Fraud & Abuse Training required for Medicare Advantage Plans

CMS has required that all providers who provide health care services to Medicare members under Medicare Advantage or Medicare Part D Programs complete compliance training on Fraud and Abuse by December 31, 2009. Many providers are unaware of this mandate, but the insurance carriers are taking it seriously. We have been advised by two insurance carriers that offer Medicare Advantage Programs that they will be enforcing the compliance training requirement.

If providers do not complete the compliance training the carriers can withhold payment for services or worse, terminate the provider’s contract. One of the carriers we have spoken with advised us that if the provider does not have a certificate on file stating they have completed the compliance training then they will withhold all payments. The other carrier stated that initially they will not withhold payment, but will contact any providers who do not have the certificate on file to discuss the training. However, if the providers who have not completed the training do not make attempts to comply they will eventually begin to withhold payments.

CMS offers an online training that takes about 85 minutes to complete. It can be found at . Some carriers who offer Medicare Advantage Plans are also offering their own compliance training plans that CMS is recognizing. Our local BC offers an online slide presentation that only takes about 10 minutes that qualifies. At the end of the training there is a certification statement that is to be completed. In this case, BC will keep the certification statement on file for the provider and will verify to any other insurance carriers of Medicare Advantage Plans that the provider has completed the training.

The compliance officer for the provider’s office must complete the training. Then they are responsible for educating their staff, either by having each staff member complete the training as well, or by having them complete a training that the compliance officer puts together as a result of the training they took. The training must be repeated on a yearly basis.

Medical billing information


4 Responses to “Fraud & Abuse Training required for Medicare Advantage Plans”

  1. Yasmin Says:

    Please let me know when and how we could be certified by the CMS for the above email.

  2. Cyndee Weston Says:

    The AMA has clarified fraud-compliance training requirements for physicians who participate in Medicare Advantage (MA). CMS clarifies that MA plans may provide training directly or may provide (emphasis) appropriate training materials. The clarification does not say MA plans must certify physicians in its network. It is up to a practice to determine if it wants to participate in the MA fraud compliance training. See this document

    Additionally one might assume that if a provider is contracted with dozens of plans all requiring them to do the same training, it’s a huge waste of time and effort. Physicians that participate in Medicare have already agreed not to bill anything fraudulent through affirmation of their agreement to participate with Medicare. This essentially is a redundant requirement from MA plans.

    The comment period on proposed changes to this very rule just ended December 8, 2009. See page 54644 of in which CMS actually admits this and proposes that providers enrolled in Medicare are deemed to have met the training requirement of MA plans. Of course, the final, final rule has not come out yet, but you should expect that healthcare providers will be exempt from this and that MA plans CAN NOT terminate a provider for failure to participate in that plan’s [required] training. Even at this time, MA plans cannot withhold monies owed or terminate a provider for not having completed this “training.”


    Cyndee Weston
    American Medical Billing Association

  3. Veeresh Says:

    this is a real good info.
    But people like me wanna know the insurances that are serious about this announcement. Because there many insurance company that do even follow their State Department of Banking and Insurance guidelines in processing the provider claims.
    please provide with the name of the insurances, also in your post you were writing that “local BC” is also offering some kinda ppt course on the same topic, can u please post the url where we can take the test.

  4. solutionsmedicalbilling Says:

    The problem is that the local BC test may not work for your area or the carriers you need it for. You should look in your area for a test specific to you.


    Medical Billing

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