Medicare Advantage: Fraud and Abuse Training
Podiatrists who contract with Medicare Advantage (MA) plans can expect to hear from those plans about a requirement to complete fraud, waste, and abuse training before December 31. Under a law regulating MA plans that became effective on January 1, 2009, the plans are required to ensure that all their subcontractors (such as contracting physicians) and their downstream entities complete waste, fraud, and abuse training. (Downstream entities are entities that do not hold a direct contract with an MA plan but are contractually obligated to provide services to the organization; for example, podiatrists that contract with a company like Regence that has a contract with an MA plan.) Through the terms of the contract between the MA plan and its podiatrists, the podiatrists would be required to complete fraud, waste, and abuse training. The training requirement would apply to podiatrists and their relevant staff members (such as staff involved in billing and coding) and the training must occur annually. Bottom line, the responsibility is on the plan and they have to provide the training, which could entail their working with others, including outside organizations or contractors to help discharge their obligations.
The Centers for Medicare and Medicaid Services (CMS) has indicated that the MA plans may either provide the training directly or provide appropriate training materials to their contracted entities. It is expected that there will be substantial variation in how MA plans implement this requirement although it is expected that most MA plans will provide training material to providers rather than provide the training themselves. While the various Blue Cross Blue Shield plans are apparently trying to adopt a more or less uniform approach, in most cases there can be no "one size fits all" approach. Some MA plans are providing training materials in the form of slide presentations. Other MA plans are requiring providers to participate in online fraud, waste, and abuse training modules. The MA plan is accountable for ensuring that materials have been provided to all of their contractors. According to CMS staff, an MA plan could potentially allow a contractor to develop its own training that would be approved by the Medicare Advantage organization in order to avoid having to undergo multiple trainings from different plans. CMS requires that the following topics be addressed in a fraud, waste, and abuse training program:
- Laws and regulations related to Medicare Advantage and Part D fraud, waste, and abuse (i.e. False Claims Act, Anti-Kickback statute, HIPAA, etc);
- Obligations of the contractor and any downstream entities to have appropriate policies and procedures to address fraud, waste, and abuse;
- Process for reporting to the Medicare Advantage organization suspected fraud, waste, and abuse in the contractor, or any downstream and related entities;
- Protections for employees of the contractor, any downstream, and related entities who report suspected fraud, waste, and abuse;
- Types of fraud, waste, and abuse that can occur in the contractor, downstream, and related entities.
Podiatrists should be aware that MA plans will likely request proof, such as a certification or attestation, that the training has been completed. In addition, since MA plans are legally required to comply with this requirement, it is likely that podiatrists' contracts with MA plans obligate them to comply with the requirement. In addition, CMS indicated this week that it will be publishing a proposed rule shortly in the Federal Register relating to these requirements. CMS acknowledges that a provider may contract with multiple plans, and is proposing changing the training requirement to make it clear that these providers would not have to undergo duplicative trainings from multiple plans.