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AHIP WFA

TermDefinition
Recognize FWA in the Medicare Program Fraud, Waste, Abuse (FWA) F - bills for services that did not happen* W - overusing services A - unnecessary costs *requires intent
Identify the major laws and regulations pertaining to FWA Civil False Claims Act, Health Care Fraud Statute, Criminal Fraud, Anti-Kickback Statute, Start Statute, Exclusions, HIPAA
Recognize potential consequences and penalties associated with violations Penalties include civil monetary penalties, civil prosecution, criminal conviction (fines or both), imprisonment, loss of prof license
Identify methods of preventing FWA look for suspicious activity, be ethical, ensure accurate data/billing, ensure coordination with other payers, know FWA policies and procedures, verify all received information
Identify how to report FWA Internal - compliance department/special investigations unit/internal hotline External - check job aid for correspondence requirements and contact OIG, DOJ, CMS
Recognize how to correct FWA 1) Design correction 2) Tailor correction, 3) Document actions 4) Monitor actions
Recognize how a compliance program operates (Written policies/procedures, compliance team responsibilities, initial/continuing training/education, communication, transparency, systemic, rapid responses) show orgs commitment to legal/ethical conduct, provide guidance on how to handle/report compliance issues goal: prevent/detect/correct non-compliance and promote org standards of conduct
Recognize how compliance program violations (misrepresentations, conflicts, ethics, FDR, HIPAA) should be reported consequences: contract termination, criminal penalties, exclusion from participating in all fed healthcare programs, fines, re-training, disciplinary actions, termination)
Non-Compliance hurts the bene and the agent... bene...delayed services, denial of benefits agent...high copayments/premiums, lower star rating, lower $
Who to call and when for reporting non-compliance employees of sponsor: call medicare compliance officer, file report through company website, call compliance hotline (if any( front-line: talk to next in chain of command, call ethics/compliance helpline, report sponsor
Created by: cmazzariti