ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans DEPARTMENT: Medicare Compliance POLICY TITLE: RELATED DEPARTMENTS: All POLICY #: 706 C VERSION #: 4 REVISION DATE: Identifying and Monitoring for Fraud Waste and Abuse 4/2016 EFFECTIVE DATE: PREPARED BY: PRODUCT: NEXT REVIEW DATE: 1/1/2013 Cathy Kajubi Medicare Advantage December 2016 Approved: David Finkel President, MedStar Family Choice Lesley Wallace Assistant Vice President, MedStar Family Choice PURPOSE This policy describes MedStar Family Choice s (MFC) efforts to identify, remediate and prevent instances of non compliance and Fraud Waste and Abuse (FWA) within its Medicare program. DEFINITIONS/ACRONYMS CMS Centers for Medicare & Medicaid Services FDR First Tier, Downstream, and Related entities FWA Fraud, Waste and Abuse MCO Medicare Compliance Officer MA Medicare Advantage MFC- MedStar Family Choice PDP Prescription Drug Plan
Employee: Any full-time, part-time, temporary, contracted or volunteer individual employed directly by MedStar Health or MedStar Family Choice involved in the administration or delivery of the Medicare benefit. First Tier Entity: Any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage (MA) Organization or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program. Downstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of the arrangement between an MAO or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services. Related Entity: Any entity related to an MAO or Part D sponsor by common ownership or control and: Performs some of the MAO or Part D functions under contract or delegation; o Furnishes services to Medicare enrollees under an oral or written agreement; or o Leases real property or sells materials to sponsor at a cost of more than $2,500. NBI MEDIC - National Benefit Integrity Medicare Integrity Contractor (NBI MEDIC) is the Medicare Part C and Part D program integrity contractor for the Centers for Medicare & Medicaid Services (CMS) under the National Benefit Integrity Medicare Drug Integrity Contract. The purpose of the NBI MEDIC is to detect and prevent fraud, waste, and abuse in the Part C (Medicare Advantage) and Part D (Prescription Drug Coverage) programs on a national level. POLICY All MFC employees and the employees of MFC s First Tier, Downstream, and Related entities (FDR) are responsible for assisting in the identification, investigation and reporting of instances of actual or suspected fraud, waste, and abuse through audits, data analysis, reporting, and other activities. PROCEDURE 1. Fraud waste and abuse can occur within many areas of an organization. It is the responsibility of all employees to identify and report suspected fraud waste and abuse activities. Employees should follow the appropriate policies and procedures for reporting fraud and abuse activities as outlined in the annual fraud waste and abuse compliance training. 2. Areas in which fraud waste and abuse can occur can include but are not limited to the following: Encounter Data Claims Submission Claims Processing Billing Procedures Underutilization Overutilization Customer Service Credentialing
Enrollment and Disenrollment Marketing 3. The Medicare Compliance Director will monitor on a frequent and routine basis reports in the areas of: Enrollment & Eligibility Member Services Complaints and Appeals Medical Claims Pharmacy Claims HIPAA Breaches Fraud Waste & Abuse 4. The Medicare Compliance Committee will review and recommend any additional reports that will assist in the identification and detection of fraud waste and abuse activities. 5. The Medicare Compliance Committee will review the results of auditing and monitoring activities on a quarterly basis or more frequently should serious issues be identified. 6. The auditing and monitoring activities will include the following: 7. An explanation/ evidence of a root cause analysis performed for any issues identified. Monitoring reports showing the outcomes of monitoring conducted on the identified issues. If monitoring occurred over a period of time, trending reports showing the trend of the issue (i.e., the issue is being or has been remediated over time or the issue is still occurring). Audit reports showing the results of any audits conducted for identified issues. Evidence/ explanation of any follow up done as a result of the monitoring/ auditing of the identified issue. An explanation of detailed corrective actions that were taken regarding the identified issues. A timeline indicating the corrective actions were fully implemented or, if not fully implemented, when the corrective actions will be completed. If corrective actions were not required, an explanation of rationale for not implementing corrective action. 8. The Medicare Compliance Director will submit quarterly reports and an annual report to the Medicare Compliance Committee to be shared with the Board of Directors. As appropriate, a NBI MEDIC referral will be created and submitted as well. The reports will summarize the overall fraud waste and abuse activity and any changes that are recommended in order to improve overall compliance. 9. As an additional resource in fraud waste and abuse detection, the Medicare Compliance Director and Medicare Compliance Officer will receive on a weekly basis reports from the Special Investigation Unit at UPMC. As the processor of MedStar Medicare Choice claims, UPMC performs FWA analytics on claims processed by UPMC. The UPMC Special Investigation Unit produces weekly activity reports as well as monthly reports of results.
10. The UPMC Health Plan Benefit Management Services (UPMC) utilizes an assortment of reporting tools and techniques to identify and evaluate potential fraud, waste and abuse (FWA) issues. Some of the tools are used by UPMC to identify and investigate FWA issues and create tips/cases where necessary or conduct risk assessments include : NHCAA SIRIS: The National Health Care Anti-Fraud Association (NHCAA) Special Investigations Resource and Intelligence System (SIRIS) is a database maintained by the NHCAA for the purpose of sharing intelligence and information related to healthcare fraud. The database includes information from all 50 states and from hundreds of healthcare insurance SIU s. The SIU reviews cases from states associated with each Evolent client for potential exposure. NHCAA Smart Briefs: The NHCAA also provides a daily email known as a Smart Brief. Smart Briefs include prominent issues and news articles related to healthcare fraud. These issues are reviewed for new trends and possible exposure to each Evolent client. High Prescriber Utilization: The High Prescriber Utilization report is sent to the SIU on a monthly basis. The report includes summarization of narcotics usage for all prescribers and the member information included with that data. The data is analyzed and outliers are identified for further review. Based on that review a clinical auditor analyzes the data identified. StarSentinel Lead Generation Software: Star Sentinel is a lead generation software system powered by General Dynamics that allows the SIU to identify red flags, review potential outliers and review algorithms used to detect potential fraud, waste or abuse issues. Reviews of StarSentinel will be conducted on a regular schedule and in an as needed manner. High Dollar and Random Audit Claim Audits: Quality Audit department audits identify potentially questionable claim issues for review by the SIU. Quality Audit conducts prepayment review of high dollar claims for appropriate charges. Random audits are conducted of claims and questionable claims are provided to the SIU for review. 11. In addition to the claims processed by UPMC, all FDRs are responsible for providing FWA reports on a routine basis, but no less than quarterly. RECORD RETENTION Medical and business documents and records must be maintained in accordance with procedures and timeframes established by applicable laws, accreditation standards, and MedStar Health s Record Retention and Destruction Policy, whichever period is longer. For the Medicare line of business the record retention period is at least 10 years. Medical and business documents include paper documents such as letters and memoranda; computer-based information, such as e-mail or computer files on disk or tape; and any other medium that contains information about MedStar Health or its business activities. MedStar also requires that all FDRs meet or exceed this strict record retention requirement. RELATED DOCUMENTS/ATTACHMENTS Medicare Compliance Plan MedStar Code of Conduct Medicare Compliance Committee Charter
MedStar Family Choice Administrative Policy and Procedure: Medicare Compliance Fraud Waste & Abuse Education and Training REGULATORY REFERENCES: 42 CFR 422.503(b)(4)(vi)(F) Medicare Managed Care Manual, Chapter 21, Section 50.6 Medicare Advantage and Part D Fraud Handbook: Practical Techniques and Approaches on Detecting and Preventing Fraud (Version 1.0, March 2014) Medicare Advantage and Part D Program Integrity Basics (Version 1.0, August 2015) REVIEW AND REVISION HISTORY DATE REVISION REASON FOR CHANGE NO. 4/2016 4 Added additional information regarding auditing and monitoring 12/2015 3 Annual Policy Revision 3/2015 2 Annual Policy revision