Genesis Annual Compliance Training Module

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Module Overview

1. Fraud, Waste & Abuse
2. Genesis Code of Business Conduct & Ethics

Mandatory Compliance Training

Annual and onboarding training on:
- Fraud, Waste & Abuse
- HIPAA & Privacy
- Code of Conduct
- Conflict of Interest
- Record Retention
- Standards of Conduct
- Interactions with Payors & Physicians

I) Fraud, Waste & Abuse Contents and Agenda

Define Fraud, Waste, and Abuse (FWA)
Identify Who Can Commit FWA
Review Applicable FWA Laws and Examples
Review the Whistleblower Protection Act
Record Retention Requirements
Additional FWA Resources
Compliance Attestation Statement

Learning Objectives

By the end of the training, you will be able to:
- Understand the definition of Fraud, Waste and Abuse
- Recognize general health care FWA
- Identify various types of health care FWA
- Identify who can commit FWA
- Identify who is responsible for combating FWA
- Understand how to report suspected health care FWA
- Understand protections when reporting suspected FWA
- Recognize pertinent laws related to FWA

What is Fraud?

Fraud is knowingly submitting false claims or misrepresentations to get payment when no entitlement exists; knowingly offering/paying remuneration (kickbacks) to induce referrals for federal healthcare programs.
The Criminal Health Care Fraud Statute makes it a criminal offense to execute a scheme to defraud a healthcare benefit program, punishable by up to 10 years imprisonment and fines up to $250,000.
Examples:
- Conspiring to submit medically unnecessary power wheelchair claims to Medicare.
- Billing Medicare for appointments patients didn’t keep.

What is Waste?

Waste means over-utilization of services or practices resulting in unnecessary costs.
Generally not criminal, but misuse of resources.
Examples:
- Excessive office visits or prescriptions
- Prescribing more medications than necessary
- Ordering excessive lab tests

What is Abuse?

Abuse describes practices that result in unnecessary Medicare Program costs and do not meet standards of care.
Examples include:
- Billing for non-covered services
- Misusing codes on claims
- Inappropriately allocating costs on cost reports

Who Can Be Involved in FWA?

Members/Patients
Employees
Health Plans
Providers/Prescribers
Manufacturers
Pharmacies
Pharmacy Benefit Managers (PBMs)

Federal & State Oversight Authorities

The Office of Inspector General (OIG), HHS
Department of Justice
Centers for Medicare & Medicaid Services (CMS)
State Attorney General Offices
State Medicaid Agencies
Medicaid Fraud Control Units
State OIG and Medicaid OIG

Laws & Regulations Related to FWA

Federal False Claims Act
Criminal Health Care Fraud Statute
Anti-Kickback Statute
Beneficiary Inducement Law
Exclusion Statute
Whistleblower Protection Act
Other Laws:
- Stark Law (Physician Self-Referral)
- Civil Monetary Penalties Law (CMPL)
- HIPAA
- Deficit Reduction Act of 2005

Federal False Claims Act (FCA)

The federal False Claims Act (FCA) makes a person liable to pay damages to the government if they knowingly:
- Conspire to violate the FCA
- Carry out other acts to get government property by misrepresentation
- Conceal or improperly avoid or decrease an obligation to pay the government
- Make or use a false record or statement supporting a false claim
- Present a false claim for payment
Individuals may face fines, imprisonment, or both for submitting false claims.
Whistleblower protections and rewards (15–30%) are available under the FCA.

Criminal Health Care Fraud Statute

It is a criminal offense to execute a scheme to defraud any health care benefit program or to obtain money or property from the program using false representations.
Punishable by fines or imprisonment for up to 10 years — or both.
Conviction does not require proof that the violator knew the law or had intent to violate it.

Anti-Kickback Statute

Prohibits knowingly and willfully offering, paying, soliciting, or receiving any remuneration to induce or reward referrals or generate federal health care business.
Safe harbor regulations define practices that are not treated as violations if specific criteria are met.
Entities remain responsible for compliance with all other applicable laws and regulations.
State laws may also apply to private insurance and Medicaid-covered goods/services.

Beneficiary Inducement Law

Prohibits offering anything of value to influence a beneficiary’s selection of a provider.
Violations may result in civil monetary penalties of up to $10,000 per act.

Exclusion & Debarment Statute

Excludes individuals/entities from participating in Medicare/Medicaid for 3–5 years or permanently, depending on the offense.
Prohibits employment or contracting with excluded persons or entities for any reimbursed services.
Federal payment is not allowed for any service provided by an excluded individual/entity.
Some states maintain their own exclusion lists for use in state-funded programs.

Exclusion Lists

HHS-OIG (U.S. Department of Health and Human Services - Office of Inspector General) maintains a List of Excluded Individuals/Entities (LEIE) available at exclusions.oig.hhs.gov.
Exclusion reasons include:
- Program-related fraud
- Patient abuse or neglect
- Licensing board actions
- Defaulting on Health Education Assistance Loans
The U.S. General Services Administration (GSA) maintains a separate Excluded Parties List System (EPLS) at sam.gov.

Exclusion List Screening

CMS requires monthly exclusion checks for employees and contractors.
All participating providers must verify none of their personnel/entities are excluded.
Search the HHS-OIG LEIE website: oig.hhs.gov
Genesis, as a Credential Verification Organization, must:
- Screen all credentialed individuals monthly
- Report any positive matches to the respective state Medicaid agency immediately

Self-Referral Prohibition (Stark Law)

Prohibits physicians from referring Medicare/Medicaid patients to an entity where they or their family have a financial relationship, unless a specific exception applies.
Penalties include:
- $15,000 per improper claim
- Denial of payment
- Mandatory refund of any improper payments

Health Insurance Portability and Accountability Act (HIPAA)

Established the Health Care Fraud and Abuse Control Program (HCFAC).
Coordinates federal, state, and local law enforcement to detect and combat fraud, waste, and abuse.
Enforces patient privacy and security rules to protect health data.

The Deficit Reduction Act of 2005

Effective January 1, 2007.
Applies to entities receiving $5 million or more in annual Medicaid payments.
Requires written policies outlining:
- The Federal False Claims Act
- Administrative remedies for false claims/statements
- Applicable state laws (civil and criminal penalties)
- Whistleblower protections
- The role of these laws in preventing and detecting FWA

Record Retention Requirements

Providers must maintain:
- Service records
- Prescription records
- Claim and billing records
Retention period: 10 years
Records must be accessible for CMS or contractor audit.

II) Genesis Code of Business Conduct & Ethics

Vision: Model of excellence in clinically integrated management.
Mission: Support member physicians in delivering person-centered care.
Values:
- Service
- Excellence
- Reliability
- Value Creation
- Integrity
- Innovation
- Collaboration
- Teamwork
- Efficiency

Ethical Standards & Compliance Oversight

Maintain ethical standards and legal compliance.
Two goals:
- Ensure understanding of relevant laws.
- Enable reporting of violations:
  - Compliance Officer: Senior HR Manager
  - Resources: Supervisors, anonymous hotline (972-419-0033 ext. 1033)
  - Reports: May be anonymous; strict no-retaliation policy

Standards

Report Violations
- Report unethical or illegal conduct to a supervisor or the Compliance Officer.
- Compliance Officer investigates and reports to the Compliance Committee.
- Confidentiality honored whenever possible.
Conflicts of Interest
- Avoid activities that compromise judgment, including:
  - Financial interests
  - Outside work
  - Gifts or favors
  - Use of company assets
  - Supervising family members

Standards

Equal Opportunity & Workplace Conduct
- Non-discrimination in employment.
- Prohibition of harassment and violence.
Interactions and Courtesies
- Accept only items of nominal value; no bribes.
- Government personnel: No gifts permitted.
- Maintain fair and transparent vendor interactions.

Standards

Company Records and Privacy
- Maintain accurate, secure records.
- Comply with HIPAA rules.
- Promptly report privacy breaches.
Compliance with Healthcare Laws
- OIG Exclusion Monitoring
- False Claims Act
- Anti-Kickback & Stark Laws
- ACA fraud prevention
- Monthly exclusion screenings

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