Please review the presentation below on Fraud, Waste and Abuse (FWA) and then complete the accompanying quiz.
Employee Training Presentation
Fraud, Waste & Abuse (FWA)
Learning Objectives
Upon successful completion of this module, you will be able to:
• Define fraud, waste, and abuse
• Explain your responsibilities in the prevention, detection, and reporting of fraud, waste, and abuse.
• Recognize indicators of potential fraud, waste, and abuse.
Introduction
With over a million health care providers and over six billion benefit transactions going on every year, health care fraud is a top priority for the US Department of Justice – second only to terrorism and violent crimes.
It is important that all employees of UMI understand what fraud waste and abuse is, how to detect it and how to assist members, providers, and other customers who may be reporting suspicious activities.
FWA Definitions
FRAUD – An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in obtaining money or an unauthorized benefit to him/herself or some other person.
WASTE – Is overutilization of services, or other practices that result in unnecessary costs.
ABUSE – A company’s activities that are inconsistent with sound fiscal, business practices that result in an unnecessary cost.
Fraud, Waste and Abuse Examples
• Billing for services not rendered and/or supplies not provided
• Double billing
• Eligibility fraud
• Misrepresentation of services
• Altering claim forms
• Soliciting, offering or receiving a kickback, bribe or rebate
What You Can Do
Comply with all statutory, regulatory, and other Medicaid and Medicare program requirements, as applicable to your job function.
Immediately report any concerns of non-compliance or suspected fraud, waste, and abuse.
Who Can Be Involved with Fraud?
• Members
• Employees
• Health Plans
• Providers/Prescribers
• Manufacturers
• Pharmacies
• Pharmacy Benefit Managers (PBMs)
How Do You Prevent FWA?
• Be on the lookout for suspicious activity and report it
• Make sure you follow identification of FWA and internal process for reporting
• Be up to date on laws and regulations
Employee FWA Reporting
Employees may contact their immediate supervisor or call the Compliance Hotline to file a complaint. The Hotline is available 24 hours a day.
The Hotline number is (954) 947-4323. All Hotline calls may remain anonymous.
Employees may report suspicious claims activity to the Special Investigations Unit via Internal Service Form, or direct contact with the unit.
Who Oversees FWA?
• Department of Justice
• The Office of Inspector General (OIG), U.S.
• Department of Health and Human Services (HHS)
• Medicaid Fraud Control Units
• Special Investigation Unit (SUI)
• And other government agencies not listed
FWA QUIZ
Below is a 6 question quiz.
Complete your name and answer all 6 questions.
A score of 80% or better is required to pass
