False Claims Act. Annual Education False Claims Act Mission Health System, Inc.

Transcription

1 Annual Education 2014

2 What is the Federal & State? The Federal is a law that establishes legal responsibility for any person or organization that submits false claims to the government for payment. The State is in addition to the Federal and increases enforcement and penalties for false claims. What is the definition of a Claim? Any request made to an employee, officer, agent, contractor, or other recipient for state or federal money, property, or service. Why do I need to know about penalties for non-compliance? You don t have to remember exact penalty amounts, but be aware of how serious the penalties are. Penalties are costly and include fines of up to $11,000 per false claim, additional monetary fines, and/or exclusion from participating in the Medicare, Medicaid, and other government programs (i.e. Mission Health Members, as health care providers, would no longer be allowed to receive payments for services provided to Medicare and Medicaid patients).

3 Examples Specifically, the Federal imposes legal responsibility on any organization or person who knowingly: Submits false or fraudulent claims for payment or approval to the Government. For example: An individual physician or staff member submits a bill to Medicare for payment of a medical service he/she knows was not provided. Makes a false record or statement regarding a false or fraudulent claim. For example: A hospital who receives payments from Medicare during a year s time, and then knowingly files a false cost report to avoid refunding the Medicare program. Plans to hide, avoid, or decrease a responsibility to pay money to the Government. For example: A staff member knowingly does not refund and/or decreases the amount due in an overpayment to a government payer or uses a false record to avoid paying money to the government.

4 What is Knowingly? Knowledge of a False Claim can be defined as a person: Having actual knowledge of the information Acting in deliberate ignorance of the truth or inaccuracy of the information Acting with reckless disregard or lack of concern to the truth or inaccuracy of the information A person does not have to have knowledge of the laws or specific intent to commit a violation.

5 What does the have to do with me? You as a nurse, pharmacist, physician, manager, clinical technician, coder, biller, etc. are responsible for compliance with the (FCA) and the Fraud Enforcement and Recovery Act (FERA) on behalf of this facility. Your everyday work is subject to the FCA and new enforcements through the FERA. Examples include, but are not limited to: Documenting thorough and accurate information in the medical record Assigning codes to diagnoses and procedures for billing Entering charges for procedures and services Submitting claims for payment Even if your job doesn t fall into the examples above (dietary, housekeeping, etc.), every employee and/or contractor must be educated about this law and know that it is their responsibility to report to Corporate Compliance any suspected concern of wrongdoing.

6 Laws that Strengthen the The following two laws significantly changed the law by definition and enforcement. Significant changes you should be aware of are: The Fraud Enforcement and Recovery Act of 2009 (FERA) Increased protections and enforcement against retaliation for whistleblowers. Whistleblowers are persons that report potential fraud and abuse to the government. Increased responsibility and enforcement for returning overpayments even when there is no false claim. For example: If you owe the government a refund, even when there is not false claim, you are responsible for returning. The Health Care Reform Law Expansion of the definition of a false claim - A claim submitted for health care items or services which violates criminal health care fraud laws is now also considered a false claim. Liability for Overpayment Retention Civil penalties of up to $50,000 Violation of FCA for not returning an overpayment within 60 days

7 Reporting a Concern Qui Tam What is that? Qui Tam is an allowance within the that any person with proof of fraud against a federal government program(s) can sue the wrongdoer on the government s behalf. These persons are sometimes referred to as whistleblowers or qui tam reporters. What happens if you report a concern in good faith? People who in good faith report a concern of suspected fraud, waste, and/or abuse are protected under federal law from retaliation. Several states, including North Carolina, also have Whistleblower Protection laws to protect reporters of suspected fraud.

8 How do I report a concern? How to Report a Concern Any suspected concerns of fraud, waste, and/or abuse related to the submission of claims to the federal government should be reported to the Corporate Compliance Officer (CCO). Reporting can be done by any of the following methods: Call or Jeri Williams, SVP, Corporate Compliance Officer Phone (828) jeri.williams@msj.org Phone the toll free hotline at ETHICS1 Mission on Demand Go to the Mission on Demand (MOD) home page Click on Departments and enter Corporate Compliance Go to the link for the Mission Integrity Page Select one of the reporting options Complete an Integrity Report Form

9 How can I find related policies and procedures? Additional information on False Claims is located on MOD and can be found by following these steps: Accessing Policies: Go to the Mission on Demand (MOD) home page Click on Policies and Procedures (left hand column) Click on your system location Search Policy by entering key search words (i.e. ) Review search results for the policy