CHOC Health Alliance’s (CHA) commitment to preventing, detecting, and correcting fraud, waste and abuse is a top priority. As part of this commitment, Providers / Medical Groups, and their employees are required to complete yearly Fraud, Waste & Abuse and General Compliance Training and attest that they have done so each year.* For this purpose, CHA has adopted a document published by CMS. Although the title of this training tool contains the words Medicare Parts C&D, the presentation is applicable to all lines of business.
Fraud is generally defined as “knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any health care benefit program, or to obtain [by false or fraudulent pretenses, representations, or promises] any of the money or property owned by, or under the custody or control of any health care benefit program.” (18 USC § 1347)
Waste is overutilization of services, or other practices that result in unnecessary costs to the health care system. It is not generally considered to be caused by criminal negligence, but by the misuse of resources.
Abuse includes any actions that may, directly or indirectly result in one or more of the following:
- Unnecessary costs to the healthcare system (including Medicare and MediCal programs)
- Improper payment for services
- Payment for services that do not meet professionally recognize standards of care
- Providing medically unnecessary services
- Accepting payment for which there is no legal entitlement, without prior knowledge that a misrepresentation of facts or circumstances has occurred.
During an investigation, “fraud” (criminal) versus “abuse” determinations will depend on specific circumstances, such as available evidence, facts of the case, and the presence of intent.
For 2017 and annually thereafter, you and your employees must complete the training and return an attestation form to CHA. Please allow 30-45 minutes to review the following presentation in its entirety.
Fraud Waste & Abuse Presentation in PDF Format
Once you complete the training presentation, please download and print your FWA Attestation Form (FWA 2017 Attestation Form). Form must be signed, dated, and faxed back to (714) 628-9148 or scanned and emailed to ProviderRelations@choc.org. Due date for attestations is December 31st, 2017.
For questions about Fraud, Waste & Abuse / Compliance Training, please contact the Compliance Analyst, at (714) 509-7002.
*Health Professionals currently enrolled in Medicare are exempt from this training; all other office employees must complete mandatory Fraud, Waste & Abuse training. If you are enrolled in Medicare, please email ProviderRelations@choc.org and provide your name and Medicare number.
