Administrative Policy & Procedure. Title: Reporting False Claims. Section: Leadership

Transcription

1 Administrative Policy & Procedure Title: Reporting False Claims Section: Leadership Policy Number: LD-1020 Origination Date: 2/2007 Effective Date: 4/6/2016 Page 1 of 6 Policy Statement Memorial Health, Inc., including, but not limited to, Memorial Health University Medical Center, Memorial Physician Practice Group d/b/a Memorial Health University Physicians, and Provident Health (hereinafter, Memorial Health ) are committed to complying with all applicable laws, and regulations including those that address healthcare fraud, waste and abuse and the appropriate billing of Medicare, Medicaid and other government funded health care programs. This includes the Federal False Claims Act and state false claims statutes. This policy and the information contained within shall be made available to all current and new Team Members and to all current and future contractors of Memorial Health. Definition of Terms Fraud, Waste, and Abuse Laws (FWA Laws) Federal and State false claims laws have been established to prevent fraud, waste, and abuse in government health care programs and allow the government to bring forth civil actions to recover damages and/or impose penalties when healthcare providers submit false claims. These laws also allow for individuals to file action ( qui tam ) on behalf of the government and the Government has the opportunity to intervene and join these law suits. Provisions within the laws protect these individuals ( whistleblowers ) from retaliation by their employer. False claims can take the form of: Overcharging for a product or service; Billing for services not rendered or goods not provided; Underpaying money owed to the government; Charging for one thing while providing another; Falsifying records, treatment plans, or medical records to maximize payments;

2 Falsifying certificates of medical necessity and billing for services not medically necessary; Billing separately for services that should be a single service; Double-billing for items or services; Failing to report overpayments or credit balances; Unlawfully giving health care providers, such as physicians, inducements in exchange for referrals for service; Summary information about the federal and state laws and reference citations are noted below: Federal False Claims Act 1 -. The FCA imposes civil penalties of not less than $5,000 nor more than $10,000, plus three (3) times the amount of damages sustained by the government for each false claim. The amount of damages is defined as the amount paid for each false claim that is filed Federal Program Fraud Civil Remedies Act 2 - creates administrative remedies for making false claims separate from, and in addition to, the judicial or court remedy for false claims provided by the Civil False Claims Act. The Act deals with submission of improper claims or written statements to a federal agency. A violation carries a $5,000 civil penalty for each such wrongfully filed claim. In addition, an assessment of two times the amount of the claim may be made, unless the claim has not actually been paid Georgia Medicaid False Claims Act 3 generally similar to the federal law and addresses fraud and abuse in the Georgia Medicaid Program and includes a qui tam provision. Violations of this act carry penalties between $5,000 and $11,000 for each false claim, plus three (3) times the amount of damages sustained by the Georgia Medicaid program arising from the violation. Georgia Taxpayer Protection False Claims Act 4. It expands Georgia s False Claims Act beyond Medicaid and imposes civil penalties for submitting a false or fraudulent claim for payment or approval to the state or local government and includes a qui tam provision. A violation of this act carries penalties between $5,000 and $11,000 for each violation. There may be additional liabilities in the amount of 1 31 U.S.C U.S.C O.C.G.A O.C.G.A

3 three (3) times the amount of damages, which the state or local government sustains because of the violation. Georgia Medicaid Unlawful Payment Statute 5 provides that it shall be unlawful: 1. For any person or provider to obtain, attempt to obtain, or retain any medical assistance or other benefits or payments under this article or under a managed care program operated, funded, or reimbursed by the Georgia Medicaid program, to which the person or provider is not entitled, or in an amount greater than that to which the person or provider is entitled, when the assistance, benefit, or payment is obtained, attempted to be obtained or retained, by: Knowingly and willfully making a false statement or false representation; Deliberate concealment of any material fact; or Any fraudulent scheme or device; or 2. For any person or provider knowingly and willfully to accept medical assistance payments to which he or she is not entitled or in an amount greater than that to which he or she is entitled or knowingly and willfully to falsify any report or document required under this article. Any person violating paragraph (1) or (2) shall be guilty of a felony and, upon conviction thereof, shall be punished for each offense by a fine of not more than $10,000.00, or by imprisonment for not less than one year nor more than ten years, or by both such fine and imprisonment. In addition to any other penalties provided by law, each person violating this law shall be liable for a civil penalty equal to the greater of (1) three times the amount of any such excess benefit or payment or (2) $1, for each excessive claim. Additionally, interest on the penalty shall be paid at the rate of 12 percent per annum. Procedures All Team Members are required to complete annual required training, which includes education regarding the federal and state false claims laws and the role of such laws in preventing and detecting fraud, waste and abuse in federal health care programs. 5 O.C.G.A (b)

4 Additionally, Memorial s Code of Business Practices, Compliance Program, Reporting False Claims Policy and other relevant policies will be provided to and/or made available to contractors of Memorial Health via direct distribution or posting on Memorial Health s internet site. Policies have been established outlining Memorial Health s commitment and processes to eliminate fraud, waste and abuse in federal and state health care programs through compliance with FWA Laws. Team Members are expected to conform to Memorial Health policies established to encourage the detection and prevention of fraud, waste and abuse. In addition to this policy, Team Members may refer to the following Memorial Health policies for greater detail regarding the methods utilized for detecting and preventing fraud, waste, and abuse: a. Leadership Policy & Procedure LD 1039, Non-Retaliation b. Human Resources Policy & Procedure HR 2003, Orientation/ Required Education Programs c. Management of Information Policy & Procedure IM 2007, Charge Capture & Charge Reconciliation d. Information Management Policy & Procedure IM 2009, Charge Description Masters Maintenance e. Conifer Health Solutions Policy NMC.01.01, Refunding and Reporting of Overpayments f. Memorial Health University Physicians Policy 3.16, Resolving Credit Balances and Refunds g. Memorial Health s Code of Business Practice booklet - This guide is provided to all Team Members during his or her new hire in-processing and can also be obtained through Compliance and Audit Services. All Team Members must complete annual compliance training on the Memorial Health intranet. h. Memorial Health s Team Member Handbook is available on the Human Resources web page. Instructions on how to access the handbook online are provided to all Team Members during his or her new hire in-processing. i. Memorial Health s System Compliance Program - This plan can be obtained from Compliance and Audit Services or via the Compliance and Audit Service s site on Memorial Health s intranet.

5 Memorial Health will not retain an overpayment or significantly delay the refund of a known overpayment. Overpayments will be refunded to the appropriate payor within the time required by law, or in accordance with the payor s policy. Memorial Health takes all issues regarding false claims, fraud and abuse seriously. Memorial health encourages its team members and contractors to report any concerns regarding actual or potential violations of false claims laws. Memorial will investigate any issues reported promptly. Questions or concerns may be reported to a team member s team leader, Compliance and Audit Services at (912) , or via the Ethics Line at Communications with Compliance and Audit Services will be handled in strict confidence. Memorial Health has in place a Non-Retaliation Policy which encourages individuals to ask questions and report concerns without fear of retaliation or adverse employment consequences. Approved by: Alysia Shirley VP, Compliance and Audit Services Jamie Watson VP, System Operations Mary B. Chatman, PhD, RN COO/CNO Margaret Gill President & Chief Executive Officer

6 Original Implementation Date: 2/2007 Originating Department: Ethics & Compliance Next Review Date: 4/2017 Past Revised Date: 8/2008, 5/2010, 9/2010, 8/2013 Past Reviewed Date: Former Policy Number(s): Attachment(s): Intranet Links: Code of Business Practice Compliance Program Employee Handbook