The prevention of fraud, waste and abuse in health insurance programs Our Mission Rooted in the loving ministry of Jesus as healer, we commit ourselves to serving all persons with special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care, which sustains and improves the health of individuals and communities. We are advocates for a compassionate and just society through our actions and our words. Our Values Service of the Poor Generosity of spirit, especially for the persons most in need Reverence Respect and compassion for the dignity and diversity of life Integrity Inspiring trust through personal leadership Wisdom Integrating excellence and stewardship Creativity Courageous innovation Dedication Affirming the hope and joy of our ministry Our Vision We envision a strong, vibrant Catholic health ministry in the United States which will lead to the transformation of healthcare. We will ensure service that is committed to health and well-being for our communities and that responds to the needs of individuals throughout the life cycle. We will expand the role of laity, in both leadership and sponsorship, to ensure a Catholic health ministry of the future. 2 Via Christi Health Preface Via Christi strives to deliver quality care and service to those we serve. This includes beneficiaries of federal health insurance programs: Medicare, Medicaid and TRICARE, which covers the U.S. military community. Our concern for quality extends beyond the care and treatment of those we serve. We also make every effort to ensure that all claims submitted for services and goods are complete and accurate. As stated in our Standards of Conduct — A Mission based on values and ethics, we are committed to ethical behavior, including compliance with all state and federal laws and regulations. This booklet has been developed by the Via Christi Corporate Responsibility Office to provide you with critical information about the prevention of fraud, waste and abuse in federal and state health insurance programs. It explains the laws that forbid the submission of false or fraudulent claims. The booklet explains how to report any concerns to the Corporate Responsibility Office, and includes a reminder that Via Christi welcomes such information and does not tolerate retaliation or retribution for such reporting. You also have rights and responsibilities when reporting concerns under the federal False Claims Act whistleblower provisions. Please take the time to read this booklet and to ask questions you may have about the content. Keep this booklet as a reference, along with the other information you have received concerning Via Christi. We want you to be informed and involved as we focus on developing and maintaining a culture of integrity and service. Sara Powers VP for Corporate Responsibility Via Christi Health 8200 E. Thorn Wichita, KS 67226 316.858.4978 3 Introduction An integral part of our Mission is caring for the poor, the disabled, the elderly and the vulnerable people in our communities. Via Christi participates in federal health insurance programs, including Medicare, Medicaid and TRICARE, to better serve the public. This booklet provides essential information about key laws that forbid fraud, waste and abuse by providers that participate in federal health insurance programs. Fraud is defined as: . the intentional deception or misrepresentation made by a person who knows that the deception could result in an unauthorized benefit. Abuse is defined as: . activities that are not consistent with sound business, fiscal, or medical practices and result in unnecessary costs. Healthcare fraud and abuse are national problems that affect every one of us directly or indirectly. It is estimated that billions of dollars are lost to fraud and abuse every year. These losses result in higher healthcare delivery costs and increased costs for health insurance coverage. Two important fraud prevention laws are the federal False Claims Act (FCA) and the Kansas Medicaid Fraud Control Act. Both laws have serious penalties for making or bringing about false or fraudulent claims for payment to the federal health insurance programs. We have the opportunity to model honesty, ethics and integrity for others employed by Via Christi ministry locations or conducting business with us. Since healthcare regulations are so complex, Via Christi has a Corporate Responsibility program to ensure full compliance with Medicare, Medicaid and TRICARE requirements regarding fraud, waste and abuse. If you have questions or concerns about compliance with antifraud requirements, contact the Via Christi Corporate Responsibility Department. 4 Via Christi Health Federal Deficit Medicare overview Reduction Act Since 1965, Medicare has provided health insurance for people age 65 and older, for some people with The Deficit Reduction Act of 2005 introduced specific long term disabilities and for patients with end- requirements for employers receiving more than stage renal (kidney) disease. Medicare is a federally $5 million per year in Medicaid payments. These funded program, created by Title XVIII of the Social healthcare providers must share information with Security Act. The Medicare program has four parts, their employees about the federal FCA, any applicable as described below: state False Claims Act, the rights of employees to be protected as whistleblowers and the employer’s Part A policies and procedures for finding and preventing Medicare Part A covers inpatient care and services fraud, waste and abuse. This booklet is provided from providers such as hospitals, skilled nursing to you to fulfill these requirements, as well as give facilities, home healthcare, hospices and similar you valuable information regarding Via Christi’s institutions. These providers are paid under the commitment to a culture of integrity and Prospective Payment System (PPS), which means ethical behavior. the payments are predetermined based upon an individual’s diagnosis and clinical needs. Medicare Federal health insurance programs does not pay for all care and services that may be provided. Some non-covered services are excluded Medicare, Medicaid and TRICARE beneficiaries make by law and others are excluded by medical criteria. up a large percentage of persons who seek care at Via Christi ministry locations. The Medicare and The government itself does not manage claims Medicaid programs continue to grow and become or pay the providers. Rather, it contracts with more complex. The laws governing these programs companies called Medicare Administrative are complicated, demanding our attention to ensure Contractors (MACs) to pay providers for services. that we follow the requirements for submitting complete and accurate claims. Part B The Centers for Medicare and Medicaid Services Medicare Part B covers hospital outpatient care (CMS), an agency within the Department of Health and services from healthcare providers such and Human Services, has reported that more than as physicians, nurse practitioners, certain other 1 billion claims are processed each year, paid to more “physician extenders,” ambulance services, clinical than 1 million healthcare providers. Both the Medicare and diagnostic laboratory tests and durable medical and Medicaid programs are under increasing pressure equipment. Payments for Part B services to hospital due to the healthcare and long-term care needs of outpatients are paid under the Ambulatory Payment retiring baby boomers. Due to rapid growth and new Classification (APC) System. Other Part B payments demands, the federal government is taking added are based on Medicare fee schedules developed by measures under the FCA to ensure that every dollar CMS. Beneficiaries must pay premiums as enrollees spent actually goes to providing treatment and care of Medicare Part B. Beneficiaries also must pay and that any dollars paid for false or fraudulent claims applicable deductibles or coinsurance amounts to are recovered by the government. the provider. The federal government also contracts with MACs to manage and pay providers for Part B In order to understand the FCA, there should be a services. basic understanding of the primary federal health insurance programs: Medicare, Medicaid and TRICARE. 5 Part C Medicare Part C, known as “Medicare Advantage,” was first established in fact 1997 to give Medicare beneficiaries the option of joining a managed care The creation of the program. CMS pays a lump sum to the managed care organization, which Health Care Fraud in turn is responsible for managing the costs of care. In addition to the Prevention and traditional services available through Parts A and B, Part C coverage can Enforcement Action also include wellness and preventative programs. Beneficiaries may enroll Team (HEAT) is an in a managed care organization approved by Medicare, such as a Health effort to fight fraud. Management Organization (HMO) or a Preferred Provider Organization (PPO), and they typically pay a premium to the organization. This group is led jointly by the Deputy Part D Attorney General and Medicare Part D is a prescription drug benefit first offered on January the Deputy Secretary 1, 2006. It was one of the many changes made to the Medicare program of Health and Human through the Medicare Modernization Act of 2003 (MMA). It covers Services (HHS). The outpatient prescription drugs, prescribed biological products, insulin team is made up (including medical supplies associated with injections of insulin) and