|
SUBJECT:
Corporate Compliance -
False Claims Liability,
Anti-Retaliation
Protections, and
Detecting and Responding to Fraud,
Waste and Abuse
POLICY:
To provide information about the role of certain federal and
state laws in
preventing and detecting fraud, waste, and abuse in federal
health care
programs.
AFFECTED
PARTIES:
This policy applies to employees (including
management), contractors, and agents of
Lakeview Medical Center. Contractors and agents include any
contractor,
subcontractor, agent, or other person which or who, on behalf of
Lakeview Medical
Center, furnishes, or otherwise authorizes the furnishing of
Medicaid health care
items or services, performs billing or coding functions, or is
involved in monitoring of
health care provided by Lakeview Medical Center.
PROCEDURE:
I. Lakeview Medical Center
provides health care services in a manner that complies
with
applicable federal and state laws and that meets the high
standards of
business and
professional ethics. To further this policy, and to comply with
Section
6032 of the
Deficit Reduction Act of 2005, Lakeview Medical Center
provides the
following
information about its policies and procedures and the role of
certain
federal and
state laws in preventing and detecting fraud, waste, and abuse
in
federal
health care programs:
A. Summary of Federal and State Laws:
The following is a summary of the
Federal False Claims Act, the Program Fraud Civil Remedies Act,
and
Wisconsin’s Medicaid Fraud Statute, and their role in preventing
and detecting
fraud waste, and abuse in federal health care programs.
Federal False
Claims Laws:
1. False Claims Act; 31 U.S.C. §§ 3729
- 3733
The federal
False Claims Act imposes liability on any person or entity who:
-
Knowingly
files a false or fraudulent claim for payments to Medicare,
Medicaid or other federally funded health care program;
-
Knowingly
uses a false record or statement to obtain payment on a
false or fraudulent claim from Medicare, Medicaid or other
federally funded health care program; or
-
Conspires to
defraud Medicare, Medicaid or other federally funded health
care program by attempting to have a false or fraudulent
claim paid.
“Knowingly” means:
-
Having actual knowledge that the information on
the claim is false;
-
Acting
in deliberate ignorance of whether the claim is
true or false; or
-
Acting in reckless disregard of whether the
claim is true or false.
A person or
entity found liable under the False Claims Act is, generally,
subject to civil money penalties of between $5,500 and $11,000
per claim plus three times the amount of damages that the
government sustained because of the illegal act. In health care
cases, the amount of damages sustained is the amount paid for
each claim that is filed that is determined to be false.
Anyone may bring
a qui tam action under the False Claims Act in the name
of the United States. The case is initiated by filing the
complaint and all available material evidence under seal with a
federal court. The complaint remains under seal for at least 60
days and will not be served on the defendant. During this time,
the government investigates the complaint. The government may,
and often does, obtain additional investigation time by showing
good cause. After expiration of the review and investigation
period, the government may elect to pursue the case in its own
name or decide not to pursue the case. If the government decides
not to pursue the case, the person who filed the action has the
right to continue with the case on his or her own.
If the
government proceeds with the case, the person who filed the
action will receive between 15% and 25% of any recovery,
depending upon the contribution of that person to the
prosecution of the case. If the government does not proceed
with the case, the person who filed the action will be entitled
to between 25% and 30% of any recovery, plus reasonable expenses
and attorneys’ fees and costs.
2. Program Fraud Civil Remedies Act;
31 US. C. §§ 3801 - 3812
The Program
Fraud and Civil Remedies Act (“PFCRA”) creates administrative
remedies for making false claims and false statements. These
penalties are separate from and in addition to any liability
that may be imposed under the False Claims Act.
The PFCRA
imposes liability on people or entities that file a claim that
they know or have reason to know:
-
Is false,
fictitious, or fraudulent;
-
Includes or
is supported by any written statement that contains false,
fictitious, or fraudulent information;
-
Includes or
is supported by a written statement that omits a material
fact, which causes the statement to be false, fictitious, or
fraudulent, and the person or entity submitting the
statement has a duty to include the omitted fact; or
-
Is for
payment for property or services not provided as claimed.
A violation of
this section of the PFCRA is punishable by a $5,000 civil
penalty for each wrongfully filed claim, plus an assessment of
twice the amount of any unlawful claim that has been paid.
In addition, a
person or entity violates the PFCRA if they submit a written
statement that they know or should know:
-
Asserts a
material fact that is false, fictitious or fraudulent; or
-
Omits a
material fact that they had a duty to include, the omission
caused the statement to be false, fictitious, or fraudulent,
and the statement contained a certification of accuracy.
A violation of
this section of the PFCRA carries a civil penalty of up to
$5,000 in addition to any other remedy allowed under other laws.
B. State False Claims Laws:
1.
Medicaid Fraud Statute, s. 49.49(1), Wis. Stats.
The state
Medicaid fraud statute prohibits any person from:
-
Knowingly
and willfully making or causing to be made a false statement
or misrepresentation of a material fact in a claim for
Medicaid benefits or payments.
-
Knowingly
and willfully making or causing to be made a false statement
or misrepresentation of a material fact for use in
determining rights to Medicaid benefits or payments.
-
Having
knowledge of an act affecting the initial or continued right
to Medicaid benefits or payments or the initial, or
continued right to Medicaid benefits or payments of any
other individual on whose behalf someone has applied for or
is receiving the benefits or payments, concealing or failing
to disclose such event with an intent to fraudulently secure
Medicaid benefits or payments whether in a greater amount or
quantity than is due or when no benefit or payment is
authorized.
-
Making a
claim for Medicaid benefits or payments for the use or
benefit of another, and after receiving the benefit or
payment, knowingly and willfully converting it or any part
of it to a use other than for the use and benefit of the
intended person.
Anyone found
guilty of the above may be imprisoned for up to six years, and
fined not more than $25,000, plus 3 times the amount of actual
damages.
II.
Lakeview Medical Center’s Policies and
Procedures for Detecting and
Preventing
Fraud
Lakeview Medical
Center’s Compliance Program is designed to be consistent with
Office of Inspector General (OIG) Compliance Program Guidance
for Hospitals. The Compliance Program and the Hospital’s
policies and procedures for detecting and preventing fraud,
waste, and abuse are available on Lakeview Medical Center’s
intranet site.
III.
Anti-Retaliation Protections
A. Individuals within an organization who observe activities
or behavior that may
violate the law in some manner and who report their observations
either to
management or to governmental agencies are provided protections
under
certain laws.
For
example,
the False Claims Act includes protections for people who file
qui tam lawsuits as described above. The False Claims Act
states that any employee who is discharged, demoted, suspended,
threatened, harassed, or in any other manner discriminated
against in the terms and conditions of employment because of
lawful actions taken in furtherance of a qui tam action
is entitled to recover damages. He or she is entitled to “all
relief necessary to make the employee whole,” including
reinstatement with the same seniority status, twice the amount
of back pay (plus interest), and compensation for any other
damages the employee suffered as a result of the discrimination.
The employee also can be awarded litigation costs and reasonable
attorneys’ fees.
B. Under Wisconsin statute 146.997, Health Care Worker
Protection, Wisconsin
law also protects health care workers who disclose any of the
following to an
appropriate individual or agency:
-
Information that a health care facility or provider
has violated any state law or rule or federal law or
regulation;
-
A
situation in which the quality of care provided by,
or by an employee of, the health care facility or
provider violates established standards and poses a
potential risk to public health or safety.
Specifically,
the health care facility or provider cannot take disciplinary
action against an individual who reports the above in good
faith. A health care facility or provider who violates this
statute shall be subject to not more than $1,000 for a first
violation.
C. Lakeview
Medical Center’s Compliance Program includes the rights of
employees to be protected as whistleblowers. The Hospital’s
Compliance Program policies and procedures are available on the
Lakeview Medical Center intranet site.
IV.
Role of False Claims Laws:
A. The false claims laws discussed above are an important
part of preventing
and detecting fraud, waste, and abuse in federal and state
health care programs because they provide governmental agencies
the authority to seek out, investigate and prosecute fraudulent
activities. Enforcement activities take place in the criminal,
civil and administrative arenas. This provides a broad spectrum
of remedies to battle these problems.
B. Anti-retaliation protections for individuals who make
good faith reports of
waste, fraud and abuse encourage reporting and provide broader
opportunities to prosecute violators. Statutory provisions, such
as the anti‑retaliation provisions of the False Claims Act,
create reasonable incentives for this purpose. Employment
protections create a level of security employees need in order
to help in prosecuting these cases.
APPROVALS:
____________________________
Name/Title Date
Original
Date: 10/99 Reviewed/Revised: 2/04, 2/07
|
