Fraud Waste and Abuse Information

Healthcare Fraud, Waste and Abuse is estimated to add from 3 percent to 10 percent to all healthcare spending. Unchecked fraud and abuse in our system can cost taxpayers billions of dollars each year and divert critical healthcare dollars away from those who need the care. Protecting government dollars used for healthcare is an important part of all of our jobs.

Definitions:

FRAUD

Is a false statement - made or submitted by an individual or entity - who knows that the statement is false, and knows that the false statement could result in some otherwise unauthorized benefit to the individual or entity. These false statements could be verbal or written.

WASTE

Generally means over-use of services, or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources

ABUSE

Generally refers to provider, contractor or member practices that are inconsistent with sound business, financial or medical practices; and that cause unnecessary costs to the healthcare system.

If you identify potential fraud, waste or abuse, please report it to us immediately so that we can investigate and respond appropriately. You can send us an email, or call Provider Services at 702-242-7088 or the Compliance & Ethics HelpCenter at 1-800-455-4521. Please note: Health Plan of Nevada (“HPN”) and Sierra Health and Life Insurance Company (“SHL”) expressly prohibit retaliation against any person who makes a report in good faith.

The Centers for Medicare & Medicaid Services (“CMS”) modified certain rules and regulations of the Medicare Advantage and the Part D programs that state that a contractor’s compliance plan must include training, education, and effective lines of communication between the compliance officer and the organization’s employees, managers, directors, as well as first tier, downstream and related entities.

As a contracted provider for HPN, HPN Medicaid or SHL Medicare Advantage programs, you are considered a first tier or downstream entity and are subject to CMS’ rules. It is our responsibility to ensure that your organization is provided with appropriate training materials for your employees and applicable subcontractors. To facilitate that, we are providing your organization with training materials, which are made available on myhpnonline.com and myshlonline.com, under the Providers tab.

Annually, your organization must administer the training materials to your employees and applicable subcontractors. It is important that you maintain records of the training (i.e. sign in sheets, materials, and any other documentation utilized in the training). Documentation of the training may be requested by HPN or SHL, CMS, or an agent of CMS to verify that the required training has been completed annually.

Frequently Asked Questions

What plans and product brands does this training apply to?

This training applies to all Part C (Medicare Advantage) and Part D plans offered through UnitedHealthcare and its affiliates including brands such as Sierra Health and Life, Health Plan of Nevada, Senior Dimensions, SmartChoice/Nevada CheckUp, AARP MedicareComplete, SecureHorizons, Evercare, UnitedHealthcare, AmeriChoice, Unison, Great Lakes Health Plan, etc.

What is the required fraud, waste and abuse training requirement?

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage and Part D plan sponsors to communicate and provide annual fraud, waste and abuse training to all entities they partner with to provide benefits or services in the Medicare Advantage and/or Part D programs.

Did the fraud, waste and abuse training requirement change for 2010?

Yes. In April 2010, CMS revised the training requirements to clarify that the first tier, downstream, and related entities who have met the fraud, waste and abuse certification requirements through enrollment into the fee-for-service Medicare program or accreditation as a Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) provider and are deemed to have met the training and education requirements for fraud, waste and abuse.

The training requirement and deemed status are noted at § 42 CFR 422.503(b)(4)(vi)(C) for Medicare Advantage and § 42 CFR 504(b)(4)(vi)(C) for Part D.

What is Health Plan of Nevada (HPN) and Sierra Health and Life Insurance Company (SHL) doing about the required fraud, waste and abuse training?

HPN and SHL, as providers of Medicare Advantage and Part D plans, will provide training materials that meet the requirements of the Centers for Medicare & Medicaid Services (CMS).

Why do I have to take this training? - OR -

How do I know if the required training applies to me?

Healthcare fraud, waste and abuse add roughly 3-10 percent to all healthcare spending. Unchecked fraud, waste and abuse in the healthcare system can cost taxpayers billions of dollars each year, and divert critical care from where it is needed.

CMS requires Medicare Advantage and Part D plan sponsors to communicate and provide annual fraud, waste and abuse training to all entities they partner with to provide benefits or services in the Medicare Advantage or Part D programs.

As a contracted provider or vendor for HPN’s and/or SHL’s Medicare Advantage programs, you are considered a first tier or downstream entity and are subject to this requirement.

If your organization has contracted with other entities to provide benefits or services on behalf of HPN and/or SHL plan members, you will need to provide this training material to that entity and ensure records are maintained by them.

How often do I have to take the training?

The training must be completed by December 31, 2010, and every year thereafter.

What if we offer our own training? - OR -

What if I have taken the training of another plan provider?

If your organization has completed a fraud, waste and abuse training program – either your own or through another health plan sponsor – and that training meets CMS requirements, we will accept documentation of that training.

Do providers or vendors have to take the training for every UnitedHealthcare Medicare Advantage plan or group they contract with?

No. We have developed one training program and you only need to complete the training once for all of our plans. If you have completed another training program, as long as the training your organization has completed meets CMS requirements, HPN and/or SHL will accept documentation of completed training.

What kind of documentation do you need?

Records of all training – including dates, methods of training, materials used for training, and identification of trained employees via sign-in sheets or other method – must be maintained. HPN, SHL, CMS or agents of CMS may request these records to verify that training occurred.

Is the training tracked? Am I required to provide attestations?

Tracking of training must be maintained and made available to HPN, SHL, CMS or agents of CMS upon request to verify the training occurred.

My organization provides benefits or services to several UnitedHealth Group Medicare businesses. Can I just take the training from one of them?

Yes. All training provided by UnitedHealthcare Medicare businesses meet the CMS training requirements.

Where can I get the training materials?

Training materials are available on the HPN and SHL websites – myhpnonline.com and myshlonline.com – under the Provider page.

What are some examples of fraud, waste and abuse?

• Fraud is a false statement made or submitted by an individual or entity who knows that the statement is false, and knows that the false statement could result in an unauthorized benefit to the individual or entity. False statements can be verbal or written.

• Waste means over-use of services, or other practices that result in unnecessary costs. In most cases, waste is not considered to be caused by reckless actions but rather the misuse of resources.

• Abuse refers to provider, contractor or member practices that are inconsistent with sound business, financial or medical practices, and that cause unnecessary costs to the healthcare system.

What should I do if I suspect fraud, waste or abuse?

If you identify potential fraud, waste or abuse, please report it to us immediately so that we may investigate and respond appropriately. You can send us an email, or call.

Contracted network providers can call 702-242-7088. Contracted vendors or delegates can call the Compliance & Ethics HelpCenter at 1-800-455-4521.