Medicare Advantage Plans requiring Compliance and Fraud, Waste, and Abuse training

Date: November 12, 2015

If you participate in a Medicare Advantage (MA) plan, you may have recently received information that modifies your contract to ensure that the MA plans – and the providers within their networks – are compliant with all Centers for Medicare & Medicaid Services (CMS) mandates.  Two of these mandates may seem new to you; they are: 1), Compliance training, and 2), Fraud, Waste, and Abuse (FWA) training.

CMS has long required that all providers for MA plans provide proof of completion for Fraud, Waste, and Abuse (FWA) training.  You are required to repeat the training and provide proof of completion on an annual basis. The purpose of the training is to assist practices with identification of FWA and develop internal policies and procedures to find and fight abuse.

Compliance training may seem new to many practices and providers although it was mandated by the Affordable Care Act (ACA).  You can link to a CMS Compliance webinar presentation here on the subject.  The webinar quotes Section 6401 of the ACA, which provides that a “provider of medical or other items or services or supplier within a particular industry sector or category” shall establish a compliance program as a condition of enrollment in Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).   The ACA also requires the Secretary of Health and Human Services (HHS), in consultation with the HHS Office of Inspector General (OIG), to establish the “core elements” and a timeline for implementation.  Importantly, neither has been forthcoming from HHS and an enforcement date has not been published.

Some plans offer an on-line training program that provides an attestation that you have completed this task.  Many plans direct providers and staff to the already-approved CMS-based training on these topics.  Other compliance and FWA training programs may be adequate as well; check with the plans to ensure that is so.  Providers may be asked to prove to the plan that the training has been completed for themselves and their staff.  This might be done via a dated certificate of completion or some other method of attestation; be sure to save these proof documents so that they can be retrieved later if needed.

Because of this mandate, some practices may wish to have a formal Compliance Plan document; Corcoran Consulting Group has such a document template that we will help you customize it based on your specific needs.

Recent News

iDose New Permanent J code

In December 2023, the US Food and Drug Administration approved iDose TR for a single administration per eye intracameral implant that continuously releases travoprost, indicated for ...

Federal Trade Commission Eyeglass Rule

Concluding a comprehensive multi-year review, the Federal Trade Commission (FTC) has announced final updates to its Ophthalmic Practice Rules, known as the Eyeglass Rule, aimed at ...

CMS Extends Deadline for MIPS 2023 Data Submission

CMS has extended the data submission period for the Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2023 performance year of the ...

Congress Passed bill for MPFS

The recent passing of a partial government funding bill by Congress on March 8 is important to Medicare beneficiaries. This bill includes policies aimed at addressing ...

Change to Processing for Telehealth Services Billed with POS 10

In calendar year (CY) 2024, the Centers for Medicare & Medicaid Services (CMS) issued a change to processing for telehealth services billed with POS 10. ...

Diabetes Cost Measure Misattributed to Ophthalmologists

The American Society of Cataract and Refractive Surgery (ASCRS), the American Society of Retina Specialists (ASRS) and the American Academy of Ophthalmology (AAO), met recently ...

Review Your 2022 MIPS Performance Feedback and Final Scores

The Centers for Medicare & Medicaid Services (CMS) has released the Merit-Based Incentive Payment System (MIPS) performance feedback and final scores for the 2022 performance ...

JZ Modifier Required July 1, 2023

The much-anticipated mandatory reporting of the JZ modifier for Part B Medicare begins July 1, 2023.  The new Medicare policy can be found here.  The ...

Cigna Hits the Brakes on Their New Modifier 25 Policy

Following fierce opposition from the physician community, the insurer Cigna announced today a delay in implementing a policy (PDF) that would have required submitting medical ...

Medical Consulting Group and Corcoran Consulting Group Announce Merger

Springfield, MO, April 27th, 2023. Medical Consulting Group (MCG), a provider of consulting services to ophthalmic practices and companies, and Corcoran Consulting Group (CCG), a ...

IHEEZO Gel gains Medicare Pass-Through

On March 13, 2023, Harrow® announced that the Centers for Medicare & Medicaid Services (CMS) has approved transitional pass-through reimbursement status for chloroprocaine hydrochloride ophthalmic ...

Cigna Change Modifier 25 Policy

As a result of a recent review, Cigna has announced it will require the submission of office notes with claims submitted for evaluation and management ...

Congress makes positive adjustments that affect ophthalmologists

In this Healio Video Perspective from Hawaiian Eye 2023, Kevin J. Corcoran, COE, CPC, CPMA, FNAO, discusses ophthalmic economic and regulatory updates for the year. ...

HHS Extends Covid-19 PHE

On Thursday, October 13, the U.S. Department of Health & Human Services (HHS) Secretary Xavier Becerra extended the nation's COVID-19 PHE for an additional 90 ...

Noridian Changes to Goniotomy LCD

Noridian has made changes to their Goniotomy coverage policy effective October 1st, 2022. It states: “Since there is no specific CPT® code for goniopuncture or ...

2021 MIPS Performance Feedback, 2021 MIPS Final Score, and 2023 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2021 performance year, ...

Telehealth Place of Service Update

With a recent change to telehealth billing, billers need to be aware of an additional Place of Service code. What changed? Effective January 1, 2022, ...

Extension of Telehealth Flexibility

Last week, the U.S. House of Representatives approved legislation to further extend the Medicare telehealth flexibilities first instituted in response to the COVID-19 pandemic. If ...

AETNA No Longer Requiring Prior Authorization for Cataract Surgery

The American Society of Cataract and Refractive Surgery (ASCRS) and American Academy of Ophthalmology (AAO) have spearheaded a year-long effort to remove the policy that ...

2021 MIPS Final Score Preview Now Available

The Centers for Medicare & Medicaid Services (CMS) has opened the Final Score Preview period for the Merit-based Incentive Payment System (MIPS).  You can now ...

Guidance for Coding Goniotomy

Summary:   Two new ophthalmic surgical products have attracted interest from surgeons:  Streamline Viscoelastic Injector® (New World Medical) and IACCESS™ trabecular trephine (Glaukos).  In both cases, ...

CIGNA Changes Their Modifier 25 Policy

As a result of a recent review, CIGNA will require the submission of office notes with all claims submitted with evaluation and management (E/M) CPT ...

CMS Reweights Scoring for Cost Category for Groups in 2021 Quality Payment Program

The Centers for Medicare & Medicaid Services (CMS) announced on Monday, April 25th, that ALL eligible MIPS providers will automatically receive re-weighting of the Cost ...

IACCESS™ Trabecular Trephine – How to Code?

Summary:   Glaukos’ new product, the IACCESS™ trabecular trephine, raises interesting coding questions.  Standalone procedures should be reported on a claim for reimbursement as unlisted procedure, ...