"cigna medicare services" is a service mark, and the "tree of life" logo is a...

"CIGNA Medicare Services" is a service mark, and the "Tree of Life" logo is a registered service mark, of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by operating subsidiaries, including Connecticut General Life Insurance Company and CIGNA HealthCare of Arizona, Inc., both of which are Medicare Advantage Organizations with a federal Medicare contract, and not by CIGNA Corporation.

“CIGNA Government Services" mean CIGNA Government Services, LLC, an affiliate of Connecticut General Life Insurance Company, Part B and DME Contracted Carrier for the Centers for Medicare & Medicaid Services.

Confidential property of CIGNA. Do not duplicate or distribute. All examples and fact patterns used herein are fictitious. © Copyright 2011 by CIGNA

Welcome to

2011

Medicare Compliance Training

for External Parties

(2011 – PowerPoint Version)

Overview of Programs

Introduction

Medicare Rules

Key Elements

Policies & Procedures

Protecting PHI

Conclusion

Agent/Broker Oversight

Introduction

The 2011 Medicare Compliance Training will cover the following topics:• Overview of CIGNA’s Medicare Programs• What Rules Must CIGNA Medicare Comply With?• Key Elements of a Compliance Program• Policies and Procedures• Protecting Personal Health Information (PHI)• Conclusion

Training Requirements

CIGNA has contracted with the Centers for Medicare & Medicaid Services (CMS) to offer multiple benefits to Medicare enrollees. As part of those contracts, CIGNA requires their employees who have direct or indirect involvement with the Medicare program to complete a Compliance training course.

Additionally, per the Federal Register Notice CMS-4124-FC, CMS clarifies that the training and communication requirements apply to all entities we partner with.

Therefore, CIGNA is making this training available in the event you do not have your own Medicare Compliance Training program established.


Introduction

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Protecting PHI

Conclusion


Introduction

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Lesson OneOverview of Medicare Programs


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Introduction

The government offers four different types of Medicare programs

Medicare Part A covers Hospital Care

Medicare Part B covers Medical Services

Medicare Part C covers Medical Services for Medicare Advantage

plans, like HMO, PPO, Private Fee for Service

Medicare Part D covers Prescription Drug

Plans

Overview of CIGNA’s Medicare Programs


Introduction

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Introduction

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Introduction

CIGNA offers three types of Medicare programs

CIGNA Government Services (CGS) -

Medicare B

CIGNA Medicare Part D Prescription Drug Program (PDP) -

Medicare D

CIGNA Medicare Select (HMO) - a Medicare

Advantage Prescription Drug (MA-PD) Plan available in Arizona (Maricopa and Pinal

counties)



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CIGNA Government Services (CGS)CGS has offices located in Nashville, TN, and Highpoint, NC and contracts with the Centers for Medicare & Medicaid Services (CMS).

CGS administers the Medicare Part B contract for NC and ID. This contract covers physician services, outpatient hospital care, and some other medical services (e.g. physical and occupational therapists) that Part A (hospital, hospice and skilled nursing home coverage) does not cover.

CGS has also been awarded the Durable Medical Equipment Regional Contract (DME MAC) for Region C, which encompasses 15 states in the southern United States. The DME contract covers equipment such as hospital beds, wheelchairs, oxygen, and diabetic supplies used by the beneficiaries in their homes.

On both contracts (Part B and DME MAC) services include claim payment, provider inquiry medical review and appeals processing. The Part B contract also includes the Provider Enrollment process for the covered states.



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CIGNA Government Services (CGS)

CGS Awarded A/B MAC Contract

On July 9, 2010, CGS was awarded the Medicare Part A/B MAC contract for Jurisdiction 15 which includes the states of Ohio and Kentucky. This contract covers physician services, outpatient hospital care, and some other medical services (e.g. physical and occupational therapists) as well as Part A services (hospital, hospice and skilled nursing home coverage).

The Jurisdiction 15 award also includes Home Health and Hospice workloads for Colorado, Delaware, District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming.



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CIGNA HealthCare of AZ offers two benefit plans

CIGNA Medicare Select Plus Rx (HMO)CIGNA Medicare Select Plus Rx – Dual (HMO SNP)

The CIGNA Medicare Select plans are located in Phoenix, AZ, and are contracted with the Centers for Medicare & Medicaid Services to offer Medicare Advantage Prescription Drug (MA-PD) benefits to Medicare eligible beneficiaries. Through this arrangement, Medicare pays CIGNA a set amount of money every month to provide medical and prescription drug coverage to Medicare beneficiaries.

What is CIGNA Medicare Select Plus Rx?CIGNA Medicare Select Plus Rx is a MA-PD Health Maintenance Organization (HMO) plan that provides medical and prescription drug coverage. CIGNA Medicare Select Plus Rx customers must receive services from network and/or contracted providers, except for emergent or urgent care, which may be obtained worldwide.

Medicare eligible beneficiaries who reside in Maricopa County or the Cities of Apache Junction or Queen Creek in Pinal County, do not have end stage renal disease, and have Medicare Parts A and B coverage are eligible for this plan.



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CIGNA HealthCare of AZ offers two benefit plans

CIGNA Medicare Select Plus Rx (HMO)

CIGNA Medicare Select Plus Rx – Dual (HMO SNP)

What is CIGNA Medicare Select Plus Rx – Dual (HMO SNP)?

CIGNA Medicare Select Plus Rx – Dual (HMO SNP) is an MA-PD

Health Maintenance Organization (HMO) Special Needs Plan

(SNP) which offers medical and prescription drug coverage to

beneficiaries who have dual coverage, such as Medicaid and

Medicare benefits.

CIGNA Medicare Select Plus Rx – Dual or CIGNA Medicare

Select beneficiaries must receive services from the CIGNA

Medicare Select network of providers. Emergent or urgent care

may be obtained anywhere within the United States.

Dual-eligible beneficiaries may join the CIGNA Medicare

Select Plus Rx – Dual (HMO SNP) plan at any time throughout

the year if the beneficiary resides in Maricopa County or

the cities of Apache Junction or Queen Creek in Pinal

County, does not have end stage renal disease, has

Medicare Parts A and B and maintains their dual-eligible

status.



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CIGNA Medicare Part D Prescription Drug Program (PDP)

CIGNA’s PDP program encompasses many offices with the core staff located in Bloomfield, CT and contracts with the Centers for Medicare & Medicaid Services (CMS) to provide:

• Individual prescription drug benefits for Medicare beneficiaries and • Employer-sponsored prescription drug plans.

Employer-sponsored prescription drug plans include:• Employer Retiree Drug Subsidy – Employers or unions with prescription drug

coverage that is at least as good as Medicare’s can apply to the Centers for Medicare & Medicaid Services (CMS) to receive a tax-free retiree subsidy.

• Employer-Specific PDP – The employer makes special arrangements with entities offering Part D Medicare plans (like, Connecticut General Life Insurance Company, CGLIC) to provide a retiree prescription drug plan that integrates the basic Part D individual coverage with the supplemental coverage (i.e., coverage for classes of prescription drugs not covered under Part D, such as coverage for Barbiturates and Benzodiazepines).



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Agent/Broker Oversight Lesson Two

What Rules Must CIGNA Medicare Comply With?


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What rules must CIGNA Medicare comply with?As a Medicare contractor, we must comply with numerous regulations. Listed below are several important links to these regulations and guidance issued by CMS.

Centers for Medicare & Medicaid Services (CMS):

http://www.cms.hhs.gov

Annual Part C and Part D Application link: http://www.cms.hhs.gov/PrescriptionDrugCovContra/04_RxContracting_ApplicationGuidance.asp#TopOfPage

Call Letter link: http://www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Announcement2011.pdf

Medicare Part D Manuals link: http://www.cms.hhs.gov/PrescriptionDrugCovContra/12_PartDManuals.asp#TopOfPage

Medicare Part C Manuals link:http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS019326&intNumPerPage=10

Instructions issued by the Centers for Medicare & Medicaid Services (CMS) via the Health Plan Management System (HPMS) link: http://www.cms.hhs.gov/PrescriptionDrugCovContra/HPMSGH/list.asp#TopOfPage Code of Federal Regulations (CFR) applicable to the Medicare link: http://www.access.gpo.gov/nara/cfr/cfr-table-search.html#page1

Pharmacies contracted with Medicare Sponsors (such as CIGNA), must comply with numerous regulations, for example:

Pharmacy specific instructions can be found at:

http://www.cms.hhs.gov/center/pharmacist.asp

Medicare Rules


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What rules must CIGNA Medicare comply with?

CIGNA and its contractors must comply with all applicable Medicare laws and regulations and any regulation deviations must be approved by Medicare. Through our contractual arrangements with the Centers for Medicare & Medicaid Services (CMS), CIGNA has agreed to adhere to all Medicare laws and regulations. The Centers for Medicare & Medicaid Services (CMS) regulations outline their expectations and CIGNA utilizes these regulations to develop our health plan operations, workflows, and internal processes to ensure we meet our contractual requirements.

CIGNA subcontractors must also ensure processes are in place to comply with regulations and develop applicable policies and procedures.

Medicare Rules


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Lesson ThreeCMS Key Elements of a

Compliance Program


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Key Elements of a Medicare Compliance Program According to the Centers for Medicare & Medicaid Services (“CMS”) the keyelements of an effective compliance program are:

• Written Policies and Procedures• Designation of a Compliance Officer and a Compliance Committee• Conducting an Effective Training and Education Program• Development of Effective Lines of Communication• Enforcement through Publicized Disciplinary Guidelines and Policies that deal

with Ineligible Persons• Auditing and Monitoring• Responding to Detected Offenses, Developing Corrective Action Initiatives

and Reporting to Government Authorities• Plan to Detect, Correct, and Prevent Fraud, Waste and Abuse

CMS requires plan sponsors to have written Standards of Conduct. One way thatCIGNA satisfies this requirement is through our Code of Ethics.

We are responsible for knowing, understanding and complying withCIGNA's Code of Ethics as well as the policies and procedures that apply to thework we do.

Key Elements of a Compliance Program


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I. Written Policies and ProceduresCMS requires plan sponsors to have written Standards of Conduct. One way that CIGNA satisfies this requirement, is through our Code of Ethics.

The Code of Ethics and related policies reflect CIGNA’s commitment to integrity, ethical conduct and legal/regulatory compliance.

A few of the policies you can find within CIGNA’s Code of Ethics are: • Conflict of Interest • CIGNA Assets

• Gifts and Entertainment

• Control, Accounting and Reporting

• Information Protection and Privacy

• Communications and Fair Disclosure

All entities contracted to perform work related to Medicare programs must review CIGNA’s Code of Ethics policies and procedures or have appropriate policies and procedures to address Code of Conduct policies, as well as Fraud, Waste and Abuse.



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I. Written Policies and ProceduresCIGNA’s Code of Ethics can be accessed by external contracted entities and individuals working on CIGNA’s behalf at this website address: http://cigna.com/about_us/governance/index.html. CMS requires entities not having their own Code of Ethics (Code of Conduct) policies to view CIGNA’s Code of Ethics training.

Corporate Governance: The Code of Ethics is located at www.cigna.com on the Corporate Governance page. Here, the Code of Ethics is available for clients, customers and other stakeholders who want to learn more about CIGNA’s commitment to integrity, ethical conduct and legal and regulatory compliance.



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II. Compliance Officer and Compliance CommitteeThe Medicare Part D Compliance Committee is led by the CIGNA Medicare Services Compliance Officer Rich Appel.

Members of the Committee are comprised of:

• CIGNA Senior Care President

• CIGNA Senior Care Operations Director

• CIGNA Senior Care Sales Director

• CHC-AZ MA-PD Operations Director

• CIGNA Special Investigations Unit Director

• CIGNA Legal Counsel

• CIGNA Pharmacy Management Clinical Director

• CIGNA Product Director

• CIGNA Pharmacy Management Network Director

The Arizona Medicare Compliance Officer is David Hu. David also leads theArizona Medicare Operations Compliance and Quality Committee (MOCQC).

The Arizona Compliance Committee is comprised of: • Vice President of AZ Medicare Operations • Regional/Local Quality Mgt• Delegated Oversight Mgt • Provider Network and Contracting Mgt • Cigna Medical Group Operations Directors and Mgt • Pharmacy Services Administration Mgt • Sales and Enrollment Mgt. • Appeal, Call Center, Claims, and Credentialing Mgt



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III. Disciplinary GuidelinesCompliance with CIGNA’s Code of Ethics and related policies as well as applicable Medicare Policies and Procedures Manuals (which incorporate legal and contractual requirements), is an ongoing performance objective for all CIGNA Medicare Services contractors.

Disciplinary actions are discussed within CIGNA’s Code of Ethics at http://cigna.com/about_us/governance/index.html.

On a case-by-case basis, the severity of the disciplinary action will be determined by the CIGNA Medicare Services Compliance Officer.

Violation of CIGNA’s Code of Ethics and related policies and/or CIGNA’s operational policies and procedures may result in disciplinary action, up to and including contract termination.



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IV. Auditing & MonitoringCIGNA Audit Programs include:

• Risk Assessment• CIGNA conducts an annual risk assessment, supplemented by a quarterly

enterprise risk assessment, to evaluate functional areas of the organization to assess potential business or control risk. Results of the assessment are scored and those areas identified as the highest risk are considered when developing the internal audit plan. Other factors are considered in the risk assessment such as areas at risk of not meeting the Centers for Medicare & Medicaid Services (CMS) standards.

• Internal Audits• The CIGNA Medicare Services Compliance Officer will coordinate with

management to implement the internal audit plan. Audits will be performed to ensure adherence to the Centers for Medicare & Medicaid Services (CMS) requirements and CIGNA’s internal policies and procedures.

• Corrective action plans will be developed and implemented in areas where processes do not meet the requirements.

• External Entity Oversight• CIGNA Medicare Services is also subject to audits from external parties

such as the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG).

• Corrective action plans for any deficiencies or findings reported during external audits will be developed and implementation will be monitored to ensure processes are strengthened and regulations are followed.



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V. Responding to Detected Offenses

Violations of the:

• Compliance Program, • federal and state statutes, • rules and regulations, or • any other types of misconduct

Will be investigated by the CIGNA Medicare Services Compliance Officer ordesignee.



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Reporting of detected criminal violations• If you know of, or reasonably suspect, a misappropriation of CIGNA assets or any other

violation of law, ethical or business policies you must report the matter

Reporting Obligation• It is the obligation of every employee and individual working on CIGNA’s behalf who knows of

or reasonably suspects a violation of CIGNA's Code of Ethics to promptly report it.

• Unless a specific policy states otherwise, the report may be oral or written, and made to: Ethics Help Line at 1.800.472.8348 or https://cignaethicshelpline.alertline.com/gcs/welcome or through the CIGNA Medicare Services Compliance Officer or Arizona Medicare Compliance Officer, as applicable.

Non-Retaliation • CIGNA will not discriminate or retaliate against anyone who, in good faith, reports violations of

laws or regulations, the Code of Ethics, or other company policies, whether those violations are by a CIGNA company, another employee or agent. In addition, employees are protected by federal law against any retaliation for taking action under the federal False Claims Act.

Compliance is Everyone’s Business…and it begins with you!



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V. Responding to Detected Offenses CIGNA’s Ethics Help Line• To facilitate confidential and retribution-free reporting of violations and requests for

information about CIGNA’s Code of Ethics, CIGNA has a toll-free, 24-hour Ethics Help Line (1.800.472.8348). Calls can be made anonymously at your discretion, or you can email https://cignaethicshelpline.alertline.com/gcs/welcome.

CIGNA's Fraud Hot Line• To facilitate confidential and retribution-free reporting of suspected fraud and

requests for information about CIGNA's Fraud, Waste and Abuse policies, or to report possible fraud, CIGNA has a a toll-free 24-hour Fraud Hotline (1.800.667.7145) and email box at [email protected].

CIGNA’s Privacy Office

• All information reported by CIGNA employees, enrollees, individuals working on CIGNA’s behalf or others shall be kept confidential by CIGNA to the extent

reasonably possible during any resulting investigation; however, it is possible that such individual’s name may become known or may have to be revealed in certain instances when governmental authorities intercede, or as may be otherwise required by law. If you have questions related to CIGNA’s Privacy Policy you can contact CIGNA’s Privacy Office at [email protected].

Information and Data Security• CIGNA’s Information Protection Policy outlines safeguards and activities needed to protect proprietary information and avoid unintended disclosures. If you witness an

act that looks like a policy violation or puts CIGNA information at risk, tell your manager, HR representative, contact CIGNA Medicare Services Compliance Officer, or call 1.800.4SAFEPC.



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Developing Corrective Action Initiatives

• Reports of suspected misconduct will be investigated and if a violation of applicable law or regulation is found to exist, CIGNA will take steps to correct the problem which may include: Development of a corrective action initiative, or, if material, Immediate referral to criminal and/or civil law enforcement

authorities, and Disclosure to CIGNA senior management and the appropriate

governmental authority, where appropriate.

Reporting to the Government

• CIGNA shall report to appropriate governmental authorities, such as the Centers for Medicare & Medicaid Services (CMS) and the Department of Health & Human Services’ Office of Inspector General (OIG), credible information of material violations of the law by CIGNA, subcontractors, providers or enrollees for a determination as to whether any criminal, civil, or administrative action may be appropriate.



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VI. Plan to Detect, Correct, and Prevent Fraud, Waste, and Abuse

The Centers for Medicare & Medicaid Services (CMS) requires all Medicaresponsors to develop a comprehensive program to detect, correct and preventFraud, Waste and Abuse (FWA).

Entities contracted with CIGNA should also have appropriate policies andprocedures to address fraud, waste, and abuse

To reflect CIGNA’s commitment to the Medicare program, CIGNA’s Special Investigations Unit:

• Administers required annual anti-fraud training for key employees;

• Detects, deters and investigates suspicious

claims;

• Provides methods to report suspicious

activity;• Maintains a process for receiving and documenting complaints of internal and external fraudulent activity;• Files reports and quarterly documentation regarding fraud, waste and abuse to the Centers for Medicare & Medicaid Services (CMS); and • Assists CMS and state and federal law enforcement in investigational activity.



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FWA Detection - the Special Investigations Unit (SIU) uses a variety of means to

help employees detect suspicious claims:

• Referrals from claim processors and customer service representatives• Red Flags Job Aids

- Medical – Medicare Part C - Pharmacy – Medicare Part D

• A dedicated phone line and email box for reporting suspected FWA• Data mining• CIGNA Pharmacy Management’s (CPM) Audit Vendor Program• CIGNA’s Narcotic Therapy Management Program

CIGNA’s SIU communicates with other SIUs, law enforcement, regulatory agencies, the

Centers for Medicare & Medicaid Services (CMS), Medicare Drug Integrity Contractors

(MEDIC) and trade groups to identify schemes and/or suspect pharmacies.



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FWA Investigation

The Special Investigations Unit (SIU) gathers information and evidence by:

Auditing claims

Interviewing members and providers

Reviewing medical records and prescriptions

Data mining

Documenting findings



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FWA Investigation

The Centers for Medicare & Medicaid Services (CMS) has contracted withcertain companies to be Medicare Drug Integrity Contractors (MEDIC).

The Special Investigations Unit (SIU) will refer cases of suspected FWA to theMEDIC for investigation.

The MEDIC’s activities include:

• Data analysis to identify potential Part D fraud;

• Investigation of potential Part D fraud for referral to law enforcement;

• Liaison to law enforcement/sponsors for Part D issues; and audits of sponsor and subcontractor Part D operations.



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FWA Prosecution

CIGNA takes appropriate action against fraud offenders by:

• Stopping payments to providers;

• Referring cases to state and federal law enforcement for legal action;

• Partnering with state insurance departments, fraud bureaus and professional organizations;

• Pursuing sanctions through state licensing boards; and

• Within 30 days of identifying a suspicion of fraud or the documentation of fraud, the Special Investigations Unit (SIU) will make a referral to the Medicare Drug Integrity Contractor (MEDIC) and the appropriate state Department of Insurance.



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FWA Restitution

CIGNA’s Special Investigations Unit tries to recover losses incurred due tofraud by:

• Pursuing and recovering damages;

• Pursuing civil remedies; and

• Pursuing criminal charges.



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FWA Prevention

Increased fraud awareness is created by:.

• Requiring training programs for key CIGNA employees, vendors and partners;

• Maintaining anti-fraud policies and procedures;

• Communicating new fraud schemes with CIGNA employees; and

• Identifying control weaknesses.



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Reporting suspected Fraud, Waste and Abuse

Please refer all suspicious claims to [email protected]

Calls pertaining to Medicare FWA should be directed to the Fraud Hot Line at 1.800.667.7145



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Lesson FourPolicies and Procedures


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Policies with provisions of special relevance to Medicareinclude but are not limited to:

Conflict of Interest

OIG/GSA Exclusion Review

Record Retention

Anti-Kickback

False Claims

Policies and Procedures


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Conflict of InterestsConflicts of interest can arise if you have a direct or indirect financial, business or personal involvement with a current or potential supplier, competitor, customer, or employee of CIGNA.

In addition, outside financial or business involvement by members of your immediate family, or by persons with whom you have a close personal relationship, may create a possible conflict of interest for you. As an individual working on CIGNA’s behalf:

• You must not take part in any transaction in which you have a personal interest if there is, or might appear to be, a conflict between your interest and the interests of CIGNA.

• You must not take part in any business transaction in which you have a personal interest if your participation is in any way related to information you received, or a relationship you developed, as an employee or director.

• You should not show preferential treatment to any provider or supplier regardless of their relationship with CIGNA. If you become aware of a situation involving preferential treatment to providers or suppliers, you should notify the CIGNA Medicare Services Compliance Officer immediately.

Each provider or entity that contracts with CIGNA will require its managers, officers and directors responsible for the administration or delivery of Part D benefits to sign a conflict of interest statement, attestation, or certification at the time of hire and annually thereafter certifying that the manager, officer or director is free from any conflict of interest in administering or delivering Part D benefits.



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OIG/GSA Exclusion ReviewOffice of Inspector General (OIG) and General Services Administration (GSA) Exclusion Review

CIGNA will not knowingly hire any individual or contract with any person or entity for it Medicareprogram who has been convicted of a criminal offense related to health care or who is listed by afederal agency as debarred, excluded, or otherwise ineligible for participation in a federal health careprogram.

CIGNA will review the Department of Health & Human Services Office of Inspector General (OIG) andGeneral Services Administration (GSA) exclusion lists to ensure that its Medicare employees andsubcontractors are not included on such lists. Primary source is NPDB for initial credentialing andre-credentialing, and CAQH for ongoing monitoring.

If CIGNA learns that an employee or contracted provider is on an OIG/GSA list, CIGNA will notify theindividual and remove the individual from any work directly or indirectly related to Federal healthcareprograms. CIGNA will also take appropriate corrective actions, which will include payment recovery forsanctioned and excluded providers.

If CIGNA learns that an individual is charged with a criminal offense related to health care or proposedfor exclusion or debarment, the individual shall be removed from direct responsibility for or involvementin all such Medicare activities until resolution of such charges or proposed debarment or exclusion.

During the contracting process, CIGNA requires all contracted entities to attest that they (i) have policies and procedures which ensure that any employee or manager responsible for administering or delivering Medicare services or benefits, is not excluded from Federalhealth care programs and (ii) review the OIG and GSA exclusions lists. The OIG and GSA listswill be checked upon initially hiring and annually thereafter. Additionally, if an employee is identified to be on such lists, that employee will immediately be removed from any work related directly or indirectly to all Federal health care programs and the entity will take appropriatecorrective actions.



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Record RetentionUnless specific conditions apply, all relevant Medicare Part C & D records will bemaintained for 10 years from the end of the final contract period or completion of anaudit, whichever is later.

CMS has authority under section 1860D–12(b)(3)(c) of the Act and §422.504(e)(2) and §423.505(e)(2) to inspect and audit any books, contracts, and records of a Part Dsponsor or MA organization and its first tier, downstream, and related entities thatpertain to any aspect of services performed, reconciliation of benefit liabilities, anddetermination of accounts payable under the contract or as the Secretary may deemnecessary to enforce the contract.

All records created in the course of business are the property of CIGNA and will bemaintained in compliance with all legal, regulatory, and/or government contractrequirements.

Unauthorized disposal or removal of records from CIGNA is prohibited.

Only official records should be retained and they should be accurate andcomplete.



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Introduction


Anti-KickbackIt is CIGNA’s policy to strictly comply with all laws that regulate governmentcontracting.

You must not offer, give, request, or receive anything of value for free or below fairmarket price in connection with the sale or recommendation of, or referral to, anybenefit plan, product or service paid partly or fully by any government program.

To ensure compliance with this policy, contracts or other business arrangementsbetween CIGNA and any health care provider or supplier (including pharmaceuticalcompanies), and between CIGNA and any government agency or program, must be inwriting and must be reviewed and approved by the member of CIGNA's legaldepartment assigned to the relevant business division.


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Anti-Kickback ExamplesExamples of potential violations would include:

• A medical provider group compensates a referral coordinator for channeling members to their practice.

• A pharmacy’s waiving of Medicare co-payments in order to encourage enrollees to fill their prescriptions there.

• A Medicare Part D plan sponsor’s acceptance of a pharmaceutical manufacturer’s offer of a free disease management program in return for encouraging Medicare enrollees to use the manufacturer’s products.

• A drug manufacturer’s provision of a free trip to an employee of a Medicare Part D plan sponsor in return for the plan sponsor’s decision to place the manufacturer’s drug in the preferred tier of the plan’s Medicare formulary.



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Introduction


False ClaimsMaking a false statement, or the submission of false claims, is among the government’shighest fraud and abuse concerns. Such actions can result in criminal prosecution, up to 5 years imprisonment and/or a fine of up to $500,000.

Examples of False Claims

Anyone who participates in submitting a false or fraudulent claim to the United States government for payment, including Medicare or Medicaid claims, can be held personally liable. Examples of prohibited conduct include, but are not limited to:

• Filing a claim for services that were never provided, were medically unnecessary, or were described inaccurately; • Inflating the number of claims processed or failing to process any claims; and • Falsifying data entered into a reimbursement-related database, cost reports, Medicare enrollee satisfaction data, or audit-related documents.


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False ClaimsAs an individual working on behalf of CIGNA, you must:

• Ensure the integrity of the product or service provided, and of the related submissions made to the government.

• Never falsify a document or knowingly submit misleading information. Exercise due care and due diligence by verifying the accuracy of all data on which the certification is to be made.

• Take every submission of information to the government seriously and review the underlying requirements associated with certifications.

• Report any false, inaccurate, or altered requests for payment or claims to a CIGNA Medicare Services Compliance Officer, CIGNA’s Chief Compliance, Ethics & Privacy Officer, CIGNA Legal Counsel or contact CIGNA’s Ethics Help Line (1.800.472.8348). Employees and subcontractors are protected from retaliation for False Claims Act complaints under 31 U.S.C. § 3730(h) and other applicable anti-retaliation protections.


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Lesson Five Protecting Personal Health Information

(PHI)


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Protecting PHI

The HIPAA Privacy and Security Rules protect Individually Identifiable Health Information, referred to as Protected Health Information (PHI), held or transmitted by a Covered Entity (Health Care Professionals, Health Plans, Health Care Clearinghouse) and their Business Associates (entities that complete functions on the Covered Entity’s behalf, such as Medicare subcontractors).

PHI includes information that identifies the individual or could reasonably be used to identify the individual. PHI is information, including demographic data, which relates to the:

• Individual’s past, present or future physical or mental health or condition;

• Health care provided to the individual; or

• Past, present, or future payment for health care provided to the individual.

The HIPAA Privacy Rule protects all PHI in any form or media, whether electronic, paper or oral. The HIPAA Security Rule applies only to electronic PHI (e-PHI). In general, this rule requires a Covered Entity to adopt additional safeguards for e-PHI ensuring the confidentiality and availability of all it creates, receives, uses, maintains, or transmits.

The Health Information Technology for Economic and Clinical Health (HITECH) Act expands certain HIPAA Privacy and Security requirements to cover Business Associates and to provide individuals with additional rights to access and control the use of their PHI, among other things.

As you can see, PHI is a critical concept that you must be familiar with.

Protecting Individually Identifiable Health Information (PHI): High Level Overview of the HIPAA Privacy & Security Rules


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All of the elements in this chart could be PHI either alone or if combined in a way that would allow for an individual to be identified. Let’s look at a couple of examples of information CIGNA holds as a Medicare subcontractor.

– Zip code alone would not be PHI, but this data element combined with address and phone number would be PHI. This is because the combination of these data elements could be used to identify an individual.

– Birth date alone would not be PHI, but coupled with SSN and claim numbers could result in identification of an individual and would be considered PHI.

– Social Security Number (SSN) alone would be PHI as this data element can be used to identify an individual.

So, it is important to remember that the context and combination of information elements will determine whether information is PHI. If you have any questions about what is or is not PHI, always check with the CIGNA Privacy Office.

Examples of Protected Health Information (PHI)

Zip Code Address Name Telephone and/or Fax Numbers

Medical Record Number

Health Plan Beneficiary Numbers

Vehicle Identifiers and Serial Numbers

Birth Date Names of Relatives and Employers

Certificate/License Numbers

Social Security Number (SSN)

Benefit Coverage Information

Account Number Finger and Voice Prints

E-mail and IP (Internet Protocol)

Address

Alternative Member Identifier (AMI)

Device Identifiers URL (Uniform Resource Locator) or

web address

Full Face Photo Date of Service

Medical Information (Medical Records, Lab Values, Health Risk Assessments

Claim Numbers/Data Eligibility/Enrollment Data

X-Rays Employer’s Name

Protecting PHIProtecting Individually Identifiable Health Information (PHI)


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Protecting Individually Identifiable Health Information (PHI) Additional Requirements

Safeguarding Protected Health Information – Members of the workforce must employ the appropriate administrative, technical and physical safeguards to protect the privacy of protected health information.

Use & Disclosure of Information: PHI Confidential information cannot be disclosed to others without the individual’s written authorization except for the purposes of treatment (providing care), payment (claim payment) or health plan operations (examples include, but are not limited to: audits and fraud and abuse detection).

Minimum Necessary – When collecting, accessing, using or disclosing PHI, or when requesting PHI to perform job functions, members of the workforce must make reasonable efforts to limit the use and disclosure to the minimum necessary to accomplish the intended purposes of the use or request.

Verification – Members of the workforce must follow CIGNA's procedures to verify the identity of a person requesting PHI and the authority of any such person to have access to PHI.

Notice of Privacy Practices: Individuals must receive and have access to a “Notice of Privacy Practices” which describes how their health information may be used or disclosed by CIGNA and what individual rights they have in relation to this information.

Individual Privacy Rights – The HIPAA Privacy Rule provides individuals with certain rights related to their PHI. These rights include: they can have access to their PHI; request amendment to their PHI; obtain an accounting of disclosures of their PHI; request restrictions on the use and disclosure of their PHI; and request alternate means of communicating with them, such as sending materials to an alternative address or location; and lodge a complaint if they believe there has been a violation of their privacy rights.


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Protecting PHI

Protecting Individually Identifiable Health Information (PHI)

Frequently Asked Questions regarding transmitting PHI:

PHI via the “Internet” – Even when transmitting PHI for permitted or required purposes (e.g., based on an individual’s authorization), it is NEVER acceptable to transmit PHI via e-mail over the internet unless the email is encrypted through the use a SecureMessage process. You MUST utilize a “SecureMessage” process.

Additionally, CIGNA's IT department has provided a secure electronic transmission solution for Medicare Part D and PFFS business with our subcontractors NationsHealth and Accenture. As a result, email sent to the following email extensions is secure:NationsHealth (email addresses ending with @uspgi.com, @nationshealth.com, and @nhrx.com) and Accenture (email addresses ending with @accenture.com).

We do not have a secure connection with the Centers for Medicare & Medicaid Services (CMS). These are email addresses ending with @cms.hhs.gov.

Important note: Even if CMS inadvertently transmits PHI, we should never reply or forward the email without removing the PHI or securing the message appropriately by using the SecureMessage solution.

PHI via fax – Prior to faxing PHI, you should ensure the receiving fax machine is attended and an authorized person is waiting to receive the fax.

For more information on any of CIGNA’s privacy practices, please see: http://www.cigna.com/privacy/index.html.


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If a member of the workforce (including a contractor) or a subcontractor becomes aware of any potential violation of the HIPAA Privacy or Security Rules, HITECH Act or CIGNA's Privacy Policies and Procedures, they should take the following steps:

Report the issue either orally or in writing to any manager, the CIGNA Medicare Services Compliance Officer, or to CIGNA’s Privacy Office.

CIGNA Medicare Services Compliance Officer – Rich Appel – 860.226.7696

CIGNA Arizona Medicare Compliance Officer – David Hu – 602.371.2429

CIGNA Privacy Office – via e-mail to - [email protected]

Instances of potential non-compliance with the Privacy & Security Rules, HITECH Act and CIGNA's Privacy Policies and Procedures

will be investigated and appropriate disciplinary action will be taken as needed.


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Reporting Privacy Policy Incidents

Report privacy complaints and incidents promptly so that appropriate action can be taken.

All employees, managers, contractors, and subcontractors will immediately notify the CIGNA Medicare Services Compliance Officer or the CIGNA Privacy Office of any incident involving a potential violation of the HIPAA Privacy or Security Rules, HITECH Act or CIGNA's Privacy Policies and Procedures.


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The Health Information Technology for Economic and Clinical Health Act (HITECH)

HITECH enhanced the existing HIPAA Privacy & Security Rules. The fundamental intention of HITECH is to promote the establishment and use of Electronic Health Records (“EHRs”). An EHR is an electronic record of health-related information about an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff.

HITECH also established new rules for the use and protection of PHI, and defined requirements for the identification, notification, and reporting of a breach - the unauthorized acquisition, access, use, or disclosure of PHI which compromises the security or privacy of such information, except where an unauthorized person to whom such information is disclosed would not reasonably have been able to retain such information.

Under HITECH, more severe civil and criminal penalties may be imposed on Covered Entities, Business Associates and individuals for violations of HIPAA.

Now more than ever, it will be important for you to notify the appropriate area within CIGNA (CIGNA Medicare Services Compliance, CIGNA Privacy Office, CIGNA Business Lead) of any inappropriate access, acquisition, misuse, or loss of PHI.


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Conclusion

Thank you for your time and attention.

Please carefully read the certification on the following slide. Contracted entities can print, sign, and date the certification and retain to support completion of the annual Medicare

Compliance Training requirement


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Completion of CIGNA’s 2011 Medicare Compliance Training

Certification

I hereby certify that I have received, read and understand the written standards of conduct related to Medicare Compliance, including the laws and regulations related to Fraud, Waste and Abuse, that I have been trained on such standards, and that I understand my responsibility to comply with the requirements of such standards.

Signature: ____________________________________________________

Date: ___________________________

Retain for your records.

Confidential property of CIGNA. Do not duplicate or distribute. All examples and fact patterns used herein are fictitious.

© Copyright 2011 by CIGNA

Certification


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