CurrentFlorida BluePolicy N/A

Preventing Medicare Fraud, Waste, and Abuse (FWA)

This document sets Florida Blue expectations and resources for first-tier, downstream, and related entities (FDRs) to detect, prevent, and report Medicare fraud, waste, and abuse and to comply with CMS requirements for codes of conduct and training.

Policy Summary

PayerFlorida Blue

PolicyPreventing Medicare Fraud, Waste, and Abuse (FWA)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFDRs must adhere to Florida Blue standards of conduct or adopt a code consistent with CMS requirements and complete FWA training.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Code of ConductCode of Conduct requirement

TrainingRequired training

ReportingReporting channels

OIG/GSAExclusion lists

FWA Prevention and Compliance Expectations

FWA prevention and compliance expectations

Requirements and recommended actions for first-tier, downstream, and related entities (FDRs):

FDRs must adhere to Florida Blue standards of conduct or adopt a code of conduct consistent with CMS requirements (42 CFR §§ 422.503(b)(4)(vi)(A) and 423.504(b)(4)(vi)(A)).

The code of conduct should reflect a commitment to detecting, preventing, and correcting noncompliance with Medicare requirements when delivering Medicare services.

FDRs are required to complete general compliance and fraud, waste, and abuse (FWA) training.

FDRs should review Florida Blue resources: Compass Code of Ethical Business Conduct and the Ethics & Compliance section on FloridaBlue.com (includes FAQs, Medicare Compliance and FWA Training, and OIG/GSA exclusion lists).

Policy Summary

PayerFlorida Blue

PolicyPreventing Medicare Fraud, Waste, and Abuse (FWA)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFDRs must adhere to Florida Blue standards of conduct or adopt a code consistent with CMS requirements and complete FWA training.

SourceLink

On This Page

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Required Provider Actions and Reporting

Documentation Required

Code of Conduct — FDR requirement

FDRs must adhere to Florida Blue standards of conduct or adopt and follow a code of conduct consistent with CMS requirements (42 C.F.R. §§ 422.503(b)(4)(vi)(A) and 423.504(b)(4)(vi)(A)). The code should reflect a commitment to detecting, preventing, and correcting noncompliance with Medicare requirements when delivering Medicare services.

Note

Reporting channels for suspected FWA

Report suspected fraud, waste, or abuse using the provided confidential channels: EthicsPoint (anonymous option), the Florida Blue SIU online fraud form, SIU email, or the Fraud Hotline/Business Ethics contact phone numbers.

EthicsPoint (confidential; option to remain anonymous) — via link provided
File a report with Florida Blue SIU at FloridaBlue.com/general/fraud-form
Email SIU: SpecInvestUnit@BCBSFL.com
Fraud Hotline: 1-800-678-8355
Business Ethics, Integrity, and Compliance Division: 1-800-477-3736, ext. 56300

Defined Terms

First Tier Entity

Definition (regulatory)A First Tier Entity is any party that enters a written arrangement acceptable to CMS with a Medicare Advantage Organization or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program (See 42 C.F.R. § 423.501).

Relationship to Florida BlueApplies to any organization contracting with Florida Blue to provide administrative or health care services for Medicare-eligible members under MA or Part D programs.

Contracting requirementMust enter a written arrangement acceptable to CMS as part of the contractual relationship.

Scope of responsibilitiesCovers entities providing either administrative services or health care services to Medicare-eligible individuals under the MA or Part D programs.

Regulatory citationReferenced regulation: 42 C.F.R. § 423.501.

OpenPayer

Preventing Medicare Fraud, Waste, and Abuse (FWA)

FWA Prevention and Compliance Expectations

Exclusion Screening / Code References

Required Provider Actions and Reporting

Defined Terms