Fraud Waste and Abuse False Claims Act Policy
Abri Health Care Services (SCC) is committed to effective and efficient operations, reliable financial reporting and compliance with all applicable laws and regulations. It is the policy of SCC to inform physicians, employees, and contractors of SCC of (i) the Federal False Claims Act; (ii) whistleblower protections in the Federal False Claims Act; (iv) the roles of such laws in preventing and deterring fraud, waste, abuse; and (v) internal processes at SCC for the prevention and detection of fraud and abuse. This policy is intended to effect compliance of SCC with the requirement under Section 6032 of the Deficit Reduction Act of 2005 (Pub. Law. 190-171, Feb. 8, 2006); the Texas Medicaid Fraud Prevention Act of the Human Resource Code Chapters 32 and 36, effective September 1, 2005; and Louisiana’s Medicaid anti-fraud laws found in Louisiana Revised Statute §14.70.1 and its implementing regulations (the latter, collectively, the Louisiana Anti-Fraud Laws”).
All Medicare First Tier, Downstream, and Related Entities (FDR’s) of SCC are required to complete and maintain proof of completion of the class “Medicare Parts C & D General Compliance Training” on the CMS Medicare Learning Network at:
Abri Health Care Services Mission Statement
Abri Health Care Services is building an organization where each team member is valued, respected and given an opportunity for personal and professional growth. We are committed to the resident and communities we serve to promote better and healthier lives. We strive to be an industry leader with uncompromising standards measured by defined clinical outcomes, customer service programs and financial sustainability.
- Maintain zero tolerance of fraud.
- Prevent, detect, and respond to unacceptable legal risk and its financial implications.
- Route non-compliance issues to appropriate areas.
- SCC employees, physicians, physician extenders, contractors, and agents are expected to abide by a high standard of ethical behavior at all times and to obey the laws and rules that apply to SCC operations and their particular duties and that are listed below.
- It is the duty of employees, physicians, physician extenders, contractors, and agents to report any transaction or conduct that they think may be a violation of federal, state, or local law or a violation of any SCC policy.
Code of Conduct Policy
To ensure the highest ethical standards and quality of care, and compliance with all applicable state and federal laws, Abri Health Care Services holds itself and others accountable to certain expectations and responsibilities. Abri Health Care Services communicates these expectations and responsibilities by continuing education, policies and procedures, and otherwise to team members, contractors, companies, agencies and all others that provide care to Senior Care Center residents on behalf of Abri Health Care Services(collectively “Team Members”). Abri Health Care Services further ensures the suitability of Team Members and applicants by screenings and reference checks. By doing so, Abri Health Care Services ensures that Team Members are eligible for their positions, and that they will successfully meet the highest ethical standards, provide the highest quality of care, and comply with all applicable state and federal laws.
To further meet the goals under this policy, Abri Health Care Services:
- submits only claims for payment that accurately reflect rendered services,
- uses accurate billing codes,
- markets in a manner that is honest, informative and non-deceptive,
- maintains the highest level of confidentiality,
- refrains from generating referrals to itself,
- trains Team Members annually on HIPAA and their corresponding obligations,
- encrypts resident confidential information on all laptops and portable storage devices,
- ensures that all resident records are handled, stored and transported in a strictly confidential manner and in accordance with all applicable laws,
- trains Team Members annually on recognizing and not engaging in conflicts of interest,
- requires Team Members to report concerns and suspected violations of this policy and potential wrongdoing,
- posts “May We Help You with Your Concerns” posters in a public location in all facilities,
- posts two “Hotline” telephone numbers [telephone numbers] to report or address suspected policy violations,
- maintains, administers, audits and enforces Operational Policies and Procedures, an Internal Audit Program, a Compliance and Business Integrity Policy, and a Fraud, Waste and Abuse – False Claims Policy,
- maintains a Corporate Compliance Officer and Corporate Compliance Committee for oversight purposes, and
- prohibits Team Members from accepting payments, bribes, rebates and/or gifts induce or reward referrals of items or services that are reimbursed by a federal health care program thereby limiting financial incentives in accordance with the Anti-kickback Statute set forth by the Social Security Act.
Additionally, all employees, physicians, physician’s extenders, contractors and their agents must continually and without exception meet and follow the Mission Statement as set forth in this handbook. Team Members must also:
- be honest, courteous, accurate and professional in all of their daily interactions with residents, families and fellow team members,
- treat others as you expect to be treated, with dignity and respect,
- follow all policies and procedures,
- obey local, state, and federal laws,
- follow the chain of command when addressing problems,
- follow the provisions of the Team Members Handbook,
- refuse all gifts, tips, or compensation from residents, families and vendors,
- refuse any remuneration for any referrals to or from outside vendors or sources, and report any offer to your supervisor or the Corporate Compliance Officer,
- refrain from submitting false claims for services not performed in accordance with the False Claims Act,
- refrain from engaging in any activity which is fraudulent or in violation of any laws relating to providing care or receiving reimbursement from Medicare, Medicaid or other reimbursement programs,
- refrain from dishonest or fraudulent billing or documentation practices,
- report any suspected illegal activity or violations of Senior Care Center policies and procedures to your supervisor or the Corporate Compliance Officer,
- refrain from the abuse or neglect of, and/or a crimes against residents, and immediately report through appropriate channels any knowledge or suspicion of a crime or abuse or neglect of a resident,
- honor residents’ rights to confidentiality and privacy,
- comply with all HIPAA requirements,
- electronically protect all resident data and report any breach of data immediately
- immediately notify the Corporate Compliance Officer of any claim that a Team Member suspects does not adhere to the False Claims Act, and
- visit the Fraud, Waste and Abuse – False Claims Act Policy posted at www.seniorcarecentersltc.com,
Notwithstanding this non-exhaustive list, Team Members should also represent and meet the spirit and intentions of this policy, ensure the highest ethical standards, provide the highest quality of care, and comply with all applicable state and federal laws.
Corporate Compliance Program
The purpose of this program is to ensure that the facility complies with all federal, state, local laws, regulations, and standards of care. Any vendor or employee of a facility who believes that someone has violated one or more of these laws, regulations, or standards of care should contact his or her supervisor or other management within the facility. Those who do not feel comfortable with contacting someone through the regular chain of command should contact the Corporate Compliance Officer, Kelly Morrison at 214-252-7600. There will be no retaliation against any vendor or employee for making a report. The reporting of such events is everyone’s responsibility and is an important part of your job.
- SCC will not take any adverse action or retribution against any employee/agent due to the good faith reporting of a suspected violation or irregularity.
- Employees, physicians, physician extenders, contractors, and agents are expected to obey the law and report any suspected violations of the following:
- Federal, state, and local laws and government regulations
- Applicable SCC policies and procedures
- Applicable SCC rules and regulations
- Compliance Program
- Code of Conduct Policy
- All clinical professional services will be documented in the medical record, and such documentation will comply with applicable payer regulations.
- All clinical professional services will be coded to accurately reflect the documentation in the medical record.
- All claims shall be submitted in compliance with applicable payer regulations or requirements.
- Employees, physicians, physician extenders, contractors, and agents will not knowingly and willfully solicit, receive, offer, or pay any remuneration directly or indirectly, in cash or in kind, in exchange for Medicare and/or Medicaid referrals.
- Employees, physicians, physician extenders, contractors, and agents will not knowingly and willfully:
- Falsify, conceal or cover up a material fact,
- Make any false, fictitious or fraudulent statement or representation, or
- Make or use false writing or document known to contain false, fictitious, or fraudulent statement in information submitted to the government.
- Employees, physicians, physician extenders, contractors, and agents will not conceal or fail to disclose knowledge of an event affecting an initial or continued right to any benefit or payment with intent to secure such benefit or payment fraudulently.
- Employees, physicians, physician extenders, contractors, and agents will not knowingly present or cause to be presented false or fraudulent claims, including situations where the service was not provided as claimed, the service was provided during a period in which the provider was excluded from participating in Federal healthcare programs, and/or the service was provided due to false or misleading information on coverage in order to influence a decision regarding when to discharge a person from inpatient hospital services.
- Employees, physicians, physician extenders, contractors, and agents will not knowingly make or present a false, fictitious, or fraudulent claim to a Federal agency.
- Employees, physicians, physician extenders, contractors, and agents will not use the U. S. Postal Service or electronic submission processes as part of a scheme to defraud the government or to obtain money by false or fraudulent pretenses.
- Employees, physicians, physician extenders, contractors, and agents will not embezzle, steal, or otherwise convert to the benefit of another person or intentionally misapply money, funds, securities, premiums, credits, property, or other assets of a health care benefit program.
- Employees, physicians, physician extenders, contractors, and agents will not willfully prevent, obstruct, mislead, delay, or attempt to prevent, obstruct, mislead, or delay the communication of information or records relating to violation of a Federal health care offense to a criminal investigator. (The Administrator and Corporate Compliance Officer should be notified immediately of such an investigation).
False Claims Act
- The False Claims Act prohibits the submission of knowingly false or fraudulent claims to the United States.
- The law is not limited to claims submitted with fraudulent or actual knowledge of their falsity, but includes:
- Deliberate ignorance
- Reckless disregard of truth or falsity
- Gross negligence
The False Claims Act was established under sections 3729 through 3733 of Title 31, Chapter 37, Sub-chapter III of the United States Code. This act prohibits the submission of “knowing” false claims and statements to obtain federal funds. This act excludes tax fraud. An example would be a health care provider billing Medicare or Medicaid for services that were not provided or were unnecessary. Title 31, Chapter 38, Subchapter III of the United States Code establishes administrative remedies for any false claims or statements. In addition, the Texas Medicaid Fraud Prevention Act was established under Chapter 36, Subchapter A of the Human Resources Code. This code seeks to address and punish those individuals and entities, participating in the Medicaid program, found to have defrauded the State Medicaid program through unlawful acts, such as filing a claim under the Medicaid program for services not rendered. This code also establishes sanction and remedies for the findings of fraud. Both of the above codes provide provisions for “Whistleblower” protection and the assurance of non-retaliation against an employee/vendor who reports any type of false claims and statements. The Louisiana Anti-Fraud Laws seek to address and punish those individuals and entities, participating in the Medicaid program, found to have defrauded the State Medicaid program through unlawful acts, such as filing a claim under the Medicaid program for services not rendered. All Abri Health Care Services entities are in compliance with the False Claims Act and these Texas and Louisiana anti-fraud laws and maintain written policies and procedures at each site for detecting and preventing fraud, waste, and abuse.
False Claims Act Liability
- The False Claims Act, 31 U.S.C. §3729, provides for liability for triple damages and a penalty from $5,500 to $11,000 per claim plus triple damages for anyone who knowingly submits or causes the submission of a false or fraudulent claim to the United States.
- Liability for certain acts – any person who:
- Knowingly presents, or causes to be presented to an officer or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval;
- Knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government; conspires to defraud the Government by getting a false or fraudulent claim allowed or paid;
- Has possession, custody, or control of property or money used, or to be used, by the Government and, intending to defraud the Government or willfully to conceal the property, delivers, or causes to be delivered, less property than the amount for which the person receives a certificate or receipt;
- Authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and, intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the receipt is true;
- Knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the Government, or a member of the Armed Forces, who lawfully may not sell or pledge the property; or
- Knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government.
Qui Tam Provision of False Claims Act
- Qui tam is a provision of the Federal Civil False Claims Act that allows private citizens to file a lawsuit in the name of the U. S. Government charging fraud by government contractors and others who receive or use government funds, and share in any money recovered.
- If the Government joins, and successfully prosecutes the case, and the person who filed the suit was not involved in the wrongdoing, that person can receive between 15 and 25 percent depending on the extent of that person’s contribution to the case.
- If the Government does not join and the person who filed the suit successfully prosecutes the case, that person will receive between 25 and 30 percent of the proceeds.
Federal Anti-Kickback Statute
- Prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate Federal health care program business. Intent must be proven.
- Penalties – Criminal fines up to $25,000 per violation and up to a 5 year prison term per violation. Civil monetary penalties and program exclusion. Civil liability of $50,000 CMP per violation and up to three times the amount of the kickback.
- Exception – Safe Harbors that might apply.
The Stark Law
- Prohibits a physician from referring Medicare and Medicaid patients for designated health services to an entity with which the physician (or immediate family member) has a financial relationship (unless an exception applies). No intent standard required for required refund. Intent must be proven for CMP.
- Prohibits the designated health services entity from submitting claims to Medicare and Medicaid for those services resulting from a prohibited referral.
- Must refund overpayment. Civil penalties potential $15,000 CMP for each service and up to three times the amount claimed.
Federal Health Care Program Exclusion
- The Office of Inspector General has exclusion authority as follows;
- Conviction of program-related crimes. Minimum period: 5 years.
- Misdemeanor conviction relating to health care fraud. Minimum period: 3 years.
- Conviction relating to obstruction of an investigation. Minimum period: 3 years.
How to Report Compliance Issues
- Notify a supervisor or manager first.
- Contact the Corporate Compliance Officer at email@example.com or 214-252-7600.
Should employees, physicians, physician extenders, contractors, and agents feel that SCC has not taken appropriate action to address a potential violation, they can also lodge a complaint concerning waste, fraud, and abuse directly to the Federal Government to the Health and Human Service’s Office of Inspector General.
- It is the policy that SCC will not take any adverse action or retribution against any employees, physicians, physician extenders, contractors, and agents of the facility due to the good faith reporting of suspected violation or irregularity.
- SCC encourages employees, physicians, physician extenders, contractors, and agents to report any suspected violations of law to the Corporate Compliance Officer and to ask questions if they are unsure of regulation.
Whistleblower Protection under False Claims Act
A whistleblower as defined by this policy is an individual or an employee who reports an activity that he/she considers to be illegal or dishonest to one or more of the parties specified in this policy. The whistleblower is not responsible for investigating the activity or for determining fault or corrective measures; appropriate management officials are charged with these responsibilities.
Examples of illegal or dishonest activities are violations of federal, state or local laws; billing for services not performed or for goods not delivered; and other fraudulent financial reporting.
If an individual or an employee has knowledge of or a concern of illegal or dishonest fraudulent activity, they are to contact his/her immediate supervisor or the Corporate Compliance Officer. The employee must exercise sound judgment to avoid baseless allegations. Intentionally filing a false report of wrongdoing will be subject to discipline up to and including termination.
Whistleblower protections are provided in two important areas — confidentiality and against retaliation. Insofar as possible, the confidentiality of the whistleblower will be maintained. However, identity may have to be disclosed to conduct a thorough investigation, to comply with the law and to provide accused individuals their legal rights of defense. The Facility will not retaliate against a whistleblower. This includes, but is not limited to, protection from retaliation in the form of an adverse employment action such as termination, compensation decreases, or poor work assignments and threats of physical harm. Any whistleblower who believes he/she is being retaliated against must contact the Corporate Compliance Officer immediately. The right of a whistleblower for protection against retaliation does not include immunity for any personal wrongdoing that is alleged and investigated.
All reports of illegal and dishonest activities will be promptly submitted to the Corporate Compliance Officer, Kelly Morrison, at (214) 252-7600 or firstname.lastname@example.org who is responsible for investigating and coordinating corrective action.