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Legal Update
from Krieg DeVault LLP
Fraud, waste and abuse training not required in all circumstances

Recently Medicare Advantage (MA) organizations, such as Anthem, have been sending notices to physicians indicating that they are required to provide fraud, waste and abuse training within their practices due to a federal regulation. The regulation cited in the notices states:

“Any entity seeking to contract as an MA organization must have administrative and management arrangements satisfactory to CMS, as demonstrated by at least the following: A compliance plan, which must include measures to detect, correct, and prevent fraud, waste, and abuse, shall include the following elements: Effective training and education between the compliance officer and the MA organization’s employees, managers and directors, and the MA organization’s first tier, downstream, and related entities.”

The portion of this regulation that potentially relates to physician groups is the last sentence relating to “the MA organization’s first tier, downstream, and related entities.”

“First tier entity” means any party that enters into an acceptable written arrangement with an MA organization or contract applicant to provide administrative services or health care services for a Medicare eligible individual. “Downstream entity” means any party that enters into an acceptable written arrangement below the level of the arrangement between an MA organization (or contract applicant) and a first tier entity.

These written arrangements continue down to the level of the ultimate provider of both health and administrative services. Therefore, if a physician group has a written agreement with a Medicare Advantage organization, such as Anthem, they will qualify as either a first tier entity or a downstream entity. Then, the contracted group is required to follow the fraud, waste, and abuse training requirements set forth in the recent notices that have been sent.

If the physician group does not have in place a written contract with a Medicare Advantage organization, it is not bound by the regulation quoted above.

For additional information, e-mail Leigh Ann Lauth O’Neill or call her at (317) 238-6346 at Krieg DeVault LLP.


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