CPCA California Primary Care Association
|
|
- Blaise Reynolds
- 7 years ago
- Views:
Transcription
1 CPCA California Primary Care Association Managing the Compliance Risk of Fraud, Abuse and the False Claims Act CPCA CFO Conference Larry Garcia Kenneth Julian April 30, 2010 Background The Patient Protection and Affordable Care Act ( Act ) recently adopted by Congress significantly expands coverage for Medicaid thereby increasing the patient base for FQHCs. The Act also makes a significant investment in FQHCs as a model of primary care delivery. Authorizes the establishment of a Community Health Center Fund ( Fund ) and appropriates: (i) $9.5 billion in 2011 for FQHCs; (ii) $1.5 billion from 2011 to 2015 for construction and renovation; and (iii) $1.5 billion for the National Health Service Corp. Authorizes an additional $34 billion from 2010 to 2015 for Section 330 grants. Establishes a prospective payment system for Medicare covered services furnished by FQHCs beginning 10/1/14. Expands the 340B Program ( Program ) to children s hospitals, critical access hospitals and RHCs effective 1/1/
2 Background, cont. However over the past few years, the federal government has placed an increased emphasis on detecting and prosecuting Medicare and Medicaid fraud as a means of managing total health care costs. Several laws impose constraints on business practices of FQHCs. Anti-Kickback and Fraud and Abuse Laws ( AKS ) False Claims Act and State Laws ( FCA ) Deficit Reduction Act of 2006 ( DRA ) Fraud Enforcement and Recovery Act of 2009 ( FERA ) RAC Audits Medicaid Integrity Program Audits National Health System Reforms 2 Key Questions: 1. What are the principal laws with which CFOs of FQHCs should be familiar? 2. How can FQHCs protect themselves and their officers and directors from exposure to significant legal liability and to potential criminal prosecution in the face of this increased scrutiny of their business practices? 3 2
3 Fraud Laws Anti-Kickback Statutes False Claims Act Deficit Reduction Act Fraud Enforcement and Recovery Act Patient Protection and Affordable Care Act 4 The Anti-Kickback Statute Federal AKS defined under 42 USC section 1320a-7b(b) to apply to: Whoever knowingly and willfully solicits or receives any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or kind i. (A) in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made.under a federal healthcare program, or ii. (B) in return for purchasing, leasing, ordering or arranging for or recommending purchasing, leasing or ordering any good, facility, service or item for which payment may be made..under a federal healthcare program Shall be guilty of a felony and shall be fined or imprisoned Case Law and the One Purpose Rule Federal Safe Harbors including the FQHC Safe Harbor 5 3
4 The False Claims Act FCA has roots in addressing Civil War procurement misconduct Elements of FCA Scienter. i.e. actual knowledge of falsity or reckless disregard of the truth Filing of a claim for payment from governmental funds Includes false statements in support of the claim Materiality Criminal False Claims 42 USC Section 1320a-7b prohibits knowingly and willfully making any false statement or representation of material fact in any claim or application for benefits under the Medicare or Medicaid Programs. 6 The False Claims Act, cont. Qui Tam Lawsuits Section 3730(d)(1)&(2) permits civil actions for false claims by a qui itam relator. If the government proceeds with an action, then the person bringing the action shall receive at least 15% but not more than 25% of the proceeds of the action or settlement of the claim If the government does not proceed with an action, the person bringing the action or settling the claim shall receive an amount determined to be reasonable but shall not be less than 25% but not more than 30% of the proceeds FCA can represent a significant exposure of an FQHC to liability where a former employee or advisor becomes a qui tam relator. 7 4
5 The Deficit Reduction Act 2006 Federal Deficit Reduction Act ( DRA ) raised the bar for compliance and created significant incentives for states to enact laws to address false or fraudulent claims in the Medicaid programs State law must create liability to state for false claims State law must create law to facilitate and reward qui tam suits State law must permit qui tam plaintiffs to file under seal with a 60 day review period by State Attorney General State law must create fines and penalties not less than federal law Employee Education. One of the most significant elements of the DRA is to require that providers receiving $5 million in annual revenues to implement an education program for its employees (i) to encourage compliance, and (ii) to inform employees on qui tam lawsuits 8 The Fraud Enforcement and Recovery Act In 2009, Congress adopted the Fraud Enforcement and Recovery Act ( FERA ) that amended the existing FCA to make significant changes. Clarifies that one does not need to meet prove as specific intent to demonstrate a violation of the law Adds to the definition of fraud the retention of any overpayment Congressional record suggests that the FCA can be violated by (i) demanding payment for services that do not conform to regulatory standards, (ii) requesting payment for services of lesser quality, (iii) submitting a claim that falsely certifies compliance, or (iv) submitting a claim by a person that has violated the law The adoption of FERA is likely to have an impact on the ability of the governmental prosecutors and private bounty hunters to recover money from health care providers including FQHCs. 9 5
6 The Patient Protection and Affordable Care Act The Act includes provisions that raise the bar of compliance for health care providers: Applies the False Claims Act to payments made by, through, or in connection with, the Exchange if payments include federal funds Narrows the application of public disclosure bar to permit an individual who has independent knowledge that materially adds to the publicly disclosed allegations, can serve as an original source Amends the AKS statute intent standard to provide that a person may violate the AKS statute without actual knowledge of, or with the specific intent to violate statute The Act also provides significant new investments into Medicare and Medicaid fraud enforcement Over $350 million to Medicaid fraud enforcement A third of which will be spent in Noncompliance Penalties As a result of this increased scrutiny, healthcare providers face increased risk of sanctions for noncompliance including: Criminal prosecutions Fines-FCA multiples (e.g. 3X) not covered by insurance Payment of prosecutor s attorneys fees Per Claim Penalties, and Potential exclusion of entities and persons from participating in the federally funded programs Most significant risks come from the existence of a system business practice: (i) that is exposed through a government investigation or qui tam lawsuit, and (ii) the aggregate amount of which is sufficient to put the financial viability of the FQHC at risk. 11 6
7 Key Questions: How can FQHCs protect themselves and their officers and directors from exposure (i) to significant legal liability and (ii) to potential criminal prosecution in the face of this increased scrutiny of their business practices? 12 Lessons From Recent Events Key lessons from recent compliance experience involving investigations of FQHCs: FQHCs are big game for regulators Doing God s Work will not protect you The most dangerous threat to the FQHC are people that worked for you Governmental enforcement agencies do NOT understand the complexity of the regulatory environment under which FQHCs must operate Conducting a self-investigation and making a self-disclosure can secure an improved bargaining position and help to mitigate the application of penalties and the requirement to undertake compliance obligations 13 7
8 Lessons From Recent Events, cont. Key lessons (cont.): Dismissed, disciplined or disappointed employees pose risk Investigators looking to make their case and not necessarily to find the truth There is no substitute for prudent A/R management Do not hire inexperienced people in high risk areas Growth is dangerous and can eat cash out of your balance sheet Governmental enforcement agencies do NOT understand the complexity of the regulatory environment under which FQHCs must operate Get legal advice rather than debate legality of billing practices among the staff 14 Recommended Actions FQHCs can and should protect themselves and their officers and directors from exposure to legal liability and potential criminal prosecution by taking the following actions: 1. Hire a qualified Chief Compliance Officer to implement a robust Corporate Compliance Program 2. Institute a proactive compliance review audits and adopt a Code of Conduct for each of its employees 3. Carefully educate your employees concerning their duties and responsibilities concerning corporate compliance and have employees periodically sign a Code of Conduct in order to identify compliance issues before they become big ticket items 4. Where appropriate, perform a self investigation and use the OIG Self Disclosure Protocol to limit exposure to legal liability 15 8
9 Compliance Programs 16 Selecting a Chief Compliance Officer Selection of Chief Compliance Officer is one of the most significant actions that can be taken to put into place a compliance program. To be successful, the selection should have the following: Input and support of the board of directors Have a dual reporting relationship to both the Executive Director and the board of directors Sufficient authority and resources to enable the Chief Compliance Officer to carry his/her compliance responsibilities Implementing a robust compliance program requires the right people, do the right thing with the right resources. An effective compliance program can (i) reduce the exposure of the organization to liability for fraud, (ii) decrease the cost of healthcare delivery, (iii) build credibility with regulators and (iv) improve business operations for the organization. 17 9
10 Proactive Compliance Actions There are several activities and techniques that can be employed to address compliance risk so that you can stay ahead of the regulators: Develop model plans and auditing techniques to assess the high risk business practices of FQHCs Conduct targeted audits and assessment of its high risk business practices Adopt policies and procedures to implement the compliance program Develop and implement a Code of Conduct for all officers, directors, employees and independent contractors Establish a system to monitor and enforce the Code Respond to allegations of non-compliance in a timely manner 18 Proactive Compliance Actions, cont. Auditing and Monitoring Plans and Techniques. FQHCs should focus on business practices that are most likely to problematic from a compliance point of view such as: i. Ensure providers and staff are familiar with appropriate billing and coding requirements for FQHCs ii. Establish processes to be certain that proper licensing and enrollment requirements have been met before payment requests are submitted iii. Perform a review to be certain that accurate cost report certifications and Medi-Cal reconciliation reports are filed iv. Screen for excluded individuals and entities before hiring and on an ongoing basis v. Protect against improper gifts and influences by suppliers on providers and staff vi. Be familiar with HIPAA and security breach notification requirements 19 10
11 Compliance Actions Educational Programs Training and Education Programs. FQHCs should develop education and training programs, to educate new and existing employees on compliance requirements for the organization. 1. Compliance programs are now mandatory even for providers with less than $5 million in annual revenues 2. Policies and procedures must be established to provide compliance training and information about (i) false claims laws, (ii) remedies and penalties for non-compliance, (iii) whistle blower protections, and (iv) the FQHC s compliance policies 3. Training should be used as a vehicle for early identification of compliance issues so that interventions can be put into place before the FQHC faces a bet-thecompany compliance issue 20 Self Investigations and the Use of the Self Disclosure Protocol Compliance Programs. The use of the Protocol is not a common compliance activity but can be an effective tool in an overall compliance program. The Protocols should be weighed and considered for any non-compliance incident or practice that involves the following: 1. The repeated or re-occurring practice in which an overpayment by the government has taken place. 2. For any act of fraud in a billing or coding practice. 3. Where substantial sums have been overpaid and it is necessary to negotiate a repayment arrangement to permit the FQHC to pay back the amounts over time. 4. Where directors, officers, employees or physician i contractors t have been involved with the practice or incident and disciplinary actions were required by the FQHC. 5. Where the compliance audits of the FQHC indicate that an act of non-compliance has taken place. 6. Where it is prudent to involve the government in an internal investigation and self assessment of high risk activities
12 Self Investigations and the Use of the Self Disclosure Protocol, cont. The Protocol may be used for the following purposes: To refer a matter of non-compliance to the OIG before an investigation is initiated by the government To open up a dialog with the OIG in a manner that the health care provider can perform the investigation of non-compliance and report its findings to the OIG To help mitigate fines, penalties and the adverse effects of non-compliance upon clinic operations Use of the Protocol does not guarantee that the OIG will not investigate the non-compliance or that the remedies imposed with be mitigated. However, it does represent an opportunity to demonstrate that the clinic can and will investigate its high risk practices and make appropriate disclosures to the OIG as part of its ongoing business activities. 22 Self Investigations and the Use of the Self Disclosure Protocol, cont. An internal investigation leading to a self disclosure should include the following elements: Formal management memo or board resolution indicating an investigation will take place Engagement of Compliance professionals to support Communications within organization regarding investigation Review of key documents Interview of personnel Self Assessment of behaviors, actions and risk Investigative Report and findings Corrective Action Plan Decision on Voluntary Disclosure 23 12
13 Self Investigations and the Use of the Self Disclosure Protocol, cont. Examples of how Protocol has/can be used by Clinics: To investigate evidence that a prior administrative team may have systematically submitted Medi-Cal claims without adequate support in the medical record to support payments. To inform the fiscal intermediary that the FQHC failed to secure a required provider number for a new location and has received payments under an inappropriate provider number. To take control of an investigation that has been initiated by a governmental agency and for which the FQHC has been served a subpoena duces tecum. To investigate a confidential complaint of kick-back payments to a provider that the FQHC obtains on its hot-line. To investigate statements of impropriety made by a terminated employee at his/her exit interview
False Claims Act CMP212
False Claims Act CMP212 Colorado Access is committed to a culture of compliance in which its employees, providers, contractors, and consultants are educated and knowledgeable about their role in reporting
More informationThe Fraud Enforcement and Recovery Act and Healthcare Reform: Implications for Compliance Initiatives and Fraud Investigations
The Fraud Enforcement and Recovery Act and Healthcare Reform: Implications for Compliance Initiatives and Fraud Investigations Presented by: Robert Threlkeld, Esq. Holly Pierson, Esq. Paul F. Danello,
More informationNORTHCARE NETWORK. POLICY TITLE: Deficit Reduction Act (DRA) EFFECTIVE DATE: 1/1/15 REVIEW DATE: New Policy
NORTHCARE NETWORK POLICY TITLE: Deficit Reduction Act (DRA) EFFECTIVE DATE: 1/1/15 REVIEW DATE: New Policy RESPONSIBLE PARTY: Chief Executive Officer/Compliance Officer CATEGORY: Compliance BOARD APPROVAL
More informationWhat is a Compliance Program?
Course Objectives Learn about the most important elements of the compliance program; Increase awareness and effectiveness of our compliance program; Learn about the important laws and what the government
More informationCHAMPAIGN COUNTY NURSING HOME SUMMARY OF ANTI-FRAUD AND ABUSE POLICIES
1. PURPOSE CHAMPAIGN COUNTY NURSING HOME SUMMARY OF ANTI-FRAUD AND ABUSE POLICIES Champaign County Nursing Home ( CCNH ) has established anti-fraud and abuse policies to prevent fraud, waste, and abuse
More informationUSC Office of Compliance
PURPOSE This policy complies with requirements under the Deficit Reduction Act of 2005 and other federal and state fraud and abuse laws. It provides guidance on activities that could result in incidents
More informationTo: All Vendors, Agents and Contractors of Hutchinson Regional Medical Center
To: All Vendors, Agents and Contractors of Hutchinson Regional Medical Center From: Corporate Compliance Department Re: Deficit Reduction Act of 2005 Dear Vendor/Agent/Contractor: Under the Deficit Reduction
More informationI. Policy Purpose. II. Policy Statement. III. Policy Definitions: RESPONSIBILITY:
POLICY NAME: POLICY SPONSOR: FRAUD, WASTE AND ABUSE COMPLIANCE OFFICER RESPONSIBILITY: EFFECTIVE DATE: REVIEW/ REVISED DATE: I. Policy Purpose The purpose of this policy is to outline the requirements
More informationCORPORATE COMPLIANCE POLICY AND PROCEDURE
Title: Fraud Waste and Abuse Laws in Health Care Policy # 1011 Sponsor: Corporate Compliance Approved by: Carleen Dunne, Director, Corporate Compliance and Privacy Officer Issued: Page: 1 of 7 June 25,
More informationCORPORATE COMPLIANCE POLICY AND PROCEDURE
Title: Fraud Waste and Abuse Laws in Health Care Policy # 1011 Sponsor: Corporate Approved by: Carleen Dunne, Director, Corporate and Privacy Officer Issued: Page: 1 of 7 June 25, 2007 Last Reviewed/Updated
More informationFraud, Waste and Abuse Prevention and Education Policy
Corporate Compliance Fraud, Waste and Abuse Prevention and Education Policy The Compliance Program at the Cortland Regional Medical Center (CRMC) demonstrates our commitment to uphold all federal and state
More informationUnderstanding Health Reform s
Compliance 101: Understanding Health Reform s New Compliance Requirements Uri Bilek Feldesman Tucker Leifer Fidell LLP Does your organization have a designated Compliance Officer? a. Yes b. No c. Don't
More informationEDUCATION ABOUT FALSE CLAIMS RECOVERY
Type: MGI Corporate Policy Number: M 700 Effective Date: June 2014 Supersedes: AP 201, 4/12 Revised: 6/14 EDUCATION ABOUT FALSE CLAIMS RECOVERY I. PURPOSE This policy is intended to ensure compliance with
More informationRobert A. Wade, Esq. Krieg DeVault LLP 4101 Edison Lakes Parkway, Ste. 100 Mishawaka, IN 46545 Phone: 574-485-2002 KD_4901979
False Claims Act Update Robert A. Wade, Esq. Krieg DeVault LLP 4101 Edison Lakes Parkway, Ste. 100 Mishawaka, IN 46545 Phone: 574-485-2002 Email: bwade@kdlegal.com KD_4901979 1 The FCA is the Fraud Enforcement
More informationPrevention of Fraud, Waste and Abuse
Procedure 1910 Responsible Office: Yale Medical Group Effective Date: 01/01/2007 Responsible Department: Administration Last Revision Date: 09/20/2013 Prevention of Fraud, Waste and Abuse Policy Statement...
More informationFrequently Used Health Care Laws
Frequently Used Health Care Laws In the following section, a select few of the frequently used health care laws will be briefly defined. Of the frequently used health care laws, there are some laws that
More informationPolicies and Procedures: WVUPC Policy Pursuant to the Requirements of the Deficit Reduction Act of 2005
POLICY/PROCEDURE NO.: B-17 Effective date: Jan. 1, 2007 Date(s) of review/revision: Nov. 1, 2015 Policies and Procedures: WVUPC Policy Pursuant to the Requirements of the Deficit Reduction Act of 2005
More informationFraud Waste and Abuse Training First Tier, Downstream and Related Entities. ONECare by Care1st Health Plan Arizona, Inc. (HMO) Revised: 10/2009
Fraud Waste and Abuse Training First Tier, Downstream and Related Entities ONECare by Care1st Health Plan Arizona, Inc. (HMO) Revised: 10/2009 Overview Purpose Care1st/ ONECare Compliance Program Definitions
More informationFalse Claims / Federal Deficit Reduction Act Notice Help Stop Healthcare Fraud, Waste and Abuse: Report to the Firelands Corporate Compliance Officer
1111 Hayes Avenue Sandusky, OH 44870 www.firelands.com False Claims / Federal Deficit Reduction Act Notice Help Stop Healthcare Fraud, Waste and Abuse: Report to the Firelands Corporate Compliance Officer
More informationThis policy applies to UNTHSC employees, volunteers, contractors and agents.
Policies of the University of North Texas Health Science Center 3.102 Detecting and Responding to Fraud, Waste and Abuse Chapter 3 Compliance Policy Statement UNTHSC developed and implemented a Compliance
More informationFederal False Claims Act (31 USC 3729 through 3733)
I. INTRODUCTION The False Claims Act (FCA) is a federal law that was created to discourage and punish profiteers from providing sub-standard supplies to the Union Army during the Civil War. The FCA was
More informationHow To Get A Medical Bill Of Health From A Member Of A Health Care Provider
Neighborhood requires compliance with all laws applicable to the organization s business, including insistence on compliance with all applicable federal and state laws dealing with false claims and false
More informationFraud Waste and Abuse Training First Tier, Downstream and Related Entities
Fraud Waste and Abuse Training First Tier, Downstream and Related Entities Revised: 04/2010 OVERVIEW Centene Corporation Purpose Bridgeway Compliance Program Definitions of Fraud Waste & Abuse Laws and
More informationCompliance with False Claims Act
MH Policy and Procedure Document Number: MH-COMPLY-001 Document Owner: Corporate Compliance Officer Date Last Author: Corporate Compliance Officer General Description Purpose: To establish written guidelines
More informationBehavioral Healthcare, Inc. 155 Inverness Drive West Suite 201 Englewood, CO 80112
1 of 6 I. Policy: It is the policy of Behavioral Healthcare, Inc. (BHI) that all employees (including management, consultants, contractors, and other agents) shall comply with all applicable Federal and
More informationCompliance and Program Integrity Melanie Bicigo, CHC, CEBS mlbicigo@uphp.com 906-225-7749
Compliance and Program Integrity Melanie Bicigo, CHC, CEBS mlbicigo@uphp.com 906-225-7749 Define compliance and compliance program requirements Communicate Upper Peninsula Health Plan (UPHP) compliance
More informationCorporate Compliance Policy Concerning the False Claims Acts, Anti- Retaliation Protections, and Detecting and Responding to Fraud
PAGE NUMBER: 1 of 16 ACCOUNTABILITY: President and Chief Executive Officer OBJECTIVES: RELATION TO MISSION: Our Lady of Lourdes Health Care Services, Inc. ( OLLHCS, Inc. ), a Catholic health system and
More informationFraud and Abuse in the Sale and Marketing of Drugs
American Conference Institute s 11 th National Forum on: Fraud and Abuse in the Sale and Marketing of Drugs MANAGING, DEFENDING AND CURTAILING WHISTLEBLOWER AND RELATOR ALLEGATIONS UNDER ANEXPANDED FALSE
More informationCOMPLIANCE AND OVERSIGHT MONITORING
COMPLIANCE AND OVERSIGHT MONITORING The contract between HCA and Molina Healthcare defines a number of performance requirements that must be satisfied by Molina Healthcare subcontracted Providers to provide
More informationDeficit Reduction Act Information for Employees, Contractors and Agents
Nationally Ranked. Locally Trusted. Denver Health Deficit Reduction Act Information for Employees, Contractors and Agents EFFECTIVE DATE: DECEMBER 31, 2006 PAGE 1 OF 5 Purpose: Provide a written policy
More informationFALSE CLAIMS ACT PRIMER
FALSE CLAIMS ACT PRIMER HCCA Compliance Institute Sunday, April 29, 2012 I. Elements of a False Claims Act Violation A. A Direct (Affirmative) False Claim Most False Claims Act cases involve direct or
More informationCORPORATE COMPLIANCE: BILLING & CODING COMPLIANCE
SUBJECT: CORPORATE COMPLIANCE: BILLING & CODING COMPLIANCE MISSION: Quality, honesty and integrity, in everything we do, are important values to all of us who are associated with ENTITY NAME ( ENTITY NAME
More informationUPDATED. OIG Guidelines for Evaluating State False Claims Acts
UPDATED OIG Guidelines for Evaluating State False Claims Acts Note: These guidelines are effective March 15, 2013, and replace the guidelines effective on August 21, 2006, found at 71 FR 48552. UPDATED
More informationVIDANT HEALTH POLICY & PROCEDURE. PREPARED BY: Office of Audit & Compliance REVISED: 11/09, 2/12 REVIEWED: 2/07, 2/08, 2/09, 3/10, 2/11
NUMBER: VH-AC 16 Page 1 of 9 EFFECTIVE: 01/2007 REVIEWED: 2/07, 2/08, 2/09, 3/10, 2/11 CEO APPROVAL: Topic: To Prevent and Detect Fraud and Abuse and Information regarding the Federal False Claims Act
More informationThe Impact of the PPACA on Fraud and Abuse Issues
The Impact of the PPACA on Fraud and Abuse Issues American Bar Association May 5, 2010 Kirk Ogrosky, Arnold & Porter LLP Lisa M. Ohrin, Katten Muchin Rosenman LLP Donald H. Romano, Arent Fox LLP The Patient
More information5037 Employee Education About False Claims Recovery 5037. The purpose of this policy is to educate employees, contractors, and agents on
5037 Employee Education About False Claims Recovery 5037 The purpose of this policy is to educate employees, contractors, and agents on the requirements of the Deficit Reduction Act (DRA) of 2005 which
More information2012-2013 MEDICARE COMPLIANCE TRAINING EMPLOYEES & FDR S. 2012 Revised
2012-2013 MEDICARE COMPLIANCE TRAINING EMPLOYEES & FDR S 2012 Revised 1 Introduction CMS Requirements As of January 1, 2011, Federal Regulations require that Medicare Advantage Organizations (MAOs) and
More informationFalse Claims and Whistleblower Protections All employees, volunteers, students, physicians, vendors and contractors
Policy and Procedure Title: Applies to: False Claims and Whistleblower Protections All employees, volunteers, students, physicians, vendors and contractors Number: First Created: 1/07 SY-CO-019 Issuing
More informationCENTERLIGHT HEALTH SYSTEM CORPORATE COMPLIANCE POLICY. SUBJECT: Detection & Prevention of Fraud, Waste & Abuse POLICY NO.:
EFFECTIVE DATE: January 1, 2007 PAGE: 1 of 8 Reference: Federal Deficit Reduction Act of 2005 (DRA) see, 6032 et seq; Office of the Medicaid Inspector General Provider Compliance guidance and CenterLight
More informationHACKENSACK UNIVERSITY MEDICAL CENTER Administrative Policy Manual
HACKENSACK UNIVERSITY MEDICAL CENTER Administrative Policy Manual Fraud and Abuse Prevention DRA Compliance Policy #: 1521 Original Issue: December, 2007 Page 1 of 6 Policy It is the policy of Hackensack
More informationPolicy and Procedure: Corporate Compliance Topic: False Claims Act and Whistleblower Provisions, Deficit Reduction Act
Policy and Procedure: Corporate Compliance Topic: False Claims Act and Whistleblower Provisions, Deficit Reduction Act SCOPE OF POLICY This policy applies to all CFS employees, including trainees, volunteers,
More informationpolicy (C) Deficit Reduction Act of 2005 and the Federal False Claims Act
Name of Policy: Detecting and Preventing Fraud, Waste and Abuse Policy Number: 3364-15-02 Issuing Office: President Responsible Agent: Compliance/Privacy Officer Revision date: July 5, 2011 Original effective
More informationADMINISTRATIVE MANUAL Subject: CORPORATE RESPONSIBILITY 21.49. Directive #: 21.49 Present Date: January 2011
Page: 1 of 18 Directive #: 21.49 Present Date: January 2011 Original Date: September 2004 Review Date: January 2013 Applicable To: SVHC & Affiliated Companies SVMC SCLM SLH FCPC POLICY In furtherance of
More informationPOLICY AND STANDARDS. False Claims Laws and Whistleblower Protections
POLICY AND STANDARDS Corporate Policy Applicability: Magellan BH (M) NIA (N) ICORE (I) Magellan Medicaid Administration (A) Corporate Policy: Policy Number: Policy Name: Date of Inception: January 1, 2007
More informationPolicies and Procedures SECTION:
PAGE 1 OF 5 I. PURPOSE The purpose of this Policy is to fulfill the requirements of Section 6032 of the Deficit Reduction Act of 2005 by providing to Creighton University employees and employees of contractors
More informationNewport Subacute Healthcare Center
Title: False Claims Act Policy Manual: Administrative Policy Manual Category: Business function Approval Signatures: Newport Subacute Healthcare Center Document #: Original Issue: 02/01/2006 Revision Date:
More informationFRAUD, WASTE & ABUSE. Training for First Tier, Downstream and Related Entities. Slide 1 of 24
FRAUD, WASTE & ABUSE Training for First Tier, Downstream and Related Entities Slide 1 of 24 Purpose of this Program On December 5, 2007, the Centers for Medicare and Medicaid Services ( CMS ) published
More informationVILLAGECARE CORPORATE COMPLIANCE POLICY AND PROCEDURE MANUAL ORIGINAL EFFECTIVE DATE: JANUARY 1, 2007
VILLAGECARE CORPORATE COMPLIANCE POLICY AND PROCEDURE MANUAL SUBJECT: COMPLIANCE WITH FEDERAL AND STATE FALSE CLAIMS LAWS AND DETECTION AND PREVENTION OF FRAUD, WASTE AND ABUSE LAST POLICY REVISION EFFECTIVE
More informationA summary of administrative remedies found in the Program Fraud Civil Remedies Act
BLACK HILLS SPECIAL SERVICES COOPERATIVE'S POLICY TO PROVIDE EDUCATION CONCERNING FALSE CLAIMS LIABILITY, ANTI-RETALIATION PROTECTIONS FOR REPORTING WRONGDOING AND DETECTING AND PREVENTING FRAUD, WASTE
More informationSample Healthcare Compliance Program
P.O. Box 153 Shell, WY 82441 307-765-2241 (direct) 888-286-2095 (e-fax) info@hcma-consulting.com www.hcma-consulting.com Sample Healthcare Compliance Program 1. Introduction COMPANY is committed to establishing
More informationSOUTH NASSAU COMMUNITIES HOSPITAL One Healthy Way, Oceanside, NY 11572
SOUTH NASSAU COMMUNITIES HOSPITAL One Healthy Way, Oceanside, NY 11572 POLICY TITLE: Compliance with Applicable Federal and State False Claims Acts POLICY NUMBER: OF-ADM-232 DEPARTMENT: Hospital-wide CROSS-REFERENCE:
More informationAddressing Government Investigations. Marcos Daniel Jimenez Partner
Addressing Government Investigations Marcos Daniel Jimenez Partner November 14, 2014 Agenda Statistics Key Players Fraud and Abuse Laws Potential Consequences Mitigation Strategies 2 Key Health Care Fraud
More informationFEDERAL LAWS RELATING TO FRAUD, WASTE AND ABUSE
FEDERAL LAWS RELATING TO FRAUD, WASTE AND ABUSE FEDERAL CIVIL FALSE CLAIMS ACT The federal civil False Claims Act, 31 U.S.C. 3729, et seq., ( FCA ) was originally enacted in 1863 to combat fraud perpetrated
More informationFALSE CLAIMS ACT STATUTORY LANGUAGE
33 U.S.C. 3729-33 FALSE CLAIMS ACT STATUTORY LANGUAGE 31 U.S.C. 3729. False claims (a) LIABILITY FOR CERTAIN ACTS. (1) IN GENERAL. Subject to paragraph (2), any person who (A) knowingly presents, or causes
More informationfraud, waste, abuse, compliance, integrity, Integrity Help Line
Policy / Procedure: KEY TERMS: fraud, waste, abuse, compliance, integrity, Integrity Help Line I. PURPOSE: To help our employees, agents and contractors understand the methods to prevent and detect fraud,
More informationADMINISTRATIVE POLICY MANUAL
SUPERSEDES: New PAGE: 838.00 POLICY: 1. It is the policy of Onondaga County hereinafter referred to as the County, to comply with all applicable federal, state and local laws and regulations, both civil
More informationTitle: Preventing and Reporting Fraud, Waste and Abuse in Federal Health Care Programs. Area Manual: Corporate Compliance Page: Page 1 of 10
Title: Preventing and Reporting Fraud, Waste and Abuse in Federal Health Care Programs Area Manual: Corporate Compliance Page: Page 1 of 10 Reference Number: I-70 Effective Date: 10/02 Contact Person:
More informationC O N F I D E N T I A L A N D P R O P R I E T A R Y. Page 1 of 7 Title: FRAUD, WASTE, AND ABUSE POLICY
Page 1 of 7 1. Purpose As a Company that does business with U.S. state and federal government health care programs (such as Medicare and Medicaid), Hill-Rom is required to maintain a system of policies
More informationFraud Prevention Training Requirements For Medicare Advantage Plans
MEDICARE ADVANTAGE (Part C) PRESCRIPTION DRUG (Part D) FRAUD, WASTE, and ABUSE EDUCATION AND TRAINING 1 INTRODUCTION CMS has mandated that Medicare Advantage Organizations (MAOs) and Prescription Drug
More informationWestlake Convalescent Hospital
Title: False Claims Act Policy Manual: Administrative Policy Manual Category: Business function Approval Signatures: Westlake Convalescent Hospital Document #: Original Issue: 02/01/2006 Revision Date:
More informationCAPITAL REGION MEDICAL CENTER ADMINISTRATIVE POLICY MANUAL
CAPITAL REGION MEDICAL CENTER ADMINISTRATIVE POLICY MANUAL ARTICLE: 5 SECTION: B SUBJECT: Leadership NUMBER: 79 DATE: January 1, 2007 SUPERSEDES Policy No. Dated: REVIEWED: March 24, 2010 PURPOSE The purpose
More information55144-1-5 Page: 1 of 5. Pharmacy Fraud, Waste and Abuse Policy. 1.0 Compliance Assurance. 2.0 Procedure
Pharmacy Fraud, Waste and Abuse Policy 1.0 Compliance Assurance This Fraud Waste and Abuse Policy ( Policy ) reiterates the commitment of this pharmacy to comply with the standards of conduct established
More informationFraud, Waste and Abuse Page 1 of 9
Page 1 of 9 Overview It is the policy of MVP Health Care, Inc. and its affiliates (collectively referred to as MVP ) to comply with all applicable federal and state laws regarding fraud, waste and abuse.
More informationSELF AUDITS AND DISCLOSURES IN A RAC WORLD. Kathleen Houston Drummy Partner Davis Wright Tremaine LLP Los Angeles, CA
SELF AUDITS AND DISCLOSURES IN A RAC WORLD Kathleen Houston Drummy Partner Davis Wright Tremaine LLP Los Angeles, CA 1 Broader Program Integrity Landscape Improper Payments As a result of error As a result
More informationOSF HEALTHCARE FALSE CLAIMS PREVENTION AND WHISTLEBLOWER PROTECTIONS
OSF HEALTHCARE FALSE CLAIMS PREVENTION AND WHISTLEBLOWER PROTECTIONS POLICY: CC-109 It is the policy of OSF HealthCare (OSF) that false, inaccurate or improper claims will not be submitted to any payer.
More informationVNSNY CORPORATE. DRA Policy
VNSNY CORPORATE DRA Policy TITLE: FEDERAL DEFICIT REDUCTION ACT OF 2005: POLICY REGARDING THE DETECTION & PREVENTION OF FRAUD, WASTE AND ABUSE AND APPLICABLE FEDERAL AND STATE LAWS APPLIES TO: VNSNY ENTITIES
More informationADMINISTRATIVE POLICY SECTION: CORPORATE COMPLIANCE Revised Date: 2/26/15 TITLE: FALSE CLAIMS ACT & WHISTLEBLOWER PROVISIONS
Corporate Compliance Plan AD-819-0 Reporting of Compliance Concerns & Non-retaliation AD-807-0 Compliance Training Policy CFC ADMINISTRATIVE POLICY AD-819-1 SECTION: CORPORATE COMPLIANCE Revised Date:
More informationStandards of. Conduct. Important Phone Number for Reporting Violations
Standards of Conduct It is the policy of Security Health Plan that all its business be conducted honestly, ethically, and with integrity. Security Health Plan s relationships with members, hospitals, clinics,
More informationMETHODIST HEALTH SYSTEM ADMINISTRATIVE TITLE: DETECTING FRAUD AND ABUSE AND AN OVERVIEW OF THE FEDERAL AND STATE FALSE CLAIMS ACTS
METHODIST HEALTH SYSTEM ADMINISTRATIVE Formulated: 6/19/07 Reviewed: Revised: Effective: 10/30/07 TITLE: DETECTING FRAUD AND ABUSE AND AN OVERVIEW OF THE FEDERAL AND STATE FALSE CLAIMS ACTS PURPOSE: Methodist
More informationDeficit Reduction Act of 2005 6032 Employee Education About False Claims Recovery
DMH S&P No. 1 Revision No. N/A Effective Date: 01/01/07 COMPLIANCE STANDARD: Deficit Reduction Act of 2005 6032 Employee Education About False Claims Recovery BACKGROUND AND PURPOSE As stated in its Directive
More informationWritten: 1/09/07 Federal and State Reviewed: 3/15/12 False Claims Act Revised: 06/13/12 Page: 1 of 5
Policy and Procedure Manual ADMINISTRATIVE SECTION --- III PATIENT RIGHTS & ORGANIZATIONAL ETHICS COMPLIANCE DEPARTMENT - COMPLIANCE Written: 1/09/07 Federal and State Reviewed: 3/15/12 False Claims Act
More informationEXECUTIVE SUMMARY Compliance Program and False Claims Recovery
EXECUTIVE SUMMARY Compliance Program and False Claims Recovery INTRODUCTION: The Federal Deficit Reduction Act of 2005, also known as the DRA, requires that providers give their employees, medical staff,
More informationFEDERAL & NEW YORK STATUTES RELATING TO FILING FALSE CLAIMS
FEDERAL & NEW YORK STATUTES RELATING TO FILING FALSE CLAIMS I. FEDERAL LAWS False Claims Act (31 USC 3729-3733) The False Claims Act ("FCA") provides, in pertinent part, that: (a) Any person who (1) knowingly
More informationDetecting and Preventing Fraud, Waste and Abuse
Detecting and Preventing Fraud, Waste and Abuse Overview It is the policy of ICS to comply with all applicable federal and state laws regarding fraud, waste and abuse. ICS acknowledges its participation
More informationCompliance Plan False Claims Act & Whistleblower Provisions Purpose/Policy/Procedures
CATHOLIC CHARITIES OF THE ROMAN CATHOLIC DIOCESE OF SYRACUSE, NY and TOOMEY RESIDENTIAL AND COMMUNITY SERVICES Compliance Plan False Claims Act & Whistleblower Provisions Purpose/Policy/Procedures Purpose:
More informationFalse Claims Act Policy 650-117 Effective Date 01/01/2007 Compliance Manual
False Claims Act Policy 650-117 POLICY Monroe County Healthcare Authority is committed to the highest possible standards of ethical, moral and legal business conduct. Prevention of health care fraud, waste
More informationColorado West HealthCare System Grand Junction, CO
Policy Title: Effective Date: 1/30/2008 Supersedes Date: N/A Colorado West HealthCare System Grand Junction, CO CWHS-WIDE POLICY FALSE CLAIMS ACT Responsible Departments: All Departments Administration
More informationCoffee Regional Medical Center FALSE CLAIMS EDUCATION
Policy/Procedure Department Administration Effective 08/15/2008 Scope Organization Cross Reference Review Date 08/14/2008,12/18/2013 Revision History Signatures Date 12/18/2013 Prepared by Lavonda Cravey
More informationNorth Shore LIJ Health System, Inc.
North Shore LIJ Health System, Inc. POLICY TITLE: Detecting and Preventing Fraud, Waste, Abuse and Misconduct POLICY #: 800.09 System Approval Date: 6/23/14 Site Implementation Date: Prepared by: Office
More informationONEIDA HEALTHCARE S CORPORATE COMPLIANCE PROGRAM
ONEIDA HEALTHCARE S CORPORATE COMPLIANCE PROGRAM Sept 2002 Revised December 2009 521 provisions Reviewed/revised: December 2012 1 Under Health Reform Law and as a condition of enrollment in Medicare and
More informationCODE OF CONDUCT. Providers, Suppliers and Contractors
CODE OF CONDUCT Providers, Suppliers and Contractors Table of Contents Code of Conduct... Honesty and integrity... Quality and Service... Responsibilities of Providers, Suppliers and Contractors... Compliance
More informationDEPARTMENT: POLICY DESCRIPTION:
DEPARTMENT: Legal and Compliance POLICY DESCRIPTION: Role of Federal False Claims Act and Similar State Civil or Criminal Statutes in Preventing and Detecting Fraud & Abuse in Federal Health Care Programs
More informationSULLIVAN COUNTY EMPLOYEE ORIENTATION FACT SHEET # 31
SULLIVAN COUNTY EMPLOYEE ORIENTATION FACT SHEET # 31 SULLIVAN COUNTY CORPORATE COMPLIANCE SUBJECT: FALSE CLAIMS ACT STATEMENT OF POLICY: Sullivan County is committed to providing quality health care in
More informationSCAN Health Plan Policy and Procedure Number: CRP-0067, False Claims Act & Deficit Reduction Act 2005
Health Plan Policy and Procedure Number: CRP-0067, False Claims Act & Deficit Reduction Act 2005 Approver Approval Stage Date Chris Zorn Approval Event (Authoring) 12/09/2013 Nancy Monk Approval Event
More informationCORPORATE COMPLIANCE POLICIES AND PROCEDURES DRA NOTICE POLICY (CPL-007) Last Revision Date: September 9, 2014
CORPORATE COMPLIANCE POLICIES AND PROCEDURES DRA NOTICE POLICY (CPL-007) Last Revision Date: September 9, 2014 Original Date: March 5, 2013 OMNICARE DRA NOTICE POLICY CPL-007 (SEPTEMBER 2014) I. PURPOSE
More informationHCCA 2013 COMPLIANCE INSTITUTE ANTI-KICKBACK STATUTE 101 SEATTLE, WASHINGTON
UW MEDICINE HCAA 2013 Compliance Institute HCCA 2013 COMPLIANCE INSTITUTE ANTI-KICKBACK STATUTE 101 April 23, 2013 Robert S. Brown Senior Compliance Specialist UW Medicine Compliance SEATTLE, WASHINGTON
More informationESTABLISHING POLICY AND PROCEDURES FOR COMPLIACE WITH 42 USC 139a(a)(68), False Claims and Whistle Blower Protections
RESOLUTION NO. COA-falseclaimsandwhistlesrev. 93-10 Date: 2/23/2010 ESTABLISHING POLICY AND PROCEDURES FOR COMPLIACE WITH 42 USC 139a(a)(68), False Claims and Whistle Blower Protections BY: Mr. George
More informationFederal Fraud and Abuse Laws
Federal Fraud and Abuse Laws Remaining in Compliance while Attesting to Meaningful Use 1 Overview This presentation provides an overview of key Federal laws aimed at preventing healthcare fraud and abuse
More informationHospital Assocation of Southern California
Hospital Assocation of Southern California Recent Developments in Fraud Enforcement and Litigation; Practical Strategies to Minimize Risks and Liabilities David V. Marshall davidmarshall@dwt.com U.S. Department
More informationObjectives. Fraud and Abuse defined Enforcement agencies Fraud and Abuse regulations Five-step action plan
Fraud and Abuse Primer: Does your Compliance Program Prevent and Detect Fraud and Abuse? Julie Dean, JD, CHC, CHRC, CHPC Sr. Managing Consultant, Compliance Objectives Fraud and Abuse defined Enforcement
More informationTM Nightingale. Home Healthcare. Fraud & Abuse: Prevention, Detection, & Reporting
Fraud & Abuse: Prevention, Detection, & Reporting What Is Fraud? Fraud is defined as making false statements or representations of facts to obtain benefit or payment for which none would otherwise exist.
More informationHow To Protect Yourself From A False Claim
False Claims Act Update Robert A. Wade, Esq. Krieg DeVault LLP 4101 Edison Lakes Parkway, Ste. 100 Mishawaka, IN 46545 Phone: 574-485-2002 Email: bwade@kdlegal.com KD_4901979 1 The FCA is the Fraud Enforcement
More informationPOLICY ON FRAUD, WASTE AND ABUSE IN FEDERAL HEALTH CARE PROGRAMS
43 New Scotland Avenue (MC-12) Albany, NY 12208 POLICY ON FRAUD, WASTE AND ABUSE IN FEDERAL HEALTH CARE PROGRAMS EFFECTIVE JANUARY 1, 2007, APPROVED NOVEMBER 14, 2006 LATEST REVISION DATE: MARCH 4, 2015
More informationStark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare
Stark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare In health care, we are blessed with an abundance of rules, policies, standards and laws. In Health
More informationCorporate Compliance and Ethics
Corporate Compliance and Ethics Title: Corporate Compliance and Ethics Course Code: EL-CCE-COMP-0 Course Outline Section 1: Introduction A. Course Contributors B. About This Course C. Learning Objectives
More informationPITTSBURGH CARE PARTNERSHIP, INC. COMMUNITY LIFE PROGRAM POLICY AND PROCEDURE MANUAL. False Claims Act Explanation and Reporting Requirements
SUBJECT: False Claims Act Explanation and Reporting Requirements NUMBER: 1004 CROSS REFERENCE NUMBER: 1823 REG. REF.: 31 U.S.C. 37-29 PURPOSE: POLICY: The purposes of this policy are to describe the Federal
More informationMedicare Advantage and Part D Fraud, Waste, and Abuse Training. October 2010
Medicare Advantage and Part D Fraud, Waste, and Abuse Training October 2010 Introduction 2008: United States spent $2.3 trillion on health care. Federal fiscal year 2010: Medicare expected to cover an
More informationReports of Compliance Concerns and Violations
The University of Chicago Medical Center Compliance Manual (UCHHS;BSD;UCPP) Reports of Compliance Concerns and Violations Issued: November 1, 1999 Reports of Compliance Concerns and Violations Revised:
More informationProgram Integrity (PI) for Network Providers
Program Integrity (PI) for Network Providers Purpose of Program Integrity Quality providers o Improved outcomes for consumers o Reduced oversight for provider o Confidence in network for LME-MCOs Financial
More informationTHE COUNTY OF MONTGOMERY POLICIES AND PROCEDURES FALSE CLAIMS AND WHISTLEBLOWER PROTECTIONS
THE COUNTY OF MONTGOMERY POLICIES AND PROCEDURES POLICY It is the obligation of the County of Montgomery (the County ) to prevent and detect any fraud, waste and abuse in its organization related to Federal
More information