Prescriptions in a Safe Place A North County reporter, David Whiting, wrote an article pertaining to drug related deaths. He reviewed coroner records and found that there were 80 accidental deaths attributed to drug overdose ages 24 and younger. ( ). These include overdoses of heroin and opiate prescription drugs. Many of these young people begin by abusing prescription drugs like OxyContin and Vicodin that contain opioids and then move to heroin because it is far less expensive.

24 Feds Bust Alleged Pill Ring That Cost Taxpayers $500 Million The FBI seized more than $16 million worth of second-hand prescription drugs, comprised of more than 33,000 bottles and more than 250,000 loose pills in one of the largest drug-diversion schemes ever, according to a federal prosecutor.

25 Required Reporting Violations of the code of conduct, ethics or any fraud, waste or abuse must be reported. Not reporting fraud or suspected fraud can make you a party to a case by allowing the fraud to continue. CHG has an internal mechanism for reporting compliance & FWA concerns (your compliance officer or compliance hotline). Fraud or suspected fraud may also be reported anonymously as outlined by any health plan on their web portals or your internal reporting mechanisms. Everyone has the right and responsibility to report possible fraud, waste, or abuse. Remember: You may report anonymously, retaliation is prohibited when you report a concern in good faith.

26 Include Policies, Procedures and Training on Whistleblower Protections Whistleblower: An employee, former employee, or member of an organization who reports misconduct to people or entities that have the power to take corrective action. A provision in the False Claims Act allows individuals to: Report fraud anonymously. Sue an organization on behalf of the government and collect a portion of any settlement. Employers cannot threaten or retaliate against whistleblowers.

27 Remember to Protect Confidentiality Carefully handle all data that can identify the member Social Security, Medicare ID (HICN) or Health Plan Member ID number. Member Name, Address, Phone, Date of Birth. Medical Record Number/Patient Account Number. Review your internal policies and practices for reporting of any security and privacy breach to your respective HIPAA security or privacy officer. Reporting MUST be done immediately if you become aware of or suspect a breach may have occurred.

28 REPORTING Compliance Issues Tell your supervisor. Contact the Compliance Officer. Call CHG s Compliance Hot Line: If the suspected fraud is not related to health care, bring to HR.

29 Contacts by Law Enforcement No obligation to speak with them. Report contact to supervisor or Compliance Officer.

30 CHG s Code of Conduct Community Health Group Code of Ethical Business Conduct is intended to focus the Board and each employee on areas of ethical risk, provide guidance to employees to help them recognize and deal with ethical issues, provide mechanisms to report unethical conduct, and help foster a culture of honesty and accountability. Each employee must comply with the letter and spirit of this Code. Appendix A Employee Code of Conduct.doc

31 Ethics Have the courage to say no. Have the courage to face the truth. Do the right thing because it is right. These are the magic keys to living your life with integrity. - W. Clement Stone

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33 Ethics No man can be dishonest without soon being found out and when his lack of principle is discovered, nearly every avenue of success is closed against him forever. P.T. Barnum

34 Newspaper Headlines Curley and Paterno Ex-Governor Penn State Scandal Ex-Governor

35 QUESTIONS?