AMENDED
ANTI-FRAUD PLAN
for
AvMed,
Inc. d/b/a AvMed Health Plans
July 2007
AvMed, Inc. d/b/a AvMed Health Plans (“AvMed”)
hereby amends the Anti-Fraud Plan of its Special Investigations Unit (“SIU”) to
identify, investigate, and rectify instances of fraud, waste and abuse
committed by participating and non-participating providers and facilities, all
vendors, employees, members, and unaffiliated third parties. AvMed’s Special Investigative Unit,
operationally established as the Audit Services & Investigations
(“AS&I”) resides in the AvMed Legal Department, collaborates with and is
supported by the Compliance Department, Risk Management Department, and
Internal Audit Department. This Plan is
also designed as an element of the AvMed Compliance Program. AvMed has a fiduciary responsibility to the
broader health care community to resist criminal behavior, instances of false
claims and improper billing and coding practices, and other schemes that
adversely impact patient safety, the quality of health care services being
delivered and that impose a tremendous financial burden on the health care
system.
In addition, AvMed’s Anti-Fraud Plan is in
compliance with Section 626.9891(a)(b), Florida Statutes, Section 626.9891(3),
Florida Statutes and Rule Chapter 69D-2.001-005, Florida Administrative
Code. Likewise, as a Medicare Advantage
Organization under contract with the Centers for Medicare and Medicaid
Services, federal law, including but not limited to 42 C.F.R.
423.504(b)(4)(vi)(H) for Part D plan sponsors, requires that AvMed have in
place a comprehensive fraud and abuse plan to detect, correct, and prevent
fraud, waste and abuse.
MISSION STATEMENT
AvMed will not tolerate health care fraud, waste or
abuse in any of its relationships with either internal or external
clientele. Furthermore, AvMed will
establish and maintain internal controls designed to prevent schemes with
unaffiliated third parties. AvMed will identify, resolve, report, and, when
appropriate, refer for prosecution, situations in which suspected fraud, waste
or abuse has occurred.
AvMed has adopted the following mission statement
for its fraud and abuse program:
The AvMed Anti-Fraud Program seeks to meet the
customer’s expectation that we will reimburse only for services that are
medically necessary and appropriate and that the benefits will be issued only
to eligible subscribers and providers.
We strive toward this goal by providing a central point for the
detection, investigation, and resolution of fraud, waste and/or abuse.
Anti-Fraud Goals
AvMed’s goals and priorities are key to its
anti-fraud program success. Key benefits
include:
¨
Quality
– Improving the quality of patient care is a
priority.
¨
Customer Relations – An effective anti-fraud program demonstrates the company’s strong
commitment to honest and responsible provider and corporate conduct.
¨
Assessment of Risk – The program will facilitate a more accurate view of risk and exposure
relating to fraud and abuse.
¨
Public and Legislative Compliance – The program facilitates compliance with state and
federal laws, and demonstrates an aggressive approach to fighting fraud/abuse.
¨
Civic Responsibility – Combating fraud/abuse through identifying and preventing criminal and
unethical conduct is considered a public duty.
¨
Financial
Savings – Through prevention, early detection
and recovery, minimizing the loss to AvMed and its clients from false claims is
a priority.
¨
Deterrence – Future
deterrence of fraud/abuse is a priority.
¨
Objective Claims Handling – Standard, unbiased claims review is required by law and is smart business.
Anti-Fraud
Plan
The components of the
Anti-Fraud Plan are as follows:
I.
Internal and External Prevention, Detection and
Investigation of Insurance Fraud
II.
Recovery
III.
Reporting
IV.
Education and Training
V.
Primary Contact Persons/Organizational Chart
I. Prevention, Detection, Investigation of
Insurance Fraud
A. Internal Fraud
Prevention,
Detection and Investigation
AvMed has adopted fraud
prevention, detection and investigation procedures. Following is a summary of AvMed’s fraud,
waste and abuse control procedures that serve to prevent internal fraud, waste
and abuse.
Comprehensive Internal Compliance Program
The current AvMed Compliance
Program provides, among other things, for the reporting of compliance
issues. Employees report improper
activity to their supervisors, the General Counsel, the Director of Internal
Audit, the Director of Compliance, Director of Audit Services & Investigations,
or anonymously to the Compliance Hotline 1-877-AVM-DUTY. The Compliance Program expressly prohibits
retaliation against those who, in good faith, report concerns or participate in
the investigation of compliance issues.
The Compliance Program provides that compliance concerns will be
investigated rigorously and resolved promptly.
Investigations regarding compliance program violations are conducted by
General Counsel, Compliance Department, Internal Audit, AS&I, or Human
Resources, depending upon the nature of the violation. Compliance and fraud and
abuse training is provided to all new employees and to existing employees on an
annual basis.
B. External Fraud
1. Prevention
and Detection
AvMed strives to
detect and prevent health care and insurance fraud, waste and abuse by
receiving referrals from a variety of sources and through the use of
sophisticated fraud detection technology.
AvMed seeks to detect fraud,
waste and abuse through a variety of methods as follows:
a.
Insurance
Fraud Detection Technology
Data will be
routinely and randomly analyzed by the AvMed Medical Department, Network
Department, Pharmacy Department and AS&I, based upon tips from all sources,
to include external vendors specific to provider, facility, member and
pharmaceutical fraud, waste and abuse as well as independent research. This data analysis will be critical in the
identification of repetitive fraud, waste and abuse patterns. Output reports will be used for existing
cases as well as the bases for new ones.
AvMed will utilize
data mining capabilities and other technological tools in preventing and
detecting insurance fraud, waste and abuse as well as the advanced
technological tools of external vendors.
Ongoing
computer-based analysis of provider, facility, member and pharmaceutical data is important.
Patterns of over-utilization, false claims, or other unusual billing
practices are addressed. Additionally,
proprietary system flags or edits within the claims systems automatically
segregate claims with certain predetermined characteristics.
b.
Fraud/Suspicious
Claim Referral Sources
The identification and
prevention of fraud, waste and abuse is a cooperative effort, involving all
employees. All employees are required to
cooperate in any investigation conducted by AvMed, its regulatory agency, or
law enforcement.
The AS&I receives
fraud, waste and abuse and/or suspicious claim referrals from the following
sources:
¨
Hotline
1-877-AVM-DUTY
¨
Tips from
enrollees, insured’s, providers, other insurers and the general public received
by AvMed;
¨
Referrals from
member services staff, claims personnel, medical management, medical claim
review staff, provider relations representatives, medical directors, quality
assurance staff, pharmacy, utilization review personnel and provider
credentialing units; other medical providers;
¨
Media reports;
¨
Through
involvement in the National Health Care Anti-Fraud Association;
¨
Information
obtained in conjunction with studies conducted by AvMed and/or its external
vendors and/or;
¨
Office of
Inspector General’s (OIG) database of excluded individuals/entities;
¨
Referrals from
law enforcement agencies such as the Florida Department of Law Enforcement, the
Florida Division of Insurance Fraud, Office of Insurance Regulation, Centers
for Medicare and Medicaid Services, MEDICs, the FBI, or other agencies engaged
in identifying, investigating and prosecuting fraudulent activities.
2. Investigation
a.
AS&I field
auditors and investigators are provided with and follow AS&I’s
Investigation Procedures in conducting prompt investigations. The Investigations Procedure includes, but is
not limited to, the following topics:
¨
Information for
investigators regarding general investigation guidelines; conducting
interviews; report writing; information disclosure; law enforcement relations;
¨
The process to
be employed when a suspicious claim is identified;
¨
The suspicious
claim indicators;
¨
The duties and
functions of the AS&I.
b. Through the course of its investigations, the
AS&I Department may work with any other department within AvMed to review
questionable claims and provide guidance.
c. The quality and credibility of allegations or
suspicious situations are assessed.
Initial exposures and recovery potential are identified to determine if
a case should be opened.
d. Cases are prioritized pursuant to commonly
accepted business practices and business objectives.
e. An investigative action plan/timeline is
developed to guide the investigation.
The action plan is periodically reviewed and revised as circumstances
change.
f. Relevant claim data for the period in
question is obtained and reviewed and evidence is gathered to support data
analysis and allegations.
g. An investigative summary/report is
prepared which summarizes the investigative findings, displays a comprehensive
understanding of the facts and financial implications and recommends a
corrective action plan to include reporting as appropriate and follow-up.
II. Recovery
AvMed contracts with numerous commercial client
groups, as well as governmental clients including, but not limited to, the
Florida Division of State Group Insurance, the U.S. Office of Personnel
Management for the Federal Employee Health Benefit Program and the Centers for
Medicare and Medicaid Services as a Medicare Advantage organization. AvMed
acknowledges its responsibility to be a proper steward and to ensure that only
eligible employees or beneficiaries are afforded coverage, only medically
necessary and medically appropriate services are covered and that anti-fraud,
waste and abuse programs and procedures are in place. Additionally, AvMed acknowledges its
responsibility to recoup overpayments to providers, vendors or others under
commercial and governmental contracts as a means of reducing unnecessary
medical claims costs. To this end, the
AvMed Audit Services and Investigations Department utilizes state of the art
technology to detect improper billing and coding practices and employs
competent nurse field auditors, data analysts and other professionals to
detect, remedy and recoup overpayments due to claims unbundling and up-coding.
These recovery
efforts are integral to the anti-fraud, waste and abuse efforts of AvMed and
supplement the other responses to such behaviors and the procedures outlined in
the AvMed Compliance Program.
III. Reporting
Pursuant to
Section 626.989(6), Florida Statutes, if the Compliance Officer and General
Counsel determines that a claim or case meets the minimal threshold under
Florida law as defined by Section 626.989(1), Florida Statutes, information
regarding suspected fraud, waste and abuse shall be reported to the Florida
Department of Insurance, Division of Insurance Fraud (“Division”), CMS, MEDICs,
and/or other law enforcement agencies.
Reports to the Division will be via website (www.fldfs.com/fraud) and
CMS/MEDICs via the MEDIC Referral Form.
All case files being referred will contain documentation that clearly
defines and supports the allegation of suspicious activity, include detection
and reported dates and be in compliance with 42 C.F.R.
423.504(b)(4)(vi)(H).
Pursuant to Section 626.989(1), Florida Statutes, a
fraudulent insurance act is committed if a person knowingly and with intent to
defraud presents, causes to be presented, or prepares with knowledge or belief
that it will be presented, to or by an insurer/HMO, self-insurer, agent,
broker, etc., any written statement as part of, or in support of, an
application for insurance, rates, claims, or any other benefit, which the
person knows to contain materially false information concerning any material
fact. Also, a fraudulent insurance act
is committed if the person conceals, for the purpose of misleading another,
information concerning any material fact.
AvMed shall cooperate fully with the Florida
Division of Insurance Fraud, CMS, MEDICs, and/or other law enforcement agencies
in their prosecution or additional investigation of cases reported on behalf of
AvMed.
IV. Education and Training
A.
Education/Fraud, Waste and Abuse Awareness
Training
Pursuant to Section
626.9891(3)(c), Florida Statutes, anti-fraud education and training of claims
adjusters or other personnel is mandatory.
AvMed has initiated a
Fraud Awareness Campaign. The purpose of
this program is to encourage and assist AvMed’s employees, members, vendors,
providers and other customers to identify, detect, and report health care and
insurance fraud, waste and abuse.
The corporate
training program is broad in scope. The
intent is to address health insurance fraud, waste and abuse and the impact
that it can have on AvMed and the program is designed to be in-person
training. Its objectives are to provide
staff members with specific tools to detect fraud, waste and abuse, instruct them
in the procedures for reporting cases of suspected fraud, waste and abuse, and
create an awareness of
the staggering financial and service consequences of fraud, waste and
abuse. AvMed’s Audit Services and
Investigations, Compliance Department and Risk Management Departments
collaborate in executing its Fraud Awareness Campaign.
All personnel are required to attend Fraud Awareness
& Compliance Training every year.
All new AvMed Staff members are provided Fraud Awareness Training as
part of the orientation process.
Mandatory attendance records are maintained by the Compliance
Department. Non-compliance of AvMed’s
Compliance and or Fraud Awareness Training will result in disciplinary
action. Employees that have specific
responsibilities in Medicare Part D business areas should receive specialized
training on issues posing compliance risks based on their job function upon
initial hire and at least annually thereafter as a condition of employment. Regular fraud
awareness bulletins are distributed to all employees and anti-fraud information
is available on the AvMed website and eZone.
The focus will be on
the critical role that each employee plays in the eradication of fraud, waste and abuse committed against AvMed and
its customers. Highlights of the program
include:
¨
Definition of
fraud, waste and abuse;
¨
Tools for
fraud, waste and abuse detection (“red flags”);
¨
AvMed’s
prevention efforts;
¨
Reporting
fraud, waste and abuse;
¨
Review of
actual investigations;
¨
Current
industry trends in the fraud, waste and abuse arena.
¨
Investigative
Procedures;
¨
Unique
Department Procedures;
¨
Case Management
System.
B.
Investigator Education/Training
Upon hire, AS&I
investigators complete a comprehensive fraud detection-training course that
provides the new investigator with information about AvMed’s Anti-Fraud Plan as
well as material regarding techniques used to combat fraud, waste and abuse.
AS&I staff
members receive technical fraud, waste and abuse training through attendance at
the National Health Care Anti-Fraud Association’s various seminars and
workshops. AS&I staff members who
attend participate in the sessions that relate most directly to their specialty
or position.
Additional training
sessions will include technical/computer training that will occur throughout
the year and address various computer applications used in AS&I positions.
V. Primary
Contact Persons/Organizational Chart
In accordance
with Florida Statutes Section 626.9891(3)(d), the personnel identified herein
should be extended immunity from civil liability concerning the sharing of
information regarding persons suspected of committing fraudulent insurance acts
with Anti-Fraud personnel employed by other HMO’s and/or insurers pursuant to
Florida Statutes Section 626.989(4)(d).
¨
Any
inquiries regarding the AvMed Anti-Fraud Plan should be directed to:
Stephen J. deMontmollin
Sr. Vice President and General
Counsel
4300 NW
89th Boulevard
Gainesville,
FL
32606
352.337.8707
steve.demontmollin@avmed.org
