CMS Fraud, Waste and Abuse Training

CMS Fraud, Waste and Abuse Training 2019

Table of Contents:

• CMS Fraud, Waste, and Abuse
• Legal Notice
• Purpose and Learning Objectives
• Target Audience
• The Social Security Act and Centers for Medicare & Medicaid Services (CMS) Regulations and Guidance
• CMS and the Social Security Act: Regulations and Guidance
• AFA Mandatory Compliance Program
• An Effective Compliance Program
• Components of an Effective Compliance Program
• Fraud, Waste, and Abuse: What are they?
• Fraud, Waste, and Abuse
• Examples of Fraud, Waste, and Abuse
• Federal Health Care Fraud and Abuse Laws
• False Claim Act (FCA)
• Anti-Kickback Statute (AKS)
• Stark Law
• Exclusion Statue
• Summary
• End of Course Quiz

Course Content Example 1:

Components of an Effective Compliance Program

1. Commitment by the organization’s senor leadership for an effective compliance and ethics program.
2. Policies and Procedures. Written standards and procedures to reduce criminal, civil, and administrative violations.
3. Should be tailored to fit specific risk assessment conducted by your organization to identify risk areas faced in the healthcare arena.
4. Chief Compliance Officer. A high-ranking individual in the organization should be designated responsible for the compliance program.
5. The officer should possess resources and authority to implement the program and should report to the senior leadership of the company.

Course Content Example 2:

 Examples of Fraud, Waste, and Abuse

   Questions to ask:

• Does the manufacturer promote off label drug usage?
• Does the manufacturer provide samples, knowing that the samples will be billed to a federal health care program?
• Does the prescription look altered or possibly forged?
• Is the prescription appropriate based on beneficiary’s other prescriptions?
• Does the beneficiary’s medical history support the services being requested?
• Is the provider writing for a higher quantity than medically necessary for the condition?
• Is the provider performing unnecessary services for members?

Course Content Example 3:

 Stark Law

Stark Law prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies

Financial relationships include:

• Ownership/investment interests
• Compensation arrangements