2012 Compliance: Fraud, Waste and Abuse (training - Ubhonline.com

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Overview • The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage Organizations (MAO) and Part D Plan Sponsors to have effective compliance programs which include: – Communicating general compliance information and distributing Standards of Conduct. – Establishing effective lines of communication. – Conducting effective fraud, waste, and abuse training. – Reviewing for exclusion and debarment from Federal health care programs. • These requirements apply to both the MAO/Plan Sponsor – and first tier, downstream, and related entity – employees (including temporary workers and volunteers), the CEO, senior administrators or managers, governing body members and downstream entities or subcontractors. United Behavioral Health (UBH) operating under the brand Optum U.S. Behavioral Health Plan of California (USBHPC) doing business as OptumHealth Behavioral Solutions of California Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2
Overview, cont. • In regulations effective June 7, 2010, CMS implemented a “deeming” exception which exempts first tier, downstream, and related entities who are enrolled in Medicare Parts A or B from the annual fraud, waste, and abuse training and education requirements. – To qualify for this deemed status, you and/or your organization must have met the certification requirements through enrollment into Parts A or B of the Medicare program or accreditation as a supplier of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). – If you or your organization qualifies for this deemed status, please retain records or evidence of your certification in your files. You may be asked to provide documentation for audit purposes. – If you or your organization have already completed a fraud, waste, and abuse training program – whether through your own program or training with another health plan sponsor – AND that training meets CMS requirements, Optum will accept documentation of that training in lieu of the administration of this training material. – Optum (UBH and/or USBHPC) will also accept documentation confirming completion of the CMS Medicare Learning Network (MLN) fraud, waste, and abuse training and education module. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3
Page 1: 2012 Compliance Fraud, Waste and Ab
Page 5 and 6: Overview, cont. • If you or your
Page 7 and 8: Compliance Expectations
Page 9 and 10: CMS Role and Definition • The Cen
Page 11 and 12: Seven Elements of an Effective Comp
Page 13 and 14: Effective Lines of Communication
Page 15 and 16: Exclusion and Debarment Review Requ
Page 17 and 18: CMS MLN FWA Training Materials
Page 19 and 20: Optum FWA Training Materials
Page 21 and 22: Fraud, Waste, and Abuse Policies
Page 23 and 24: Pertinent Laws and Regulations •
Page 31 and 32: Examples of Fraud, Waste, and Abuse
Page 33 and 34: Examples of Fraud, Waste, and Abuse
Page 35 and 36: Additional Resources • CMS’ Pre
Page 37 and 38: ANSWERS - Quiz and Self Assessment
Page 39: Documentation Requirements Attentio

2012 Compliance: Fraud, Waste and Abuse (training - Ubhonline.com

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