Fraud, Waste and Abuse

Detecting and Preventing Fraud, Waste and Abuse  
Blue Cross and Blue Shield of Nebraska (BCBSNE) is committed to detecting, mitigating and preventing fraud, waste, and abuse. Providers are also responsible for exercising due diligence in the detection and prevention of fraud, waste and abuse, in accordance with the BCBSNE Detection of Fraud, Waste and Abuse policy. BCBSNE encourages providers to report any suspected fraud, waste and/or abuse to the BCBSNE Corporate and Financial Investigations department, the Corporate Compliance Officer, the Medicare Compliance officer, or through the anti-fraud hotline, 877-632-2583. The reports may be made anonymously.  

What is Fraud?  
Fraud is determined by both intent and action and involves intentionally submitting false information to the government or a government contractor (such as BCBSNE) to get money or a benefit. 

Examples of Fraud  
Examples of fraud include:  

• Billing for services not rendered  
• Billing for services provided to a member at no cost  
• Upcoding services  
• Falsifying certificates of medical necessity  
• Knowingly double billing  
• Unbundling services for additional payment

Providers and Vendors are Required to Take CMS Training on Medicare Fraud  
Providers must understand fraud, waste and abuse in Medicare and participate in required compliance programs per Centers for Medicare & Medicaid Services (CMS) regulations. Review these resources for more information:  

• Combatting Medicare Fraud, Waste, & Abuse cms.gov/Outreach-and-Education/MLN/WBT/MLN3995723-MLNPartsCD/FWA/story.html  
• Medicare Compliance  

Providers and vendors should make sure that governing body members and any employees (including volunteers and contractors) providing health or administrative services in connection with the BCBSNE Medicare Advantage program complete the training within 90 days of being hired and annually thereafter. Be sure to keep the certificate generated by the website as proof that you took the training and retain evidence of training for 10 years from the end date of your contract with BCBSNE. You need to be able to provide proof to BCBSNE or CMS if requested. 

What is Waste?  
Waste includes activities involving payment or an attempt to receive payment for items or services where there was no intent to deceive or misrepresent, but the outcome of poor or inefficient billing or treatment methods cause unnecessary costs.  

Examples of Waste  
Example of waste include: 

• Inaccurate claims data submission resulting in unnecessary rebilling or claims  
• Prescribing a medication for 30 days with a refill when it is not known if the medication will be needed  
• Overuse, underuse and ineffective use of services  

What is Abuse?  
Abuse includes practices that result in unnecessary costs or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  

Examples of Abuse  
Examples of abuse include: 

• Providing and billing for excessive or unnecessary services 
• Routinely waiving member coinsurance, copayments or deductibles 
• Billing Medicare patients at a higher rate than non-Medicare patients 

Medicare Part D Program  
As part of an ongoing effort to combat fraud, waste and abuse in the Medicare Part D program, CMS’ program integrity contractor, the NBI MEDIC (Health Integrity, LLC), requests prescriber prescription verifications. The NBI MEDIC routinely mails prescriber prescription verification forms containing the beneficiary’s name, the name of the medication, the date prescribed and the quantity given. The form also asks the prescriber to check yes or no to indicate whether the prescriber wrote the prescription. The prescriber is asked to respond within two weeks. If no response is received, then the investigator follows up with a second request.  

A timely and complete response to prescription verification is important as it is likely to result in the elimination of an allegation of wrongdoing and/or prevent the payment of fraudulent prescriptions without need for further investigation.  

Providers who are involved in the administration or delivery of the Medicare Part D prescription drug benefit are strongly encouraged to respond in a timely manner to prescription verifications when contacted by the NBI MEDIC.  

Additionally, effective Jan. 1, 2016, if you want to participate in Part D to cover a prescription, not only must you have a valid NPI number, but you must also be either: (1) enrolled in Medicare or (2) validly opted-out of the program. BCBSNE will reject an otherwise valid prescription, if it was written by a prescriber who is neither enrolled in Medicare nor validly opted-out of the program.  
 
Repayment Rule  
Under the Patient Protection and Affordable Care Act, effective March 23, 2010, providers are required to report and repay overpayments to the appropriate Medicare administrative or other contractor (Fiscal Intermediary or Carrier) within the later of (a) 60 days after the overpayment is identified, or (b) the date of the corresponding cost report is due, if applicable.  

Under the Affordable Care Act, a provider is obligated to report and return an overpayment by the later of (1) 60 days after the date on which the overpayment was identified; or (2) the date any corresponding cost report is due (if applicable). Failure to do so may render the provider subject to liability and penalties under the False Claims Act.