Business Ethics & Fraud, Waste and Abuse Prevention

This course is for front-line staff, billers and supervisors at DME/HME suppliers, community pharmacies and medical billing companies. It explains, in plain language, the federal laws that govern health care claims and the everyday decisions that keep you and your employer on the right side of them.

You will learn the CMS definitions of fraud, waste and abuse; the False Claims Act, including whistleblower and anti-retaliation protections; the Anti-Kickback Statute and safe harbors; the Stark Law; the Civil Monetary Penalties Law and beneficiary inducements; criminal health care fraud; OIG exclusion and LEIE screening; and the seven elements of an effective compliance program from OIG’s November 2023 General Compliance Program Guidance.

Two lessons focus on real risk areas: proof of delivery, documentation, upcoding, unbundling, refills and telemarketing rules for DME suppliers, and return-to-stock, inducements and compounding for pharmacies. The final lesson covers conflicts of interest, gifts, accurate records, the 60-day overpayment rule, and how to report concerns without fear of retaliation.

The course includes six lessons with knowledge checks and a 25-question final assessment. A score of 80% (20 of 25) is required to pass and receive a certificate of completion.