Unitedhealth Group Incorporated · NYSE:UNH
Unitedhealth — Investor Presentation (July 2021)
19 slides from Unitedhealth's investor presentation, July 2021
Slide 1: Fraud, Waste and Abuse (FWA) and General Compliance Training
Fraud, Waste and Abuse (FWA) And General Compliance Training
Slide 2: Introduction
Introducti on Fraud, waste and abuse continue to take a heavy toll on the health care system. In 2017 the United States Department of Justice recovered nearly $2.4 billion from health care fraud schemes. A compliance program contains measures to prevent, detect and correct fraud, waste and abuse. We
Slide 3: FWA Definitions
FWA FRAUD Definitions Fraud is intentionally misrepresenting or concealing facts to obtain something of value. The complete definition has three primary components. • Intentional dishonest action or misrepresentation of fact • Committed by a person or entity • With knowledge that the dishonest actio
Slide 4: Detect Suspicious Activity
Detect Suspicious Activity Provider Fraud and Abuse Key Indicators: • Submitting bills or claims for treatment or services that were never provided • Falsifying the date of service to correspond with a member’s coverage period • Billing for non-covered services using incorrect codes in an attempt to
Slide 5: Detect Suspicious Activity
Detect Suspicious Activity Pharmacy Fraud and Abuse Key Indicators: • Inappropriate pharmacy billing – Billing for medication that was never dispensed – Billing for brand name drugs, but dispensing generics • Prescription drug shorting – Intentionally providing less than the prescribed quantity and
Slide 6: Detect Suspicious Activity
Detect Suspicious Activity Employee Fraud and Abuse Key Indicators: • Falsification of patient records by an employee • Recording untrue information in a patient record Note: If the patients that had their records falsified were being served through a government program, billing for services related
Slide 7: Report Suspicious Activity
Report Suspicious Activity Health care fraud impacts everyone. It is your responsibility to report any and all suspicions of fraud, waste and abuse; violations of policies or procedures and federal or state laws; and illegal or unethical conduct. <Enter where your employees can report suspicious act
Slide 8: Health Care Fraud Awareness and Legal Consequences
Enforcement Elements Health care Awareness fraud, waste and abuse is on the rise. Anti-fraud and abuse laws protect insurers, their employees and members, as well as public health benefit programs and taxpayer dollars. There are legal consequences for committing fraud, waste and abuse. The actual co
Slide 9: HIPAA Awareness
Enforcement Elements HIPAA Awareness The U.S. Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) • Includes fraud and abuse provisions that strengthen Federal enforcement tools • Protects patient privacy and against medical identity theft Title II of HIPAA includes provision
Slide 10: U.S. Federal Health Care Fraud Statute
Enforcement Elements Awareness U.S. Federal Health Care Fraud Statute • Makes it a crime to defraud any health care benefit program • Only requires evidence that fraud has occurred to prosecute In addition to the laws that address the protection of government dollars, the Federal Health Care Fraud S
Slide 11: U.S. Federal and State Anti-Kickback Statutes
Enforcement Elements Awareness U.S. Federal and State Anti-Kickback Statutes • Makes it a crime to reward others or themselves for medical referrals • Prevents providers from profiting from referrals Federal and state anti-kickback statutes make it a crime to knowingly and willfully offer, pay, soli
Slide 12: U.S. Stark Law
Enforcement Elements Awareness U.S. Stark Law The U.S. Stark Law, which focuses on physician self-referrals, is related to anti- kickback statutes; both are intended to prevent health care providers from inappropriately profiting from referrals. This means a physician generally may not refer a patie
Slide 13: U.S. False Claims Act
Enforcement Elements Awareness U.S. False Claims Act • Prohibits filing of false or fraudulent records, statements or claims • Claim is broadly defined to include any submission that results or could result in payment. • Provides protection for those who report suspicions of fraud. The U.S. Federal
Slide 14: U.S. False Claims Act (cont.)
Enforcement Elements Awareness U.S. False Claims Act (cont.) The U.S. Health Care Reform Law of 2010 (Patient Protection and Affordable Care Act) expanded the False Claims Act to add liability for reverse false claims. Under the reverse false claims provisions, overpayments or any funds received or
Slide 15: U.S. State False Claims Acts
Enforcement Elements Awareness U.S. State False Claims Acts U.S. State False Claims Acts have been enacted in several U.S. states to discourage fraud against state health care programs. Medicaid programs and related submissions are subject to both the Federal and State False Claims Acts.
Slide 16: We all have a role to play
We all have a role to play - be alert for suspicious activities that have the potential for fraud, waste and abuse and respond by reporting anything you may notice. The Company relies on all of us to raise our hands when we see something suspicious.
Slide 17: Attestation
ATTESTATION (optional) By completing the Signature fields, you confirm you understand the information you read and agree to the reporting expectations. Please provide your First and Last name to complete the signature below and save a copy of your attestation for your records. First Name: Last Name:
Slide 18: Appendix
APPENDIX
Slide 19: Regulatory Definitions of Fraud, Waste, and Abuse
REGULATORY DEFINITIONS OF FRAUD, WASTE, AND ABUSE PROGRA MEDICARE ADVANTAGE and PART D PROGRAMS M: TERM DEFINITION SOURCE FRAUD Fraud is knowingly and willfully executing, or attempting to execute, a United States Code – 18 U.S.C 1347 scheme Medicare Managed Care Manual, Chapter 21 – or artifice
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