Federal False Claims Act (31 USC 3729 through 3733)

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1 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 significantly revised in 1986 to combat all forms of fraudulent activities against the government, including health insurance programs such as Medicare and Medicaid. In accordance with the Deficit Reduction Act of 2005 (DRA), the following information is provided to employees, management and contractors, who shall recognize their rights and responsibilities regarding the FCA and Kentucky laws and regulations on the prevention and detection of health care fraud, waste and abuse. II. STATEMENT OF COMMITMENT TO COMPLIANCE Employees, management and contractors are responsible for understanding and diligently exercising the hospital s commitment to compliance. Below is the hospital s Statement of Commitment to Compliance. The University of Louisville Hospital/James Graham Brown Cancer Center ( hospital ) is committed to providing health care services in full conformity with applicable legal, regulatory, ethical and professional standards. To demonstrate this commitment, the hospital has developed and implemented a voluntary compliance program with the intent, in part, to prevent and detect health care fraud, waste and abuse. Employees, management and contractors of the hospital are obligated to report, and will never be retaliated against for reporting, any conduct that they believe violates a legal, regulatory, ethical and/or professional standard. Reporting suspected misconduct in a frivolous or vexatious manner or failing to report suspected misconduct; however, may result in disciplinary action in accordance with the hospital s progressive discipline policy. Employees, management and contractors are furthermore obligated to maintain the hospital s reputation for lawful and ethical behavior; therefore, compliance-related training and adherence to the hospital s Corporate Compliance Handbook and Policies/Procedures are mandatory and conditions of employment and contractual relationships. III. THE FEDERAL FALSE CLAIMS ACT Federal False Claims Act (31 USC 3729 through 3733) This act prohibits misconduct that revolves around the submission of false claims to the United States. Generally, a false claim is a misrepresentation of health care services sent to the United States government or its contractors for approval or payment. A false claim has been broadly interpreted to include any misstatements or omissions on a claim, a claim for services that were not rendered, improper coding of a claim and a claim for services that were not properly documented. Following are some examples of fraudulent claims. 8Billing for services or items that were not rendered or provided 8Billing for services that were not medically necessary 8Double billing for items or services 8Physician billing for services that were provided by interns, residents or fellows in a teaching hospital 8Engaging in a pattern or practice of presenting fraudulent claims 8Misrepresenting the eligibility of patients 8Falsifying certificates of medical necessity Eff. 8/07 Page 1 of 7

2 8Falsifying treatment plans or medical records to maximize payments 8Failing to report overpayments or credits 8Unlawfully giving health care providers inducements in exchange for referrals for service The FCA imposes liability on any person who knowingly submits a claim to the federal government that he or she knows, or should know, is false. A person acts knowingly if he or she has actual knowledge of the falsity of the submitted information or acts in deliberate ignorance or recklessly disregards the truth or falsity of the information. The FCA also allows private individuals to file a lawsuit on behalf of the United States. These individuals, known as qui tam relators or whistleblowers, must meet certain requirements to pursue a lawsuit. For example, the whistleblower must be the original source of the information and the lawsuit must be filed in a federal district court. The government may or may not decide to participate in the lawsuit. In either case, the whistleblower may share in the amount recovered should a violation be proven. When the government has intervened in the lawsuit, the whistleblower may receive at least 15 percent, but no more than 25 percent, of the proceeds. When the government has not intervened in the lawsuit, the whistleblower may receive at least 25 percent, but no more than 30 percent, of the proceeds. The FCA provides protection to whistleblowers who are discharged, demoted, suspended, threatened, harassed or in any other manner discriminated or retaliated against by their employer due to lawful actions taken under the FCA. This anti-retaliation provision provides compensation to whistleblowers upon their demonstration that retaliation occurred. For example, whistleblowers may be rewarded job reinstatement with comparable seniority, two times the amount of back pay, interest on back pay and reimbursement for other damages, e.g. legal expenses. If a court determines a lawsuit is clearly frivolous or vexatious, the whistleblower may have to pay the defendant for its legal expenses. Submitting False Claims (18 USC 287) This section prohibits and criminalizes knowingly making or presenting a claim that is false, fictitious or fraudulent to a department or agency of the United States. Penalties include fines of up to $250,000 for individuals and $500,000 for organizations per claim and imprisonment of up to 5 years. False Statements (18 USC 1001) This section criminalizes making a false statement of material fact; concealing a material fact and using a false writing or document. Penalties include fines of up to $250,000 for individuals and $500,000 for organizations per claim and imprisonment of up to 5 years. Federal Administrative Remedies for False Claims (31 USC 3801 through 3812) This section addresses the submission - not the payment - of a false claim. Penalties include fines of up to $5,000 per claim and twice the amount of the claim. Unlike the FCA, investigations and recoveries under this statute are handled by federal agencies, e.g. Office of the Inspector General (OIG), rather than the courts. Also unlike the FCA, private individuals who report alleged wrongdoing may not share in the amounts recovered should a violation be proven. Eff. 8/07 Page 2 of 7

3 Medicare and Medicaid Fraud (42 USC 1320a-7b(a)(1)) This section forbids knowingly and willfully making, or causing to be made, a false statement or representation of material fact in a claim for payment under a federal health care program. Penalties include fines of up to $25,000 and imprisonment of up to 5 years. Mandatory Exclusion (42 USC 1320a-7(a)) and Permissive Exclusion (42 USC 1320a-7(b)) This section addresses exclusion, which occurs when Medicare and Medicaid payment is barred for any items or services that the excluded party furnishes or orders to be furnished. Exclusion is an administrative remedy imposed by the Secretary of the Department of Health and Human Services (DHHS) via its designee, the OIG. Exclusion is based on a finding that an individual or entity has committed any fraudulent, abusive or otherwise wrongful acts related to the delivery of health care goods and services. The period of exclusion can range from 1 to 10 years or be permanent. Mandatory exclusion is, without discretion, applied and based on the conviction of certain state or federal health care fraud and abuse laws. Permissive exclusion is, discretionary in part, applied and based on certain types of misconduct found from a court, licensing board or other agency or action by the DHHS. Civil Monetary Penalties Act (42 USC 1320a-7a) This act allows the DHHS to impose administrative penalties and assessments against providers who file false or otherwise improper claims for payment under federal and state health care programs. Civil penalties include fines of up to $10,000, and up to $100,000 in some circumstances, per claim filed under Medicare, Medicaid and certain federal grant programs. Furthermore, triple damages may be imposed. IV. KENTUCKY LAWS AND REGULATIONS KRS This statute imposes civil liability against providers found, by the preponderance of the evidence, to be in violation, including $500 per submitted claim and up to 3 times the amount of excessive payments. Providers also face exclusion from the Medicaid program, liability for restitution and interest of any wrongful payments, legal expenses related to the investigation and enforcement of civil payments. These remedies are separate from and cumulative to any other administrative, civil or criminal remedies available under federal or state laws or regulations. KRS (1) This statute requires any person, who knows or has reasonable cause to believe that a violation has been or is being committed by any person, corporation or entity, to report or cause to be reported the following information, if known, to the state Medicaid Fraud Control Unit (MFCU) or the Medicaid Fraud and Abuse hotline: the alleged offender s name; the alleged offender s address; the alleged offender s place of employment; Eff. 8/07 Page 3 of 7

4 the nature and extent of the alleged violation; the identity of the complainant; and any other information that the receiving person reasonably believes might be helpful with the investigation of the alleged fraud, waste or abuse. KRS (2) This statute makes reports received under KRS (1) confidential and protects anyone who makes such a report, in good faith, about the alleged offenses of another from any civil or criminal liability based on the report. KRS (3) This statute states that no employer shall discharge or in any manner discriminate or retaliate against any person who, in good faith, makes a report required or permitted by KRS to , testifies or is about to testify in any proceeding regarding any report or investigation. Any person injured by any act in violation of this law shall have a civil cause of action in Circuit Court to enjoin further violations and to recover the actual damages sustained with the costs of the lawsuit, including a reasonable fee for the person s attorney of record. KRS This statute requires any professional, who is licensed or regulated by the Commonwealth and is convicted or pleads guilty to a violation of any of the criminal provision of KRS to , to forfeit such license for a mandatory period of 5 years. KRS This statute requires that the Commonwealth have a lien against all property of any provider who has been found to defraud the Medicaid program for an amount equal to the sum defrauded plus any interest and penalties. KRS This statute is intended to protect the programs and agencies under the jurisdiction of the Kentucky Cabinet for Health and Family Services (CHFS) from a wide range of misconduct. Wrongful conduct punishable under this statute includes making false claims, making false statements both oral and written, presenting false documents, devising schemes, entering into conspiracies, concealing or covering-up material facts or inducing others to engage in such conduct. Furthermore, wrongful conduct punishable under this statute includes any matter within the jurisdiction of the CHFS. For example, KRS (2) prohibits any person from knowingly or wantonly making, presenting or causing to be made or presented to the CHFS any false, fictitious or fraudulent statement, representation or entry in any application, claim, report or document used in any benefit or payment determination. KRS (4) prohibits any person from knowingly falsifying, concealing or covering up by any trick, scheme or device a material fact, making any false, fictitious or fraudulent statement or representation or making any false writing or document that contains any false, fictitious or fraudulent statement. Persons found to have violated KRS may face significant penalties including Class D and C felonies. Eff. 8/07 Page 4 of 7

5 KRS (8) This statute defines health care provider abuse as practices that are inconsistent with sound fiscal, business or medical practices, that result in unnecessary cost to the Medicaid Program or that result in reimbursement for services that were not medically necessary or that fail to meet professionally recognized standards for health care. KRS This statute prohibits, with certain exceptions, a provider from knowingly soliciting, receiving or offering any remuneration, including any kickback, bribe or rebate, for furnishing medical assistance benefits or in return for purchasing, leasing, ordering or arranging for or recommending the purchasing, leasing, ordering of any good, facility, service or item for which payment may be made under a government program. No provider shall knowingly make, offer or receive a payment, rebate of fee or charge for referring a recipient to another provider for the furnishing of benefits. Penalties include Class D felony charges and repayment of all related claims. 907 KAR 1:671.1(20)(a) This regulation prohibits billing for services or supplies that were not furnished. 907 KAR 1:671.1(20)(b) This regulation prohibits billing for medical care, services or supplies that are in excess of accepted standards of practice for the medical care or other type of service, e.g. not medically necessary, billing for medical care, services or supplies that are in excess of established limits communicated, in writing, to providers by the state Medicaid agency and failing to bill a third-party payor when the provider has knowledge of third-party coverage and chooses not to bill that payor. 907 KAR 1:671.1(40)(a,b) This regulation prohibits knowingly submitting or causing the submission of false claims and knowingly making or causing to be made false, fictitious or fraudulent statements, or misrepresentations of material fact in claiming a Medicaid payment, or for use in determining payment rights. 907 KAR 1:671.1(40)(c) This regulation prohibits having knowledge of an event that affects the right of a provider to receive payment and concealing or failing to disclose the event or other material omission with the intention that a payment be made or the payment is made in a greater amount than otherwise owned. 907 KAR 1:671.1(40)(e) This regulation prohibits the soliciting or accepting of kickbacks, bribes or rebates in exchange for referring goods, facilities, services or items that are reimbursed by government programs. Eff. 8/07 Page 5 of 7

6 907 KAR 1:671.1(40)(f) This regulation prohibits billing for services or supplies that are not documented with regard to their provision and medical necessity and altering, falsifying, destroying or concealing medical records, income and expenditure reports or any other records that support reimbursement. 907 KAR 1:671.1(40)(h) This regulation prohibits accepting a gift, money, donation or other compensation as a condition of admission or continued stay in a facility. 907 KAR 1:671.1(40)(i) This regulation prohibits charging or agreeing to charge or collect a fee from a Medicaid beneficiary for covered services which are in addition to amounts paid by Medicaid, except for required copayments or recipient liability, if any, required by Medicaid. 907 KAR 1:671.1(40)(k) This regulation prohibits furnishing medical care, service, or supplies that do not meet professionally recognized standards for health care, e.g. sub-standard care, furnishing medical care, services or supplies that are found to be non-compliant with licensure standards, failing to correct deficiencies or violations reported to the OIG and furnishing medical care, services or supplies that are beyond the scope of the provider s professional qualifications of licensure. 907 KAR 1:671.1(40)(m) This regulation prohibits having payments made through a third-party, either directly or by power of attorney, as prohibited by 42 CFR regarding reassignments. 907 KAR 1:671.1(40)(n) This regulation prohibits offering or providing a premium or inducement to a Medicaid beneficiary in return for the beneficiary s patronage of the provider or other provider to receive medical care, services or supplies under the Medicaid program. 907 KAR 1:671.1(40)(o) This regulation prohibits knowingly failing to meet disclosure requirements, including making false statements to government agencies about compliance. 907 KAR 1:671.1(41) This regulation prohibits unbundling, which is defined as billing separately for each component of a group of procedures that are commonly used together and for which Medicare and/or Medicaid provide a special bundled reimbursement rate. Eff. 8/07 Page 6 of 7

7 V. RESPONSBILITIES OF EMPLOYEES, MANAGEMENT AND CONTRACTORS Employees, management and contractors are responsible for being familiar with and seeking guidance about their rights and responsibilities relating to the FCA and other compliance matters, which are fully explained in the hospital s Corporate Compliance Handbook and Policies and Procedures listed below. These documents are available at anytime via the hospital s Intranet site (UHCNET), Internet site ( and hard copy (requests should be submitted to the Corporate Compliance Department). 8Policy/Procedure Policy/Procedure Policy/Procedure Policy/Procedure Policy/Procedure Policy/Procedure Policy/Procedure Policy/Procedure Policy/Procedure Policy/Procedure Compliance Issue Resolution Code of Conduct Auditing and Monitoring V.P. Compliance & Ethics Duties/Responsibilities Problem Reporting and Nonretaliation Records Management Policy Education and Training Hotline Sanction Screening Prevention and Detection of Fraud, Waste and Abuse Employees, management and contractors are furthermore responsible for addressing suspected misconduct, including concerns about false claims, through the various means available at the hospital or any communication channel they feel is appropriate. All levels of management observe an opendoor policy. For example, employees, management and contractors may address concerns through the Vice President of Compliance & Ethics, the Human Resources Department and/or the employee hotline ( ). Calls to the employee hotline may, at the caller s request, be anonymous and are otherwise treated confidentially to the fullest extent practical or allowed by law. The hospital is committed to protecting employees who report actions in good faith and strictly prohibits retaliation. Eff. 8/07 Page 7 of 7

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