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Travis Sutphin Manager, Regulatory


COMPLIANCE TRAINING ... regard to position * Auditing & Monitoring Risk Assessment and Work Plan External Audits by government ... or control of, any healthcare ... – PowerPoint PPT presentation

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Title: Travis Sutphin Manager, Regulatory

Travis SutphinManager, Regulatory

Welcome to Compliance Training
  • This training includes
  • 7 Elements of an Effective Compliance Program
  • Reporting compliance violations
  • Non-Retaliation Policy
  • Non-compliance or fraud violation
  • Who to contact
  • Fraud and Abuse Prevention
  • HIPAA Compliance Training
  • Principles of Professional Conduct

Health Insurance Portability and Accountability
  • Health Insurance Portability and Accountability
    Act (HIPAA )
  • Privacy Protection for the privacy of Protected
    Health Information (PHI) effective April 14, 2003
    (including Standardization of electronic data
    interchange in health care transactions,
    effective October 2003)
  • Security Protection for the security of
    electronic Protected Health Information (e-PHI)
    effective April 20, 2005
  • Health Information Technology for Economic and
    Clinical Health Act (HITECH)
  • Extends Privacy and Security provisions of HIPAA
    to business associates of covered entities,
    including criminal and civil penalties
  • Breach notification requirements for unsecured

What is the difference between Privacy Security
  • The Privacy Rule sets the standards for how
    covered entities and business associates are to
    maintain the privacy of Protected Health
    Information (PHI)
  • The Security Rule defines the standards which
    require covered entities to implement basic
    safeguards to protect electronic Protected Health
    Information (e-PHI)

What is HIPAA?
  • Protects the privacy and security of a patients
    health information
  • Provides for electronic and physical security of
    a patients health information
  • Prevents health care fraud and abuse
  • Simplifies billing and other transactions,
    reducing health care administrative costs

Who must follow HIPAA
  • The covered entity consists of CarePoint Health
    Plan and its employees, to the extent that such
    employees use and disclose individually
    identifiable health information
  • Other covered entities include providers, billing
    clearing houses, FDRs and contractors
  • Business Associates
  • A person or entity which performs certain
    functions, activities, or services for CarePoint
    Health Plan involving the use and/or disclosure
    of PHI, but the person or entity is not a part of
    CarePoint Health Plan or its workforce.
  • CarePoint Health Plan is required to have
    agreements/contracts with business associates
    that protect a members PHI

Covered Transactions Consist of
  • Enrollment and disenrollment
  • Premium payments
  • Eligibility
  • Referral certification and authorization
  • Health claims
  • Health care payment and remittance advice

What patient information must we Protect?
  • Protected Health Information (PHI)
  • Relates to past, present, or future physical or
    mental condition of an individual provisions of
    healthcare to an individual or for payment of
    care provided to an individual.
  • Is transmitted or maintained in any form
    (electronic, paper, or oral representation)
  • Identifies, or can be used to identify the

Examples of PHI(Health Information with
  • Name
  • Address (including street, city, parish, zip code
    and equivalent geo codes)
  • Any date (birth, admit date, discharge date, date
    of death)
  • Telephone and Fax numbers
  • Electronic (email) addresses
  • Social Security Number
  • Medical Records
  • Any other unique identifying number,
    characteristic or code

What is the most important thing to remember
about HIPAA
YOU may not use or disclose an individuals
protected health information, except as otherwise
permitted, or required, by law. If you have
questions, please see your Supervisor or the
Compliance Department.
Acceptable uses of PHI
  • Treatment
  • Includes direct patient care, care coordination,
  • Payment
  • Includes any activities required to bill and
    collect for health care services provided to
  • Health Care Operations
  • Includes business management and administrative
    activities, quality improvement, compliance,
    competency, and training

Acceptable Uses of PHI
  • Must use or share only the minimum amount of PHI
    necessary, except for requests made
  • for treatment of the patient
  • by the patient, or as requested by the patient to
  • by the Secretary of the Department of Health
    Human Services (DHHS)
  • as required by law
  • to complete standardized electronic transactions,
    as required by HIPAA
  • Healthcare operations
  • CarePoint Health Plan must get a signed
    authorization from the member for any other use
    or disclosure of PHI. The authorization must
  • Identify who may use or release the PHI and
    identify who may receive the PHI
  • Identify when the authorization expires
  • Be signed by the member or someone making health
    care decisions (personal representative) for the

Acceptable Uses of PHICopying, Downloading and
Faxing Information
  • Employees should not download or copy any PHI,
    except as necessary to perform their jobs. As a
    general rule PHI should not be removed from the
  • Faxing is permitted. Always include, with the
    faxed information, a cover sheet containing a
    Confidentiality Statement
  • The documents accompanying the transmission
    contain confidential privileged information. The
    information is the property of CarePoint Health
    Plan, Inc. and intended only for use by the
    individual or entity named above. The recipient
    of this information is prohibited from disclosing
    the contents of the information to another party.
  • If you are neither the intended recipient, or the
    employee or agent responsible for delivery to the
    intended recipient, you are hereby notified that
    disclosure of contents in any manner is strictly
    prohibited. Please notify name of sender at
    facility name by calling phone immediately
    if you received this information in error.

Member Rights
  • The right to request restriction of PHI uses
  • The right to request alternative forms of
    communications (mail to P.O. Box, not street
    address no message on answering machine, etc.)
  • The right to access and copy patients PHI
  • The right to an accounting of the disclosures of
  • The right to request amendments to information

How does HIPAA Affect Your Job
  • Only use, view and discuss PHI if you need it to
    do your job
  • Only share PHI with those who need it to do their
  • Refrain from discussing PHI in public areas, such
    as elevators and reception areas
  • Dont be careless or negligent with PHI in any
  • You must report to the Manager, Regulatory
    Compliance any breach in confidentiality

HIPAA Best Practices
  • Secure PHI in locked offices and cabinets
  • Dispose of PHI by shredding
  • Remove PHI immediately from any commonly used
    copiers, printers and fax machines
  • Lock your computer any time you leave your work

  • HITECH is a part of the American Recovery and
    Reinvestment Act of 2009
  • Amends certain sections of HIPAA creating new
    requirements for covered entities and their
    business associates regarding health records,
    Breach notifications, increased enforcement and
  • The law requires covered entities and business
    associates to notify individuals, the Secretary
    of Health and Human Services and, in some cases,
    the media in the event of a breach of unsecured
    protected health information
  • Unsecured
  • Information must be encrypted or destroyed in
    order to be considered secured
  • Information that has not been rendered unusable,
    unreadable, or indecipherable to unauthorized

HITECH and Breach Situations
  • A Breach is an unauthorized acquisition, access,
    use or disclosure of PHI that compromises the
    security of the PHI
  • Examples include
  • Laptop containing PHI is stolen
  • Receptionist who is not authorized to access PHI
    looks through member records
  • Billing statements containing PHI mailed or faxed
    to the wrong individual/entity

Exceptions to Breach
  • Unintentional acquisition, access, use or
    disclosure by a workforce member (employees,
    volunteers, trainees, and other persons whose
    conduct, in the performance of work for a covered
    entity, is under the direct control of such
    entity, whether or not they are paid by the
    covered entity) acting under the authority of a
    covered entity or business associate
  • Example billing employee receives and opens an
    e-mail containing PHI about a member which a UM
    nurse mistakenly sent to the billing employee.
    The billing employee notices he is not the
    intended recipient, alerts the UM nurse of the
    e-mail and then deletes it. The billing employee
    unintentionally accessed PHI to which he was not
    authorized to have access. However, the billing
    employees use of the information was done in
    good faith and within the scope of authority, and
    therefore, would not constitute a breach and
    notification would not be required, provided the
    employee did not further use or disclose the

Exceptions to Breach (continued)
  • Inadvertent disclosures of PHI from a person
    authorized to access PHI at a covered entity or
    business associate to another person authorized
    to access PHI at the same covered entity,
    business associate, or organized healthcare
    arrangement in which covered entity participates
  • If a covered entity or business associate has a
    good faith belief that the unauthorized
    individual, to whom the impermissible disclosure
    was made, would not have been able to retain the
  • Example EOBs are sent to the wrong individuals.
    A few of them are returned by the post office,
    unopened as undeliverable. It could be concluded
    that the improper addresses could not have
    reasonably retained the information. The EOBs
    that were not returned as undeliverable, however,
    and that the covered entity knows were sent to
    the wrong individuals, should be treated as
    potential breaches.

Reporting Breaches
  • All employees who suspect a Breach has occurred
    must report it immediately to the Compliance
    (Privacy) Officer and Manager, Regulatory
  • Breaches must be reported to
  • The affected individuals (without unreasonable
    delay and in no event later than 60 days from the
    date of discoverya breach is considered
    discovered when the incident becomes known to the
    Covered Entity or Business Associate not when the
    covered entity or Business Associate concludes
    the analysis of whether the facts constitute a
  • Secretary of Health Human Services-HHS- (timing
    will depend on number of individuals affected by
    the breach)
  • Media (only required if 500 or more individuals
    of any one state are affected)

Conflicts of Interest, Gifts and
Conflicts of Interest (COI)
  • It is the policy of CarePoint Health Plan to
    prohibit employees and other associates from
    engaging in any activity that conflicts or
    appears to conflict with the interests of
    CarePoint Health Plan. Examples
  • Individual has the opportunity to use his or her
    position for personal financial gain or to
    benefit a company in which the individual has a
    financial interest.
  • Outside financial or other interests may
    inappropriately influence the way in which an
    individual carries out his or her
  • When an individuals outside interests otherwise
    may cause harm to CarePoint Healths reputation,
    staff, or patients.
  • Employees are required to disclose any conflict
    or potential conflict the employee or family
    member may have.

Conflicts of Commitment
  • Exists when an outside relationship that may
    deter an individual from devoting an appropriate
    amount of time, energy, creativity, or other
    personal resources to his or her CarePoint Health
    Plan responsibilities.
  • Examples
  • Selling Mary Kay cosmetics during working hours
  • Assuming multiple part-time positions not
    allowing to meet required commitment timeframe
  • Assuming directorship position requiring
    significant time involvement and having
    conflicting schedule in private practice

Gifts and Entertainment
  • You are prohibited from accepting any
    compensation (gifts, favors, money) from
    patients, patients family members or vendors
    except items such as candy, fruit, flowers, etc.
    absolutely no cash! (refer to CarePoint Health
    Plan Code of Conduct)

Outside Employment
  • Outside employment must be reported on the
    Conflict of Interest questionnaire and you must
    notify HR and your supervisor
  • You may not use CarePoint Health time or
    materials in connection with your outside job.

Medicare, Medicaid and other RegulationsComplian
ce Requirements
Centers for Medicare and Medicaid Services (CMS)
  • Federal regulatory agency that provides oversight
    of Medicare, Medicaid and Childrens Health
    Insurance Program

State Agencies Division of Medical Assistance
and Health Services and Medicaid Fraud Division
  • The Medicaid Fraud Division of the Office of the
    State Comptroller works to the efficiency and
    integrity of State Medicaid, FamilyCare, and
    Charity Care. They investigate, detect and
    prevent Medicaid fraud and abuse.
  • The Division of Medical Assistance and Health
    Services (DMAHS) administers Medicaid and NJ
    FamilyCare programs.

Compliance Requirements
  • Training upon hire, and annually thereafter and
    in response to any issues that may arise where
    education is beneficial
  • Compliance incorporates measures to detect,
    prevent and correct fraud, waste and abuse
  • Compliance is communicated, using training and
    educational materials, and through the ethical
    behavior of all staff
  • CarePoint Health Plan FDRs (subcontractors) must
    also ensure processes are in place to comply with
    regulations, develop applicable policies and
    procedures, and have compliance programs that
    address the 7 elements of an effective compliance
    program in accordance with CMS Guidelines

Compliance is Your Responsibility
  • All employees and contractors are held
    accountable for compliance
  • Compliance is a part of our day-to-day
  • Managers must ensure that employees are fully
    trained in all standards, policies and procedures
  • Employees should request additional training to
    ensure they are performing/behaving in compliant
  • It is your responsibility to know when and where
    to report any concerns or issues you may

7 Key Elements of an effective Compliance Program
  • Written Compliance Policies Procedures
    Standards of Conduct
  • Chief Compliance Officer with direct access to
    the CEO and Board
  • Education And Training for all staff
  • Effective Lines of Communication
  • Consistent enforcement of well publicized
    disciplinary standards
  • Effective system for Routine Monitoring, Auditing
    Identification of Compliance Risks
  • Quick and appropriate response to any
    deficiencies identified by employees or during
  • In addition, there is a Code of Business Conduct
    and Ethics

Compliance Officer Compliance Committee
  • Compliance Officer you can reach the compliance
    officer at
    or by calling 201-821-8705
  • Manager of Regulatory Compliance at or by calling
  • Compliance Committee made up of senior level
    staff and responsible for helping to identify
    compliance issues and supporting compliance

Written Policies and Procedures
  • CarePoint Health Plan has a Code of Business
    Conduct and Ethics
  • CarePoint Health Plan is committed to integrity,
    ethical conduct and legal/regulatory compliance
    and has implemented policies to support this
  • All entities contracted to perform work related
    to Medicare and Medicaid Services programs must
    review CarePoint Health Plans Code of Business
    Conduct and Ethics booklet as well as policies
    and procedures unless they can demonstrate that
    they have policies and procedures to address
    Ethical Conduct , as well as Fraud, Waste and

Disciplinary Actions
  • Compliance violations are subject to disciplinary
  • Non-compliance with the Compliance Program
    Standards will be subject to disciplinary action.
  • The Compliance Officer recommends discipline
    based on the nature, frequency and severity of
    the non-compliant act
  • Working with the Director of Human Resources and
    the supervisor (and the CEO, if necessary), the
    Manager, Regulatory Compliance will determine
    the best course of disciplinary action including
  • Verbal warning
  • Written warning
  • Suspension
  • Termination
  • Restitution.

Disciplinary Actions
  • CarePoint Health Plan believes coaching and
    counseling are the best tools for correcting
    non-compliant performance
  • Our goal is to have a culture of compliance where
    each employee performs well and succeeds in their
  • Managers should document all coaching/counseling
    sessions related to non-compliance
  • If coaching is unsuccessful, repeated incidents
    of non-compliance will result in further
    corrective actions
  • Serious non-compliant offenses may result in more
    advanced steps of corrective action up to and
    including immediate termination
  • Disciplinary standards are applied fairly without
    regard to position

Auditing Monitoring
  • Risk Assessment and Work Plan
  • External Audits by government contractors or
    initiated by CarePoint Health Plan in response to
    issues or suspected non-compliance
  • Internal Audits based on the annual work plan or
    in response to suspected non-compliance
  • All employees and contractors are expected to
    fully cooperate with all auditing and monitoring

Responding to Compliance Issues
  • The Manager, Regulatory Compliance, or
    designee, thoroughly investigates each report of
    an alleged violation
  • Confirmed cases of violations will be handled as
  • Corrective actions will be implemented ASAP
  • Self-reporting to government agencies,
    involvement of legal counsel when overpayment is
    identified (see policy). Self reporting helps
    with mitigating FWA, saving money for the State
    and Federal Governments. NJ Law provides for a
    fair and reasonable process.
  • To prevent future violations, there will be
    immediate training and potentially a review of
    policies and procedures to determine any needed
  • Follow-up auditing and monitoring

Non-Intimidation, Non-Retaliation
  • CarePoint Health Plan will not discriminate or
    retaliate against anyone who, in good faith,
    reports violations of laws or regulations, the
    Principles of Professional Conduct, or CarePoint
    Health Plan policies, whether those violations
    are by an employee or contractor
  • In addition, employees are protected by federal
    law against any retaliation for taking action
    under the federal False Claims Act
  • Retaliation should be reported to the Director of
    HR or the Manager, Regulatory Compliance
  • Please remember to report non-compliance in
    good-faith. False reports may lead to
    disciplinary action
  • You can report directly to the Manager,
    Regulatory Compliance by emailing or by calling
  • You can report confidentially by calling the
    hotline number at 888-671-6191

Fraud, Waste and Abuse (FWA)
  • HealthCare Fraud is defined in Title 18, United
    States Code (U.S.C.) 1347(a)(1) and (2) as
  • Knowingly and willfully executing, or attempting
    to execute, a scheme or Artifice to defraud any
    healthcare benefit program or to obtain (by means
    of false or fraudulent pretenses,
    representations, or promises) any of the money or
    property owned by, or under the custody or
    control of, any healthcare benefit program.
  • Abuse is defined as excessive or improper use of
    services or actions that are inconsistent with
    acceptable business or medical practice. It
    refers to incidents that, although not
    fraudulent, may directly or indirectly cause
    financial loss such as charging in excess for
    services or supplies, providing medically
    unnecessary services and billing for items or
    services that are not covered.
  • Waste is the overutilization of services, or
    other practices that, directly or indirectly,
    result in unnecessary costs to the Medicare and
    Medicaid program. Waste is generally not
    considered to be caused by criminally negligent
    actions but rather the misuse of resources.

Why is this important and what can we do?
  • Scams alone cost the health care industry more
    than 100 billion annually
  • Saves dollars for the health plan
  • Detecting, correcting and preventing fraud,
    waste, and abuse requires collaboration between
  • CarePoint Health Plan Employees
  • Providers of services, such as physicians, nurses
    and pharmacies
  • FDRs
  • State and Federal Agencies
  • Members

Where can we find examples of FWA?
  • A physician, nurse, pharmacist or other
  • A pharmacy, hospital , home health agency or
    other institutional provider
  • A clinical laboratory, DME provider or other
  • An employee of any provider or vendor
  • A billing service
  • A Pharmacy Benefits Manager (PBM)
  • A beneficiary
  • Any individual in a position to file a claim for
    a Medicare or Medicaid benefits

Some Examples
  • Billing for missed appointments or services never
  • Equipment a member never received or continuing
    to bill for equipment which was returned
  • Billing that appears to be a deliberate
    application for duplicate payment, altering claim
    forms, electronic claim records, medical
    documentation to obtain a higher payment amount
  • Incorrect reporting of diagnosis or procedures to
    maximize payments
  • Unbundling or exploding charges,
    misrepresentations of dates and descriptions of
    services furnished or the identity of the
    beneficiary or the individual who furnished the
    services, billing non-covered or non-chargeable
    services as covered items or failing to return an

Examples of Potential Provider Fraud
  • Submitting photocopies instead of original
    documents, submitting several medical bills on
    different dates, with the same or overlapping
    dates of service for the same patient
  • White-out and varying ink color on claims, which
    may indicate altered or fabricated claims,
    threats to go to legal action or government
    agencies if payments arent settled quickly,
    excessively large claims or absence of
    documentation or medical records

Examples of Potential Member Fraud
  • A member who allows someone else to use their
    insurance card (e.g. ineligible member using
    eligible members services)
  • Members who intentionally misrepresent
    information in order to enroll in a plan or to
    have specific benefits covered once enrolled in
    the plan (e.g. misrepresentation of medical
  • Failure to report other health insurance and
    intentionally causing a payor to be primary when
    it should be secondary
  • Pharmacy-related Fraud
  • Prescription forging or altering
  • Theft of DEA number or prescribing pad
  • Submitting false claims

Examples of FWA Related to Agents Brokers
  • Unlawful marketing
  • Offering cash inducements
  • Unsolicited door-to-door sales
  • Use of unlicensed agents
  • Embezzlement
  • Identity theft
  • Requiring premium upfront

Examples of Fraud related to Finance
  • Receiving Medicare or Medicaid premiums for
    members who are not enrolled or should not be
  • Diverting funds
  • Publishing false financial statements
  • Paying claims to a tax ID that does not belong to
    the billing provider
  • Colluding with vendors during the bid process so
    the vendor is guaranteed award of the bid

Examples of Fraud by Utilization Management
  • Directing members to a healthcare provider who is
    a friend or family member
  • Denying services as not medically necessary in
    order to save CarePoint Health Plan money
  • Authorizing services which are medically
    unnecessary services
  • Coaching a member on how to present a medical
    condition to a provider or to the health plan so
    it is covered

Examples of Fraud by Provider Relations
  • Credentialing providers who do not meet CarePoint
    Health Plans credentialing standards
  • Limiting providers in a specialty in order to
    increase referrals to a specific provider
  • Incentivizing a provider to not provide medically
    necessary services

Examples of Fraud by Senior Management
  • Failing to notify the board of compliance risks
    and acts of non-compliance, especially which
    would make the health plan liable for sanctions,
    legal and/or regulatory actions, civil penalties,
    and other liabilities
  • Neglecting to address and appropriately respond
    to confirmed cases of fraud and abuse
  • Neglecting to self-report and/or return
    overpayments to CMS

When Fraud is Detected
  • Improper payments must be paid back
  • Providers/companies maybe barred from
    participation in government-sponsored health
    insurance programs
  • Fines can be levied
  • Law enforcement may be contacted
  • Arrests and convictions may occur
  • Employees will be disciplined, which may include
  • Contractors will be sanctioned, which may include
    requests for corrective action plans and
    termination of the agreement

When Member Fraud is Detected
  • Members
  • Could lose their benefits
  • Their medical records could be wrong
  • May be limited to certain doctors, drug stores,
    and hospitals
  • This is called a lock-in program
  • May have to pay money back
  • With government programs, such as Medicare and
    Medicaid , members may be fined or arrested for

What Federal Laws Regulate Fraud Abuse
  • False Claims Act (FCA)
  • Stark Law
  • Anti-Kickback Statute
  • Deficit Reduction Act
  • Criminal Penalties for Acts involving Federal
    Health Care Programs
  • The False Claims Whistleblower Employee
    Protection Act
  • Administrative Remedies for False Claims and

Required Sanctions Check
  • It is the responsibility of CarePoint Health Plan
    to ensure that NO employee is excluded from
    participating in the Medicare and Medicaid
  • Sanctions checks (OIG, SAM, NJ, NY and PA State
    Debarment) are done upon hire and now monthly to
    ensure employees have not been excluded.
  • Examples include fraud, abuse, defaulting on
    government loans, violations of any practice act,

False Claims Act
  • 31 U.S.C. 3729-3733
  • Also, N.J. False Claims Act, 2A32C-1, et seq.
  • Forbids submitting a claim known to be false
    making or using a false record or statement
    material to a false claim or obligation
    conspiring to defraud by improper submission of
    false claims or concealing, improperly avoiding,
    or decreasing an obligation to pay money to the
  • Potential penalties for violation
  • Violators of the False Claims Act are liable for
    three times the dollar amount that the government
    is defrauded and civil penalties of 5,500 for
    each false claim.
  • Exclusion from participation in federal health

Stark Statute
  • 42 U.S.C. 1395nn
  • Also known as Physician Self-Referral Statute
  • Prohibits a physician from making a referral for
    certain designated health services to an entity
    in which the physician (or a member of his/her
    family) has an financial ownership/investment
    interest or with which he/she has a compensation
    arrangement unless an exception applies

Anti-Kickback Statute
  • 42 U.S.C. 1320a-7b(b)
  • Prohibits offering, soliciting, paying or
    receiving remuneration for referrals for services
    that are paid in whole or in part by the Medicare
    and Medicaid program
  • In addition, the statute prohibits offering,
    soliciting, paying or receiving remuneration in
    return for purchasing, leasing, ordering,
    arranging for, or recommending the purchase,
    lease or order of any goods, facility, item or
    service for which payment may be made in whole or
    part by the Medicare and Medicaid program

Deficit Reduction Act
  • Public Law No. 109-171, 6032, passed in 2005
  • Designed to restrain Federal spending while
    maintaining the commitment to the federal program
  • The Act requires compliance for continued
    participation in the programs
  • The development of policies and education
    relating to false claims, whistleblower
    protections and procedures for detecting and
    preventing fraud abuse must be implemented

False Claims Act (FCA) DRAFT 11.12.13
  • Federal FCA was written to address issues that
    arose out of the Civil War. (a.k.a. Lincolns
  • President Lincoln asked Congress to write a law
    so that the Government could go after companies
    that sold faulty equipment like rifles to the
    United States. The law was written and passed
  • The False Claims Act provides both criminal and
    civil penalties, contains a qui tam provision,
    and permits a the whistleblower to collect a
    portion of the damage

Additional Federal and State Regulations
  • Program Fraud Civil Remedies Act
  • This final rule implements the Program Fraud
    Civil Remedies Act of 1986 (PFCRA), which
    authorizes NSF (Nat Science Foundation) to
    impose, through administrative adjudication,
    civil penalties and assessments against any
    person who makes, submits, or presents, or causes
    to be made, submitted, or presented, a false,
    fictitious, or fraudulent claim or written
    statement to the agency.
  • NJ Health Care Claims Fraud Act
  • This law makes health care claims fraud a
    criminal offense and provides for the forfeiture
    of professional licenses (i.e. medical, dental,
    chiropractic, nursing) in certain instances in
    which a practitioner commits health care claims
    fraud. The law also extends to non-practitioners
    who commit health care claims fraud (i.e.
    hospital billing personnel).

Additional Federal and State Regulations DRAFT
  • NJ Medical Assistance and Health Services Act-
    This law provides for criminal penalties for
    fraud committed in connection with the New Jersey
    Medical Assistance (Medicaid) Program. A criminal
    penalty of up to 10,000 or imprisonment for not
    more than 3 years or both shall apply as follows
  • Any person who willfully obtains medical
    assistance benefits to who he/she is not entitled
    to and on any provider who willfully receives
    medical assistance payments to which it is not
  • Any person or entity who, with an intent to
    fraudulently secure benefits not authorized or in
    greater amount than authorized
  • Knowingly and willfully makes or causes to be
    made any statement or representation of a
    material fact in any cost study, claim form, or
    any document necessary to apply for or receive
    any benefit or payment under the Act
  • Conceals or fails to disclose the occurrence of
    an event which affects an initial or continued
    right to benefit payment
  • Any provider, person or entity who solicits,
    offers, or receives any kickback, rebate, or
    bribe in connection with the furnishing of
    services for which payment is made under the Act
    or whose cost is reported to obtain benefits or
    payments under the Act, or the receipt of any
    benefit or payment under the Act.
  • This statute also allows for civil penalties in
    addition to the criminal penalties for violations
    of the Act.

Additional Federal and State Regulations DRAFT
  • NJ False Claims Act
  • The New Jersey False Claims Act is a statute that
    imposes civil liability equal to that of the
    federal False Claims Act on any person or entity
    who knowingly submits a false claim, uses a false
    record or uses a false statement to an employee,
    officer or agent of the State, or to any
    contractor, grantee or other recipient of State
    funds, for payment or approval

NJ Conscientious Employee Protection Act
  • New Jersey law prohibits an employer from taking
    any retaliatory action against an employee
    because the employee does any of the following
  • Discloses, or threatens to disclose, to a
    supervisor or to a public body an activity,
    policy or practice of the employer or another
    employer, with whom there is a business
    relationship, that the employee reasonably
    believes is in violation of a law
  • Provides information to, or testifies before, any
    public body conducting an investigation, hearing
    or inquiry into any violation of law, or a rule
    or regulation issued under the law by the
    employer or another employer, with whom there is
    a business relationship
  • Provides information involving deception of, or
    misrepresentation to, any shareholder, investor,
    client, patient, customer, employee, former
    employee, retiree or pensioner of the employer or
    any governmental entity
  • Provides information regarding any perceived
    criminal or fraudulent activity, policy or
    practice of deception or misrepresentation which
    the employee reasonably believes may defraud any
    shareholder, investor, client, patient, customer,
    employee, former employee, retiree or pensioner
    of the employer or any governmental entity
  • Objects to, or refuses to participate in, any
    activity, policy or practice which the employee
    reasonably believes
  • is in violation of a law, or a rule or regulation
    issued under the law or, if the employee is a
    licensed or certified health care professional,
    constitutes improper quality of patient care
  • is fraudulent or criminal
  • is incompatible with a clear mandate of public
    policy concerning the public health, safety or
    welfare or protection of the environment.
    N.J.S.A. 3419-3.

NJ Conscientious Employee Protection Act
  • The protection against retaliation, when a
    disclosure is made to a public body, does not
    apply unless the employee has brought the
    activity, policy or practice to the attention of
    a supervisor of the employee by written notice
    and given the employer a reasonable opportunity
    to correct the activity, policy or practice.
    However, disclosure is not required where the
    employee reasonably believes that the activity,
    policy or practice is known to one or more
    supervisors of the employer or where the employee
    fears physical harm as a result of the
    disclosure, provided that the situation is
    emergency in nature.

Fraud Abuse Prevention Strategies
  • Prevention - Engage beneficiaries and providers,
    educate providers on billing mistakes, stop and
    prevent future improper payments and deny or
    revoke an individuals or organizations
    application for participation in the network if
    there is evidence of impropriety such as previous
    convictions or false information on the
    application, or if the provider does not meet
    state/federal licensure or certification
  • Detection - Identify and report potential fraud,
    identify trends that indicate fraud, quickly
    identify new fraud schemes
  • Recovery - Recover improper payments, work to
    suspend payments to providers subject to credible
    fraud allegations
  • Reporting - Everyone has a responsibility to
    report instances of suspected or potential fraud
    and abuse and you can do so without fear of
    retaliation. You can also report confidentially.

Reporting Suspected or Potential Violations
  • Internal options for reporting compliance
  • Manager, Regulatory Compliance or by calling
  • Compliance Hotline (888) 671-6191
  • Compliance Fax (908) 378-7846

Reporting Suspected or Potential Violations
  • External options for reporting compliance
  • New Jersey Office of the Attorney General
  • New Jersey Department of Health, Office of
    Professional Misconduct
  • New Jersey Department of Banking and Insurance,
    Frauds Bureau 1-800-446-7467
  • Call 1-800-MEDICARE or Call 1-800-HHS-TIPS
  • Medicaid Fraud Division 888-937-2835

CarePoint Health Plans FDR Employee Attestation
  • I have reviewed and understand the information
    contained within the attached slides (Compliance
    Training Program) and agree to comply with all
    the stated regulations. As an employee of an
    CarePoint Health Plan FDR, I understand that
    failure to comply with the stated regulations
    could lead to disciplinary action(s).
  • Employee Name_____________________________
  • Employee Signature__________________________
  • Employer Name_____________________________
  • Date______________________________________