False Claims Act

Preventing Fraud, Waste and Abuse

Appendix A - False Claims Act Policy

PURPOSE

The purpose of this policy is to educate officers, directors, shareholders, employees, contractors and agents regarding the Federal False Claims Act (“FCA”) and to provide general information regarding the Agency’s efforts to detect and prevent fraud, waste, and abuse with respect to its business activities.

FALSE CLAIMS LAWS

            A.        THE FEDERAL FALSE CLAIMS ACT

The Federal False Claims Act is a law that bars a person or entity, such as the Agency, from “knowingly” presenting or causing to be presented a false or fraudulent claim for payment or approval to the federal government, and from “knowingly” making, using or causing to be made a false record or statement to get a false or fraudulent claim paid or approved by the federal government.  The Act also prohibits a person or entity from conspiring to defraud the government by getting a false or fraudulent claim allowed or paid.  These prohibitions extend to claims submitted to federal health care programs, such as Medicare or Medicaid.

The Federal False Claims Act broadly defines the terms “knowing” and “knowingly.”  Specifically, knowledge will have been proven for purposes of the Federal False Claims Act if the person or entity: (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.  The law provides that a specific intent to defraud is not required in order to prove that the law has been violated.  Examples of potential false claims include knowingly billing Medicare for services that were not provided, billing for services that were provided but not medically necessary, submitting inaccurate or misleading claims for actual services provided, or making false statements to obtain payment for products or services.

A person or entity found guilty of violating this law is obligated to repay all of the falsely obtained payment or reimbursement and will be liable for a civil penalty of up to $11,000, plus three times the amount of actual damages sustained by the government as a result of the prohibited conduct for each violation of the Act.  In addition to being liable for damages and civil penalties, violating the Federal False Claims Act can subject a person or entity to exclusion from participation in federal health care programs, such as Medicare and Medicaid. 

            B.        WHISTLEBLOWER PROTECTIONS

Private persons are permitted to bring civil actions for violations of the Federal False Claims Act on behalf of the United States (also known as “qui tam” actions) and are entitled to receive percentages of monies obtained through settlements, penalties and/or fines collected. Persons bringing these claims (also known as “relators” or “whistleblowers”) are granted protection under the law.  Specifically, any whistleblower who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against by his or her employer because of reporting violations of the Federal False Claims Act will be entitled to reinstatement with seniority, double back pay, interest, special damages sustained as a result of discriminatory treatment, and attorneys’ fees and costs.

POLICY AND PROCEDURE

The Agency strives to provide detailed information and education to all of its officers, directors, shareholders, employees, contractors and agents regarding the False Claims Act, including, the penalties and remedies for violations of these laws and the applicable whistleblower provisions and protections.

The Agency requires all of its officers, Program Directors, shareholders, employees, contractors and agents to comply with all federal and state laws and regulations governing the administration and operation of health care entities.

The Agency prohibits its officers, directors, shareholders, employees (or contractors or agents acting on its behalf) from knowingly submitting to any federally or state funded program a claim for payment approval or reimbursement that includes false or fraudulent information or is based on false or fraudulent documentation.

Any person having knowledge or information regarding suspected fraud, waste, or abuse by the Agency or any of its officers, directors, shareholders, employees, contractors or agents, should promptly contact your immediate supervisor or one of the following individuals:

• President;

• Chief Financial Officer;

• Chief Program Officer;

• Senior Vice President, Human Resources; or

• Any Program Vice President.

In accordance with this policy, the Agency will investigate all allegations of suspected fraud, waste or abuse and will take prompt and effective remedial action where appropriate. 

The Agency will make every effort to detect and prevent fraud, waste and abuse before it occurs through education, training, and compliance audits.  These efforts will include, without limitation: distribution of this policy to all of the Agency’s officers, Program Directors, shareholders, employees, contractors and agents; compliance training that aids in the ability to detect and report suspected fraud, waste, and abuse; training with regard to the investigation and response to reports of suspected fraud, waste and abuse; and conducting internal audits and reviews of billing and coding policies and procedures.

The Agency strictly prohibits retaliation in any form against an individual who (1) makes a good faith report of suspected fraud, waste or abuse, (2) files a complaint under the various false claims acts, or (3) participates in an investigation or litigation under the various false claims acts.  Any retaliatory action is subject to appropriate corrective action, up to and including termination of employment or termination of the business relationship with the Agency.

2.01 Whistleblower Protection Policy

The Agency strives to conduct its business with the highest standards of ethics, integrity, honesty, fairness and professionalism, and in compliance with all federal, state and local laws.  This policy is intended to encourage Board members, staff (paid and volunteer) and others to report suspected or actual occurrence(s) of illegal, unethical or inappropriate events (behaviors or practices) without retribution.  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.

REPORTING:

• The individual should promptly report the suspected or actual event to his/her supervisor or one of the following individuals: President, Chief Financial Officer, Chief Program Officer, Senior Vice President of Human Resources, or an appropriate Board Committee or member.

• The individual can report the event with his/her identity or anonymously.

• Supervisors, managers and/or Board members who receive the reports must promptly act to investigate and/or resolve the issue.

• The appropriate management representative will investigate and report back to the individual within a reasonable time of the initial report, regarding the investigation, disposition or resolution of the issue. A copy of the report shall be submitted to the President.

PROTECTIONS:

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 Agency 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.  If the whistleblower believes that s/he has been retaliated against, s/he should refer to the Dispute Resolution Policy for appropriate steps to seek resolution.

The right of a whistleblower for protection against retaliation does not include immunity for any personal wrongdoing that is alleged and investigated.  Anyone who retaliates against the individual who made the report (in good faith) will be subject to discipline, up to and including termination of Board status or employment.

An individual who makes a report that is not done in good faith is subject to discipline, up to and including termination of Board status or employment, or other lawful means to protect the reputation of the Agency and members of its Board and staff.

RIGHTS:

If the investigation of a report, that was done in good faith and investigated by internal personnel, is not to the individual’s satisfaction, then s/he has the right to report the event to the appropriate legal or investigative agency.

ACTIONS:

In accordance with this policy, the Agency will investigate all allegations of illegal, unethical or inappropriate events (behaviors or practices) and will take prompt and effective remedial action where appropriate.

If employees, volunteers or Board members have any questions regarding this policy, they should contact the Senior Vice President of Human Resources.