Fraud Waste and Abuse Compliance

Key to Integrity: Eye Care for the Adirondacks (ECFTA) Principles of Business Ethics:  Compliance and Fraud Prevention Guide affirms ECFTA commitment to integrity and doing business with health care professionals, entities and vendors who are equally committed to upholding ECFTA values. As part of the health care delivery system, it is important that we conduct ourselves in an ethical, legal and above-board manner. Integral to such conduct is a commitment to compliance and to detecting, preventing and correcting fraud, waste and abuse in the administration of vision plan benefits and services. Our understanding of these commitments and our willingness to raise ethical concerns are essential to the well being of our customers, members and to the success of our business relationships.

Honesty: Act fairly and honestly with those who are affected by our actions and treat them, as we would expect them to treat us in the situation were reversed.

Compliance: Comply not only with the letter of all federal and state rules, laws and regulations, but also with the spirit of the law or regulation. Act in such a manner that the full discloser of all facts related to any activity would reflect favorably upon the company or you.

Business Responsibility and You: Adhere to the highest ethical standards of conduct in all business activities and act in a manner that enhances ECFTA and your standing as a corporate citizen and ethical competitors within the business community. Pursue no business opportunity that requires violation of these principles.

Responsibility for Reporting Violations: You are responsible for reporting suspected ethical violations. ECFTA promotes relationships based on mutual trust and respect and provides an environment in which health care professionals, entities and vendors may question a company practice without fear of adverse Consequences.

Ethical violations include, but are not limited to, the following: violations of laws or policies, dishonest or unethical behavior, conflicts of interest, fraud, questionable accounting and internal controls or any suspicious activity.

Fraud, Waste and Abuse Detection and Correction: ECFTA’s Principles of Business Ethics: Compliance and Fraud Prevention Guide is designed to provide practical guidance and a reference point for developing your own policy and procedures for compliance and fraud prevention. You are responsible for recognizing behavior that may be considered fraud, waste or abuse. When such behavior is detected, it should not only be reported, but measures will be put in place to confirm that such behavior does not occur in the future.

Compliance with Federal and State Laws

ECFTA is committed to complying with applicable state and federal rules, laws, regulations, Medicare & Medicaid requirements and other requirements as they pertain to providing services to its members. ECFTA requires such compliance not only for the company and its employees, but also for all contracted providers, suppliers and vendors providing services to its members. While there are a multitude of laws and regulations governing the activities of ECFTA, there are several key laws that govern the actions of health care professionals, entities and vendors.

Fraud, Waste and Abuse

ECFTA has zero tolerance for any activity that constitutes fraud, waste or abuse. The detection, correction and prevention of fraud, waste and abuse is essential to maintaining a health care system that is affordable for everyone. Both state and federal law enforcement agencies are increasingly focused on investigating health care fraud, waste and abuse. In 2006, Centers for Medicare and Medicaid (CMS) issued the Medicare Fraud, Waste and Abuse Guidance that may be found at:

http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/PDBManual_Chapter9_FWA.pdf

The following are definitions of fraud, waste and abuse:

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under applicable federal or state law. Some examples of fraud include, but are

Not limited to:

– Double billing
– Unbundling of services
– Up-coding; Billing for more expensive services or procedures than were actually provided or performed
– Forging a member’s prescription to be used for another beneficiary.
– Prescription forging or altering
– Submitting a bill for services never rendered to an insured beneficiary
– Falsifying the date of service to correspond with the member’s coverage period
– Submission of false claims
– Performing unnecessary procedures
– Enrollee fraud; identity theft and member card sharing

An example of double billing is a provider who deliberately charges both the patient and the member’s insurance company for the full cost of the same examination and keeps the extra money.

Waste means to use up health care benefits or spend health care dollars without real need.

Abuse means practices that are inconsistent with sound fiscal or business practices and result in unnecessary cost to health care system, or in reimbursement for services that are not medically necessary or that fail to meet standards for health care. It also includes beneficiary practices that result in unnecessary cost to health care system.

Potential fraud, waste and abuse are risks associated with the business of providing health care insurance. Contracted health care professionals, entities and vendors are responsible for developing their own comprehensive plan for detecting, correcting, and preventing fraud, waste and abuse.

Federal False Claims Act

False claims are the leading type of Medicaid and Medicare fraud and abuse. This act was enacted to give leverage to the federal government against persons/entities involved in fraudulent activities while dealing with the government and to impose civil penalties. Under the False Claims Act, those who knowingly submit, or cause another person to submit false claims for payment by the government are liable for three times the government’s damages plus civil penalties per false claim. Health care fraud was established as a federal criminal offense, with the basic crime carrying a federal prison term in addition to significant financial penalties (USC, Title 18, Section 1347).

The False Claims Act prohibits any person or entity from:

– Knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval.
– Knowingly making, using or causing to be made or used, a false record or statement to get a false or fraudulent claim paid or approved.
– Conspiring to defraud by getting a false or fraudulent claim allowed or paid.
– Knowingly making, using, or causing to be made or used, a false record or statement to conceal, avoid or decrease an obligation to pay or transmit money.

A violation of the False Claim Act occurs if the person or entity:

– Has actual knowledge of the fraudulent activity and does not report the occurrence.
– Acts in deliberate ignorance of the truth or falsity of the information.
– Acts in reckless disregard of the truth or falsity of the information; no proof of specific intent to defraud is required.

Federal law does not consider an innocent mistake as a legitimate defense for submitting a false claim, and the violation could result in a multitude of penalties.

Anti-Kickback Laws

The federal anti-kickback laws that apply to Medicare and Medicaid prohibit health care professionals, entities and vendors from knowingly offering, paying, soliciting or receiving remuneration of any kind to induce the referral of business under a federal program. In addition, most states have laws that prohibit kickbacks and rebates. Remuneration under the federal anti-kickback statute includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind.

Violators are subject to criminal sanctions such as imprisonment, as well as high fines, exclusion from Medicare and Medicaid, very costly civil penalties and possible prosecution under many similar state laws.

The anti-kickback law is extremely broad and covers a wider range of activities than just traditional kickbacks. Federal regulations include safe harbors that protect certain technically prohibited activities from prosecution. If you are unsure whether an activity violates the anti-kickback law; you should seek the advice of a legal professional.

Antitrust Laws

State and federal antitrust laws prohibit monopolistic conduct and agreements that restrain trade. ECFTA is committed to competition and consumer choice in the marketplace. All health care professionals, entities and vendors must adhere to antitrust laws and must avoid any agreements or understandings with competitors on price, customers, markets or other terms of dealing and avoid trade practices that unfairly or unreasonably restrain competition in dealings with providers or customers. Examples of illegal practices are price-fixing conspiracies, corporate mergers likely to reduce the competitive vigor of particular markets and predatory acts designed to achieve or maintain monopolistic power.

HIPAA – PHI

Safeguarding Confidential and Proprietary Information

Personal information is the foundation of the health care industry. In 1996, the Health Insurance Portability and Accountability Act (HIPAA) focused on the balance between the individual’s right to privacy of protected health Information (PHI) versus the business need to access the information.

Those that play key roles in health care delivery have access to significant amounts of detailed information about individuals. Much of this information is required for reasons such as diagnosis and treatment of individuals and payment for services received. This information must be safeguarded to prevent inappropriate disclosure and unwarranted invasion of the rights to privacy of members.

Organizations are required to have policies and procedures regarding the federal and state privacy and security laws and regulations. To meet the basic requirements contained within these laws and regulations, your organization should have the following in place:

Privacy and security policies that define what types of information are to be safeguarded, such as confidential information, protected health information, financial information or nonpublic personal information.

Administrative, physical and technical safeguards that assist with the protection of information defined within the privacy and security policies. Organization size and available technology should be considered when determining the appropriate safeguards to implement.

Development of privacy, security and ethics training programs for new employees with the commitment of your organization to safeguard and respect the privacy of information.

Written agreements with contractors, including subcontractors and independent contractors, who have access to this information as part of performing a function on your behalf.

A process for employees to identify and report any violation or potential violation of privacy and/or security.

Conflicts of Interest

Business decisions and actions must be based wholly on the best interests of ECFTA members and must not be motivated by personal considerations or relationships. A good general rule is to avoid any action or association that would be embarrassing to you or ECFTA if it were disclosed to the public or be perceived as a potential conflict of interest.

Gifts to Health Care Professionals, Entities and Vendors

Many gifts given to health care professionals, entities or vendors by companies serve an important and socially beneficial function. For example, companies have long provided funds for educational seminars and conferences. However, there has been growing concern about certain gifts from industry to health care professionals, entities or vendors. Some gifts that reflect customary practices of the industry may not be consistent with the American Medical Association’s (AMA) principles of medical ethics. To avoid the acceptance of inappropriate gifts, health care professionals, suppliers and vendors should observe the AMA medical ethics guidelines listed on their web site at http://www.ama-assn.org/.

Individuals Ineligible for Employment

As a vision care provider, ECFTA is subject to strict government regulation and oversight. The government requires that ECFTA refrain from hiring or contracting with individuals who have engaged in certain types of activities. Individuals will be ineligible for hire or continued employment or any contractual relationship if they have been or are:

– Convicted of a criminal offense related to health care.
– Listed as debarred, excluded or otherwise ineligible for participation in federal health care programs.
– Identified and listed on the Executive Order 13224 – Blocking Property and Prohibiting Transactions with persons Who Commit, Threaten to Commit or Support Terrorism
– Listed on the Department of Health and Human Services Office of Inspector General (OIG) and General Services Administration (GSA) exclusion lists.

ECFTA reserves the right to obtain certifications from all health care professionals, entities and vendors to verify that their employees are not on such lists.

In addition, ECFTA is subject to the Violent Crime Control and Law Enforcement Act, which make it a felony for ECFTA to hire or contract with an individual who has ever been convicted of any felony involving dishonesty or a breach of trust. These individuals will be ineligible for hire or continued employment at ECFTA or for any contractual relationship.

ECFTA Fraud, Waste and Abuse Policies and Procedures

It is the policy of ECFTA Vision Care to empower all employees, contracted providers, suppliers and vendors to monitor, detect and prevent internal and/or external attempts of individuals who intentionally provide false or fraudulent claim pretenses in order to obtain money or property.

ECFTA Vision Care’s Principles of Business Ethics is responsible for preventing the loss of corporate assets through internal or external fraudulent or wasteful payments, to comply with state and federal fraud, waste and abuse prevention regulations and clients’ requirements, and to promote anti-fraud awareness through training.

Getting Answers to Compliance and Business Ethics Questions

Our fundamental objective is to promote appropriate and efficient use of vision care services. We provide the following resources to increase understanding of our code of ethics and compliance and fraud prevention programs. Anonymity is respected and available at your request.

If you have questions or become aware of any code of ethics violations, contact ECFTA Vision care at:

Phone: 518-566-2020

Email: kimc@eyecareadk.com

Mail: Eye Care for the Adirondacks
Kim Coplen- Compliance Officer
450 Margaret Street
Plattsburgh, New York 12901

You are encouraged to call this number for clarification regarding a company policy, or a federal, state or local law or regulation. You may also call the ECFTA customer care center to report suspected fraud, waste or abuse. If you choose to remain anonymous, ECFTA encourages you to provide enough information regarding the potential violation to allow the company to review the situation and respond appropriately.

ECFTA is responsible for detection, correction and prevention of health insurance fraud, waste and abuse. In an effort to facilitate proper business practices and preserve reasonable premium rates, ECFTA staff investigates and works with appropriate law enforcement, as well as state and federal agencies, when dealing with insurance fraud, waste and abuse by providers, insured, agents, employer groups, company employees, first-tier entities, downstream entities, related entities and other individuals.

Reporting and Investigation of Violations

Reporting of Violations

If you become aware of a possible violation of any federal or state rule, law, regulation or policy, or of any violation of ECFTA’s Principles of Business Ethics: Compliance and Fraud Prevention Guide, immediately report it by calling the ECFTA.

No Retaliation

ECFTA strictly prohibits retaliation against any health care professional, entity or vendor who, in good faith, reports an actual or possible violation of any federal or state law or regulation, any policy or ethical standard. The customer care center may be accessed anonymously. If you wish to remain anonymous, please provide enough information to enable ECFTA to investigate the issue. Anyone who in good faith reports a violation is referred to as a ‘whistleblower’ and is protected from any retaliation by the company. A number of laws contain whistleblower protection, including the false claims act.

Investigation of Violations

ECFTA promptly investigates any reported potential violations of its principles of business ethics: compliance and fraud prevention guide, federal or state rules, laws, regulations and other policies and procedures. All reported issues are treated as confidentially as possible. You are expected to cooperate fully in any investigation of an alleged violation. If you wish to remain anonymous, please provide enough information to enable ECFTA to investigate the issue.

Reporting mechanisms and our internal processes are designed to raise standards across the industry and contribute to the goals of good governance.

Corrective Action for Violations

Health care professionals, entities and vendors should do what is permissible, acceptable and expected. That means using common sense, good judgment and proper behavior. Violation of any federal or state law or regulation, or of ECFTA’s principles of business ethics: compliance and fraud prevention guide and other policies and procedures could compromise ECFTA’s integrity and reputation, and will result in penalties and/or corrective action, up to and including termination of a provider’s contract, and based on the violation, it will be reported to the appropriate authorities.

In an effort to facilitate proper business practices and preserve reasonable premium rates, the ECFTA quality assurance staff investigates and works with appropriate law enforcement, as well as state and federal agencies, when dealing with insurance fraud, waste and abuse by providers, insured, agents, employer groups, company employees, first-tier entities, downstream entities, related entities and other individuals.

Thank you for your continued support of ECFTA’s principles of business ethics: compliance and fraud prevention guide.

Remember…You Are the Key to Integrity!

DISCLAIMER: This guide is intended for educational purposes. The descriptions included in the guide of federal laws and regulations are general only and should not be relied upon in asserting or defending a claim or in determining whether a particular activity is consistent with the law. If such legal advice or other expert assistance is required, the services of a professional should be sought.