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 concerns and problems in relation to compliance and ethics. Colorado Access encourages employees, providers, contractors and consultants to report any concerns relating to potential fraud, waste, and abuse, including concerns related to false claims. No Colorado Access employee, provider, contractor or consultant will be discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated or retaliated against solely because of actions taken to report potential fraud, waste and abuse. The purpose of this policy is to provide an overview of key provisions of the False Claims Act (the FCA ) and related compliance requirements as required by the Deficit Reduction Act of 2005 (the DRA ) for Colorado Access. Justification: Regulatory Departments/LOBs Involved: All Referenced Polices: CMP201 Problem Reporting and Non-Retaliation CMP211 Fraud, Waste and Abuse Definition of Terms: False Claims Act: The FCA prohibits the knowing submission of unjustified or false claims to obtain federal funds, including Medicare and Medicaid programs. 1 Deficit Reduction Act of 2005: The DRA is a federal law requiring numerous changes to the Medicaid program. The DRA requires that entities that receive or make annual payments of at least five million dollars under a state Medicaid plan, as a condition of receiving or making such payments, establish and disseminate to all employees and certain contractors written policies that provide detailed information about: The Federal False Claims Act; Federal administrative remedies for false claims and statements; Whistleblower protections under Federal and state laws; Any state laws pertaining to civil or criminal penalties for false claims and statements; and Policies and Procedures for preventing and detecting fraud, waste and abuse. 2 Claim: The definition of claim under the FCA, includes any request or demand, whether under a contract or otherwise, for money or property which is made to a contractor, provider or other recipient, if the United States Government provides any portion of the money or property which is requested or demanded, or if the government will reimburse such contractor, provider, or other recipient for any portion of the money or property which is requested or demanded. 3 1 31 USC 3729-3733 2 Social Security Act 1902(a)(68) 3 31 USC 3729(b)(2) Page 1 of 7
Knowing/Knowingly: The definition of knowing or knowingly under the FCA means that a person, with respect to information 4 : Has actual knowledge of the information; Acts in deliberate ignorance of the truth or falsity of the information; or Acts in reckless disregard of the truth or falsity of the information; and No proof of the specific intent to defraud is required. Whistleblower: The person who may bring a civil action for a violation of the FCA on behalf of the government. I. Detailed Information on the False Claims Act A. The FCA is a federal statute that prohibits fraud involving any federally funded program, including the Medicare and Medicaid programs. The FCA imposes liability on any person or entity who: 1. Knowingly presenting or causing to be presented a false or fraudulent claim for payment or approval; 2. 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; 3. Conspiring to defraud by getting a false or fraudulent claim allowed or paid; 4. Delivering or causing to be delivered less property than the amount for which the person receives a certificate or receipt; 5. With intent to defraud, making or delivering a receipt without completely knowing that the information on the receipt is true; 6. Knowingly buying public property from a government employee who does not have the legal right to sell the property; and 7. Knowingly making or using a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government. The FCA does not require proof of a specific intent to defraud for there to be a violation of the law. Examples of the types of activities prohibited by the FCA including billing for services that were not actually rendered, double-billing for items or services, upcoding (the practice of billing for a more highly reimbursed item or service than the one provided) or unbundling (the practice of billing services separately to secure a higher reimbursement). B. Administrative Remedies. The FCA establishes an administrative remedy against any person who presents or causes to be presented a claim or written statement that the person knows or has reason to know is false, fictitious, or fraudulent due to an assertion or omission to certain federal agencies (including the Department of Health and Human Services). The administrative remedy for violating the FCA is three times the dollar amount that the government is defrauded and civil penalties of $5,500 to $11,000 for each false claim by the party responsible for the claim. 4 31 USC 3729(b)(1) Page 2 of 7
1. Qui Tam Actions. The FCA provides for actions by private persons (qui tam lawsuit) to encourage individuals to come forward and report misconduct involving false claims. A qui tam action allows any person with actual knowledge of allegedly false claims to file a lawsuit on behalf of the U.S. government. Such persons are referred to as Whistleblowers. A qui tam lawsuit is initiated by Whistleblower on behalf of the government and is filed under seal (i.e., kept confidential) while the government reviews and investigates the allegations contained in the complaint. After the review and investigation period, the government may elect to join in the case in its own name or decide not to join in the case. If the government decides not to join in the case, the Whistleblower can continue with the lawsuit independently. If the lawsuit is successful, the Whistleblower may receive 15% to 30% of any recovery or settlement. The Whistleblower may also be entitled to reasonable expenses including attorney s fees and costs for bringing the lawsuit. 2. Whistleblower Protection. The FCA also includes anti-retaliation protections for Whistleblowers who make good faith reports of fraud, waste and abuse. The FCA prohibits retaliation against a Whistleblower for filing an action under the FCA or committing other lawful acts, such as investigating a false claim or providing testimony for, or assistance in, a FCA action. Any Whistleblower employee who is discharged, demoted, suspended, threatened, harassed or in any other manner discriminated or retaliated against in the terms and conditions of employment by his/her employer because of lawful acts done by the employee on behalf of the employee or others in furtherance of an action under the FCA shall be entitled to all relief necessary to make the employee whole. Such relief shall include reinstatement, two times the amount of back pay plus interest and other costs, damages and attorneys fees and costs. 3. Miscellaneous Information. For the party that had responsibility for the false claim, the government may seek to exclude individuals suspected or convicted of violating the FCA from participation in federal health care programs or may impose other obligations, including the requirement that individual(s) or entities accused of violating the FCA enter into a Corporate Integrity Agreement. II. Colorado False Claims Statutes A. Medicaid Claims 5 The Colorado False Medicaid Claims statute makes it unlawful for any person or entity to: 1. Intentionally or with reckless disregard make or cause to be made any false presentation of a material fact in connection with a claim; 5 CRS 25.5-4-303.5 to 25.5-4-310 Page 3 of 7
2. Intentionally or with reckless disregard present or cause to be presented to the state department a false claim for payment or approval; 3. Intentionally or with reckless disregard present or cause to be presented any cost document required by the medical assistance program that the person knows contains a false material statement; 4. As to services for which a license is required, intentionally or with reckless disregard make or cause to be made a claim with knowledge that the individual who furnished the services was not licensed to provide such services. 5. Intentionally or with reckless disregard offers, solicits, receives or pays any remuneration (kickback, bribe, rebate) directly or indirectly, overtly or covertly, in cash or kind for referring an individual for any item or service paid under the medical assistance act or in return for purchasing, leasing, ordering, or arranging for any good, service, facility or item that is paid for under the medical assistance act. Any person or entity that violates provisions of this statute can be subject to civil penalties of between five thousand dollars ($5,000) to fifty thousand dollars ($50,000) per claim or two times the amount of all medical assistance received. Colorado law does not provide for qui tam actions or Whistleblower protections. B. Offering a False Instrument for Recording 6 The Colorado statute on offering a false instrument for recording provides criminal penalties for: 1. Presenting or offering a written instrument that contains a material false statement or material false information to a public office or a public employee with the knowledge or belief that it will be registered, filed or recorded or become a part of the records of that public office or public employee. 2. A person who violates this statute knowingly and with intent to defraud commits offering a false instrument for record in the first degree and is guilty of a felony. 3. A person who violates this statute knowingly commits offering a false instrument for record in the second degree and is guilty of a misdemeanor. III. Colorado Access Policies & Procedures: A. Incorporating the FCA into the Colorado Access Compliance Program 1. In addition to all other requirements of the current Colorado Access Compliance Program, Colorado Access will educate employees and others, as required by the DRA, about the Whistleblower provisions of the FCA which provide that no person will be subject to retaliatory action as a result of their reporting or pursuing information related to false claims, including false claims submitted by a provider, contractor, or consultant and/or employees, or others paying or arranging to pay false claims. 6 CRS 18-5-114 Page 4 of 7
2. No Colorado Access employee will be discharged, demoted, suspended, threatened, harassed, or in any other manner retaliated against solely because of actions taken to report potential fraud, waste and abuse under the FCA (see policy and procedure CMP201 Problem Reporting and Non-retaliation). IV. Reporting Potential Fraudulent Activity A. Colorado Access employees, providers, contractors and consultants are encouraged and expected, as described in Colorado Access compliance training, Policies and Procedures, and Standards of Business Conduct, and the Colorado Access Employee Handbook, to bring forward concerns or complaints about compliance issues pertaining to Colorado Access business operations (see policy and procedure CMP201 Problem Reporting and Non-retaliation). This assists Colorado Access in investigating and correcting compliance issues, including those related to the FCA and DRA. B. The Colorado Access Compliance Program attempts, in part, to detect, investigate, prevent, minimize, and report potential or suspected instances of fraud, waste and abuse. It is the policy of Colorado Access that its employees, providers contractors, consultants, and agents report issues of suspected or potential fraud, waste and abuse to their supervisor, the Compliance Hotline (877-363-3065), a member of the Compliance Team, or the Colorado Access Compliance Officer. The reporting individual or party may request confidentiality and reports to the Compliance Hotline may be made anonymously. The employees of Colorado Access and any contractors, providers, consultants, and agents must make reasonable efforts to assist in detecting, investigating, reporting and preventing false claims and other fraudulent or abusive practices. C. While Colorado Access encourages employees, providers contractors, consultants, and agents to report instances of suspected fraud, waste and abuse as set forth in the prior paragraph, they may report fraud, waste, abuse, or misconduct directly to the Office of the Inspector General by: Online: Mail: http://www.oig.hhs.gov/fraud/report-fraud/index.asp Office of the Inspector General Department of Health & Human Services Attn: HOTLINE P. O. Box 23489 Washington, DC 20026 OIG Hotline: (800) HHS-TIPS (800) 447-8477 OIG Hotline Fax: (202) 223-8164 TTY: (800) 377-4950 D. Colorado Access shall report incidents of fraud, waste and abuse as set forth under policy and procedure CMP211 Fraud, Waste and Abuse. Page 5 of 7
V. Failure to Report Fraudulent Activity VI. An employee who fails to report, either through appropriate internal reporting channels or to governmental officials, when that person knows of conduct constituting a violation of the FCA or other compliance standards, may be subject to discipline, up to and including termination. Summary of Other Relevant Federal Laws A. Civil Money Penalties for False Claims in Federal Health Care Programs ( CMPL ) 7 Provides for monetary penalties against anyone who presents a claim to a federal or state officer, employee or agency that he or she knows or should have known was not provided as claimed. CMPL can also be imposed on a provider who: 1) submits a bill for services provided by a person who is not licensed or is excluded from federal or state health care programs; 2) violates the anti-kickback statute, or 3) violates the prohibition on physician self-referral, or Stark Laws. B. Criminal Penalties for False Claims in Federal Health Care Programs 8 A fine of up to $25,000.00 and/or imprisonment of up to five years may be imposed on any person in connection with the furnishing items of services under a federal health care program and who is convicted of a felony for knowingly and willfully: 1. Making a false statement or representation of material fact in any application for a benefit or payment under or for use in determining rights to such benefit or payment in a federal health care program; Concealing or failing to disclose, with intent to defraud, any event affecting his or her initial or continued right to any benefit or payment; 2. Presenting or causing to be presented a claim for a provider s service for which payment may be made under a federal health care program and knowing that the individual who furnished the service was not a licensed provider; or 3. For a fee counseling or assisting an individual to dispose of assets in order for the individual to become eligible for medical assistance under a state Medicaid program if disposing of the assets results in the imposition of a period of ineligibility for such assistance. C. Federal Anti-Kickback Statute 9 The Anti-Kickback Statute was designed to prevent fraud and abuse in federal health care programs by making it a crime for anyone to knowingly and willfully solicits or receives, or pays anything of value (remuneration) including any kickback, bribe, or rebate in return for referring an individual to a person for any item or service for which payment may be made in whole or in part under a federal health care program. Punishment for felony conviction for violating the anti-kickback law is a fine of not more than $25,000 or imprisonment for not more than five years, or both, administrative civil money penalties 7 42 USC 1320a-7a 8 42 USC 1320a-7b 9 42 USC 1320a-7b Page 6 of 7
of up to $50,000, and exclusion from participation in federal health care programs. The law contains several safe harbors that provide protection from prosecution for certain transactions and business practices with further guidelines provided in 42 C.F.R. 1001.952. 10 11 D. Federal Anti-Self-Referral Statute (Stark Laws) Subject to specific exceptions, prohibits a physician from referring federal health care program patients for certain designated health services to an entity with which the physician or an immediate family member has a financial relationship. No specific intent is required. A financial relationship is either a direct or indirect ownership interest or compensation arrangement. Certain regulatory exceptions apply. A physician who violates the Stark Laws is subject to substantial civil money penalties and exclusion from participation in the federal health care program for improper claims. The Stark Laws impose specific reporting requirements on entities that receive payment for services covered by federal health care programs. Failure to report would subject the entity to civil money penalty of up to $10,000 for each day for which reporting is required to have been made. 10 42 USC 1320 a-7b 11 42 USC 1395(nn) Page 7 of 7