For some reason, it seems independent pharmacies think fraud, waste, and abuse prevention compliance is difficult. While it is boring, and it clearly has some scary ramifications when not followed, it’s actually very simple and easy to implement. In this article, we will discuss why having a Fraud, Waste, and Abuse or FWA compliance program is important, things you can do to get started, examples of other people who thought they didn’t need to have all their FWA items in place, the issues they got into and, some solutions to keep you from getting into hot water with Medicare and OIG.
Good news, if you are not billing Medicare Part B, C (Advantage) or D and now Medicaid, you don’t have to do FWA training or follow their rules.
But chances are very good that you are in the 99.99% of pharmacies that have Medicare patients. Medicare patients are your bread and butter and your state Medicaid program, and several third-party programs will require annual training and compliance with a host of different items. This includes Conflict of Interest and OIG and SAM Exclusion Verifications just to name a few.
To recap, if you want to participate in Medicare, Medicaid, and most Part D insurance plans, you will need to have an active FWA compliance program in place.
What should a FWA compliance program look like?
It will probably have about 10 Policies & Procedures, a process to conduct monthly verification checks via the OIG-SAM Exclusion Verification Report (which, by the way, need to be retained for 10 years), annual Conflict of Interest certifications (COI), posting the CMS 10147 in your pharmacy, and training your staff on YOUR Policies & Procedures annually. It is not a canned training program that is unrelated to your program.
Super simple! Let’s pretend you forgot to do COI Certifications for the last two years or you haven’t been running all employees, owners, 1099 (or contract) employees, BAA’s including: assisted-living facilities and vendors whose products and services are billed to a federal health care plan (Medicare, Medicaid, Tri-care) through OIG-SAM Exclusion Verification and someone is on the Exclusion List. Maybe you did your annual training requirement, but you never documented it. What’s the worst that could happen? Well, you have violated your Part D contract, and since PBM’s are the enforcers, they can take back all reimbursements to the date of the last time you did whatever it was that you were supposed to be doing. Then, Medicare & Medicaid are notified.
So, let’s say it was only for 1 month; can your facility survive if all Part D reimbursements were taken back for last month? Let’s be crazy and say you never did your annual training or you have an individual on the exclusion list since 2006. That’s right, they can take back ALL reimbursements up to 10 years! We like to say if it isn’t documented, it never happened. So, make sure you have signed and dated documents!
There have been hundreds of cases where people blatantly committed fraud, knowingly and willfully. Don’t do it. You will eventually get caught. This is one thing the government has gotten really good at!
FWA Fraud Cases
- According to a Press Release from the DOJ February 5, 2020, Two Owners of Telemedicine Companies Charged for Roles in $56 Million Conspiracy to Defraud Medicare and Receive Illegal Kickbacks in Exchange for Orders of Orthotic Braces.
- According to a Press Release from the DOJ February 26, 2020, Two Los Angeles Pharmacy Owners Sentenced for Multimillion-Dollar Scheme that Billed Medicare, Cigna $11.8 Million in Fraudulent Medication Claims for prescription drugs.
- According to a Press Release from the DOJ May 13, 2020, Six Dallas, Texas-area pharmacy owners and marketers were charged in a superseding indictment today for their roles in a scheme involving compound drug claims to TRICARE and the U.S. Department of Labor (DOL), the vast majority of which were the product of over $14 million in illegal kickbacks and bribes.
- According to a Press Release from the DOJ February 27, 2020, Queens Pharmacy Owner Found Guilty of Health Care Fraud and Money Laundering Charges for Role in Billing Scheme. A federal jury found a New York pharmacy owner guilty of health care fraud and money laundering charges for his role in a scheme to defraud Medicare by billing for prescription medications that were not provided to patients.
Don’t be like these people who were ignorant or just ignored the rules and had employees working for their practice or medical facility who were on the OIG Exclusion List. These locations include Hospitals, Pharmacies, Chiropractors, Dentist, Medical Doctors, Metal Health Facilities, Skilled Nursing homes:
- According to OIG’s Civil Monetary Penalties and Affirmative Exclusions Report:
- On December 26, 2019, A Maryland Dentist settled case Involving Excluded Individual for $94,096.64
- On November 6, 2019, A Texas Ambulatory Surgery Center Settles Case Involving Excluded Individual Resulting for $121,550.12
- On July October 11, 2019, A Texas Chiropractic Practice Settles Case Involving Excluded Individual, for $10,000 Settlement
- According to a January 23, 2017, article from the OIG: An Excluded and Unlicensed New Jersey Dentist Who Assumed Identity of Another Dentist Agrees to Settlement of $1.1 Million and 50-Year Exclusion to Resolve Civil Monetary Penalty Case
If you want to follow the rules, and ensure you get to keep all the money you collect, but don’t have the time to create your own policies and procedures, or maybe you have a lot of employees, vendors, and business associates to run through the OIG exclusion database, R.J. Hedges & Associates has a simple and easy solution for you. The R.J. Hedges Fraud, Waste, and Abuse Prevention Program ensures you are in compliance with Medicare Parts B, C and D, Medicaid and third-party payers.
The program provides a platform that allows your monthly exclusion verification to be completed in seconds versus having to manually enter the data every month into two different databases, and consists of a series of policies and procedures including:
- Anti-Kickback
- Conflict of Interest
- False Claims Submission
- OIG and GSA Exclusion Verifications
- General Compliance
- FWA Training
- Whistleblower Protection
If you already have a program in place and want to see how compliant you are with FWA rules and regulations, feel free to take our free FWA Assessment.
