Prevention of Fraud, Waste and Abuse

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1 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... 1 Procedures... 1 Related Information... 5 Contacts... 5 Revision History... 5 Forms and Exhibits... 5 Policy Statement It is the policy of Yale Medical Group that its employees, contractors and agents comply with federal, state and local laws and regulations that apply to the performance of their responsibilities at Yale Medical Group, including those that pertain to the prevention of fraud, waste and abuse in the provision of health care services. Yale Medical Group employees are required to fulfill various medical billing compliance training requirements, particularly medical billing compliance, and abide by Yale Medical Group s related policies and procedures. Faculty and staff should report suspected material violations of laws and regulations to a supervisor, Director of Billing Compliance, Dean, the Controller, University Auditing or the Vice President and General Counsel, depending on the nature of the suspected violation. If the issue is not adequately addressed by these University contacts, individuals may call the Yale University Fraud or Illegal Activity Hotline: No Yale University employee, contractor or agent has the authority to direct, participate in, approve, or to allow any violation of any of the laws described in this policy. The University will not take, or tolerate, any intimidating or retaliatory act against an individual who, in good faith, makes a report of practices reasonably believed to be a violation of this Policy. Procedures 1. Scope A. This policy applies to all employees and authorized agents of the Yale Medical Group. This policy serves to (1) inform employees, contractors and agents of Yale Medical Group of the federal civil False Claims Act (referenced in this policy as FCA ) and similar state and federal laws that prohibit the submission of false or fraudulent claims, including the remedies and fines for violations that can result from such activity; and (2) provide information regarding the Yale Medical Group s efforts to detect and prevent fraud, waste, and abuse in the provision of health care. 2. Definitions A. Deficit Reduction Act of 2005 ( DRA ) Federal law which, among other things, requires that state Medicaid Plans be amended to require certain health care organizations to establish written policies that address the following: (1) the federal civil False Claims Act ( FCA ); (2) state laws pertaining to civil or criminal penalties for false claims and statements; (3) the whistleblower protections provided under both federal and state laws, and the role of these laws in preventing and detecting fraud, waste and abuse; (4) the administrative remedies found in the Program Fraud Civil Remedies Act; and (5) Yale Medical Group s policies and procedures for detecting and preventing fraud, waste and abuse. B. Federal civil False Claims Act ( FCA ) Federal law which prohibits knowingly presenting or causing to be presented to the U.S. government a false or fraudulent claim for payment or approval; knowingly making, using, or causing to be made or used a false record or statement to get a false or fraudulent claim paid or approved; and conspiring to defraud the government Page 1

2 by getting a false or fraudulent claim paid or allowed. 3. Federal False Claims Act Information A. The federal civil False Claims Act, 31 U.S.C. 3729, et seq. ( FCA ), was originally enacted in 1863 after a series of Congressional inquiries disclosed several instances of fraud among defense contractors during the Civil War. The current FCA was passed by Congress in 1982 and was amended in The FCA contains provisions designed to enhance the government s ability to identify and recover losses it suffers due to fraud. Since the FCA s enactment, the government has recovered substantial sums through litigation or settlement of allegations that corporations and individuals violated the statute and thereby improperly obtained federal health care program funds. Congress and the government believe that the FCA is a very effective means to detect fraud, by encouraging individuals to uncover and report fraud, and to prevent fraud, by creating strong incentives for companies and individuals to be vigilant in their pursuit of compliance and avoid liability for multiple damages and penalties under the statute. 4. FCA Prohibitions A. The federal civil False Claims Act prohibits any individual or company from knowingly submitting false or fraudulent claims, causing such claims to be submitted, making a false record or statement in order to secure payment from the federal government for such a claim, or conspiring to get such a claim allowed or paid. Under the statute the terms knowing and knowingly mean that a person (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information. Examples of the types of activity prohibited by the FCA include billing for services that were not actually rendered, and upcoding (the practice of billing for a more highly reimbursed service or product than the one provided). B. The FCA is enforced by the filing and prosecution of a civil complaint. Under the Act, civil actions must be brought within six years of a violation, or, if brought by the government, within three years of the date when material facts are known or should have been known to the government, but in no event more than ten years after the date on which the violation was committed. 5. Penalties A. Individuals or companies found to have violated the statute are liable for a civil penalty for each claim of not less than $5,500 and not more than $11,000, plus up to three times the amount of damages sustained by the federal government. 6. Qui Tam and Whistleblower Protection Provisions A. The FCA authorizes the United States Attorney General to bring actions for false or fraudulent claims submitted by individuals or companies that do business with, or are reimbursed by, the United States. The statute also authorizes private citizens to file a lawsuit in the name of the United States alleging violations of the statute. Commonly known as a qui tam action, a lawsuit brought under the FCA by a private citizen commences upon the filing of a civil complaint in federal court under seal and service of a disclosure of material evidence on the Attorney General. The government has sixty days to investigate the allegations in the complaint and decide whether it will join the action, in which case the complaint is unsealed, and the Department of Justice or a United States Attorney s Office takes the lead role in prosecuting the claim. If the government decides not to join, the whistleblower may pursue the action alone, but the government may still join at a later date if it demonstrates good cause for doing so. As an incentive to bring these cases, the Act provides that whistleblowers who file a qui tam action may receive a reward of 15-30% of the monies recovered for the government plus attorneys fees and costs. This award may be reduced if, for example, the court finds the whistleblower planned and initiated the violation. The FCA also provides that putative whistleblowers who prosecute clearly frivolous qui tam claims Effective Date 10/01/2006 Page 2

3 can be held liable to a defendant for its attorneys fees and costs. B. Whistleblowers are also offered certain protections against retaliation for bringing an action under the Act. Employees who are discharged, demoted, harassed, or otherwise confront discrimination in furtherance of such an action or as a consequence of whistleblowing activity are entitled to all relief necessary to make the employee whole. Such relief may include reinstatement, double back pay, and compensation for any special damages including litigation costs and reasonable attorneys' fees. 7. Federal Program Fraud Civil Remedies Act Information A. The Program Fraud Civil Remedies Act of 1986 ( PFCRA ), provides for administrative remedies against persons who make, or cause to be made, a false claim or written statement to certain federal agencies, including the Department of Health and Human Services. PFCRA was enacted as a means to address lower dollar frauds, and generally applies to claims of $150,000 or less. PFCRA provides that any person who makes, presents, or submits, or causes to be made, presented or submitted a claim that the person knows or has reason to know is false, fictitious, or fraudulent is subject to civil money penalties of up to $5,000 per false claim or statement and up to twice the amount claimed in lieu of damages. Violations are investigated by the Department of Health and Human Services, Office of the Inspector General and enforcement actions must be approved by the United States Attorney General. PFCRA enforcement can begin with a hearing before an administrative law judge. Penalties may be recovered through a civil action brought by the Attorney General or through an administrative offset against clean claims. Because of the availability of other criminal, civil and administrative remedies, cases are not routinely prosecuted under PFCR. 8. Connecticut State Law Information A. Similar to the FCA and the PFCRA, certain Connecticut statutes impose penalties on persons or entities that make false statements in connection with a claim for payment to a government health care program. Regulations of Connecticut State Agencies 17-83k-1 et seq. prohibits, among other things, the (1) knowing and willful submission of false representations of material fact in connection with a claim for payment under the Medicaid program; (2) provision of services that are not medically necessary; and (3) violation of the federal and state laws governing the Medicaid program. These regulations provide sanctions for violations that include but are not limited to restitution, suspension from participation in the program and/or limitation on a person or an entity s participation in the program. Connecticut General Statutes et seq. also make it unlawful deliberately to submit or to conspire to submit a claim for payment to any health insurer which contains any false, deceptive or misleading information, such as a false representation that goods or services were medically necessary. Violators are subject to penalties for larceny, including fines and imprisonment. Likewise, 53a-118 et seq. subject persons or entities to penalties for larceny for knowingly submitting false claims for payment to a local, state or federal agency or for knowingly accepting the benefits of a claim which the person or entity knows to be false. It is a Class D felony to tamper with or fabricate physical evidence (Connecticut General Statute 53a- 155) and a Class A misdemeanor to knowingly make false written statements under oath with the intention to mislead a public servant (Connecticut General Statute 53a-157b). B. Connecticut General Statute 17b-102 provides a financial incentive to persons to report vendor fraud to the Department of Social Services. Under Connecticut Regulation 17b et seq. and Connecticut General Statutes 53a-290 et seq., vendor fraud includes: the submission for payment of a false claim for goods or services; accepting greater payment than is due for the provision of goods or services; soliciting to perform unnecessary services or to sell unnecessary goods; performing services unauthorized by the Department of Social Services when such authorization is necessary; and accepting payment from someone other than the state as additional compensation in excess of the amount legally authorized. That Effective Date 10/01/2006 Page 3

4 award may be reduced or barred altogether if: (1) the person reporting has materially participated in or benefited from the fraudulent activity being reported; (2) there is no direct correlation between the information reported and the amounts recovered by the state; (3) the person reporting requested anonymity; or (4) the reported activity is already the subject of an investigation.. In addition, 17b-25a creates a toll free vendor fraud telephone hotline. Penalties for vendor fraud are set forth in the Connecticut General Statues 17b-99. C. Connecticut law protects persons from retaliation who in good faith report suspected violations of state or federal law, including reports of criminal fraud. For instance, 4-61dd protects persons who disclose to state agencies knowledge of corruption, unethical practices or violations of laws. Connecticut Regulation Section 4-61dd-1 et seq. sets forth the rules for contested case proceedings under the statute. Likewise, 31-51m protects persons who report illegal activities and unethical practices from retaliation and discrimination. Section 31-51q addresses the liability of employers for discipline or discharge of employees who exercise certain constitutional rights. 9. Prevention of Fraud, Waste and Abuse at Yale University A. Employees, contractors and agents always have a responsibility to report concerns about actual or potential wrong-doing to appropriate people within the University. Employees, contractors and agents of Yale University should immediately report any suspicion of fraud, waste or abuse in connection with University business (see Yale University s Standards of Business Conduct and the related Institutional Resources for Guidance on the Standards of Business Conduct Individuals should, in appropriate cases, report such concerns first to a supervisor or a department head. They may also contact the Yale Medical Group ( YMG ) Billing Compliance Officer for issues relating to medical billing at YMG or, for any issue, University Auditing or the Office of the General Counsel. If the issue is not adequately addressed by these University contacts, individuals may call the Yale University Fraud or Illegal Activity Hotline: B. Yale University s compliance program and policies protect employees who in good faith report potential problems or concerns from retaliation retribution or harassment. Yale, through YMG, engages in specific compliance efforts to detect and prevent fraud, waste and abuse in health care transactions. These compliance efforts include annual medical billing compliance training, a medical billing compliance manual, billing compliance audits, the 24-hour confidential hotline maintained by an outside firm for reporting compliance concerns, and a comprehensive Medical Billing Compliance Program. C. The Compliance Office in coordination with General Counsel and University Audit will thoroughly investigate any allegation of an FWA violation. If the allegation is supported, the Compliance Officer after consultation with General Counsel will notify the appropriate entity including Medicare, Medicaid, Medicare Managed Care, and/or Commercial Insurance carriers on a timely basis or within 48 hours. D. If you would like more information on YMG s compliance program or policies, or on how to report any concerns, please visit or contact Judy Harris, Compliance Officer at or Effective Date 10/01/2006 Page 4

5 Related Information Social Security Act (42 U.S.C. 1396a(a)) Section 1902(a) 31 U.S.C U.S.C dd 17b-25a 17b-99 17b m 31-51q Yale University Standards of Business Conduct Yale University Policy 1101 YMG Compliance Program YMG Compliance Manual 53a-118 et seq. 53a-155 & 53a-157b 53a-290 et seq et seq. 4-61dd-1 et seq k-1 et seq. 17b et seq. rds.html Guiding Principles for Business and Financial Administration y/alert/plan2006.html y/manual/manual.html Contacts Title or Department Telephone Yale University Auditing Yale University Legal and Regulatory Affairs, Office of the Vice President and General Counsel YMG Chief Operating Officer YMG Compliance Officer Revision History Forms and Exhibits The official version of this information will only be maintained in an on-line web format. Any and all printed copies of this material are dated as of the print date. Please make certain to review the material on-line prior to placing reliance on a dated printed version. Effective Date 10/01/2006 Page 5

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