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Purpose To provide detailed information about the federal false

By Robin Brown,2014-05-05 21:28
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Purpose To provide detailed information about the federal false

SUBJECT: Employee Education about False Claims Recovery (Deficit Reduction Act of 2005) POLICY NUMBER: _______________________ PAGE _________ OF __________

    GENERATED BY: Integrity-Compliance Office

    SCOPE. This policy covers all employees of Covenant Health and The Covenant Health Integrity-Compliance Office has a toll-free those Covenant Health subsidiaries involved in furnishing Medicaid hotline (1-888-731-3115) for compliance reporting. In addition, items or services (collectively referenced as “Covenant” in this concerns maybe reported via an internet connection. Any report policy) and the employees of Covenant contractors and agents who maybe made anonymously, if desired. All reports to the Integrity-perform billing and coding functions or who, on behalf of Covenant, Compliance Office are treated as confidential to the greatest extent furnish or authorize the furnishing of Medicaid health care items or possible. Further, all forms of information received, transmitted, services or are involved in monitoring of health care provided by discussed, or archived by the Integrity-Compliance Office, Covenant (“Contractors and Agents”). including but not limited to, verbal and written communications,

    documents, reports, correspondence, network transmissions, and PURPOSE. To comply with the education requirements set forth electronically or magnetically stored data are treated as confidential. in Section 6032 of the Deficit Reduction Act of 2005. 2. False Claims Laws. State and federal false claims laws combat POLICY. It is the policy of Covenant to provide its employees

    with detailed information regarding Covenant’s policies and fraud and abuse in governmental health care programs, including procedures for detecting and preventing fraud, waste, and abuse. Medicare, Medicaid, and TennCare. False claims laws do this by Further, it is the policy of Covenant to provide detailed information making it possible for the government to bring civil actions to regarding the federal and state false claims laws to its employees, recover damages and penalties when false claims are submitted. and to Covenant Contractors and Agents for the benefit of their These laws often permit “qui tam relator” suits, which are lawsuits employees, with respect to the role of such laws in preventing and brought by private (i.e., nongovernmental) parties. The federal detecting fraud, waste and abuse in federal health care programs. False Claims Act ("FCA") provides, in pertinent part, that: 1. Detecting and Preventing Fraud, Waste, and Abuse. (a) Any person who (1) knowingly presents, or causes to be presented, to an Covenant is strongly committed to detecting and preventing fraud, officer or employee of the United States Government or a member of the waste, and abuse. To this end, Covenant has adopted an active Armed Forces of the United States a false or fraudulent claim for payment or integrity-compliance program and operates under a code of conduct. approval; (2) knowingly makes, uses, or causes to be made or used, a false The Covenant compliance program requires compliance with both record or statement to get a false or fraudulent claim paid or approved by the legal requirements and ethical standards and is composed of the Government; (3) conspires to defraud the Government by getting a false or following key elements: fraudulent claim paid or approved by the Government;... or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to (i) Support for the program comes from the highest levels of the organization. conceal, avoid, or decrease an obligation to pay or transmit money or property (ii) A Corporate Compliance Officer leads Covenant’s compliance efforts. to the Government, (iii) A Code of Conduct sets forth Covenant’s expectations concerning * * * compliant behavior and there are policies and procedures that support the is liable to the United States Government for a civil penalty of not less than compliance effort and address key compliance areas. $5,000 and not more than $10,000, plus 3 times the amount of damages which (iv) The program provides for safe, secure, and confidential reporting the Government sustains because of the act of that person ... .31 U.S.C. ? 3729. mechanisms for reporting of employee concerns (anonymously, if requested) and to seek guidance on compliance issues. The Tennessee Medicaid False Claims Act provides, in pertinent (v) The program provides for training employees, contractors, and related part, that: parties on the elements of the program. (vi) there is an effective system of internal controls to monitor compliance Any person who: (1)(A) presents, or causes to be presented, to the state a claim efforts. for payment under the Medicaid program knowing such claim is false or (vii) The program calls for an on-going compliance risk assessment and annual fraudulent; (B) makes, uses, or causes to be made or used, a record or statement assessment and renewal of the compliance program. to get a false or fraudulent claim under the Medicaid program paid for or approved by the state knowing such record or statement is false; (C) conspires All Covenant employees and Contractors and Agents are required to to defraud the state by getting a claim allowed or paid under the Medicaid act in a manner consistent with the requirements of the Covenant program knowing such claim is false or fraudulent; or (D) makes, uses, or causes to be made or used, a record or statement to conceal, avoid, or decrease Health integrity-compliance program and to review the Covenant an obligation to pay or transmit money or property to the state, relative to the Code of Conduct issued by the Covenant Health Integrity-Medicaid program, knowing such record or statement is false; is liable to the Compliance Office, the principles and requirements of which apply state for a civil penalty of not less than five thousand dollars ($5,000) and not to all dealings with Covenant. Should any Covenant employee, or more than twenty-five thousand dollars ($25,000), plus three (3) times the any Contractor or Agent (or employee of the same), obtain amount of damages which the state sustains because of the act of that person. Tenn. Code Ann. ? 71-5-182. information that reasonably leads it, him, or her to believe there has

     or may have been a violation of law or of Covenant's compliance For purposes of these false claims laws, "knowing" and program by Covenant or any of its employees, Contractor, or

    "knowingly" mean that a person, with respect to information (1) has Agents, such person must promptly report and disclose the same to actual knowledge of the information; (2) acts in deliberate the Covenant Health Integrity-Compliance Office and provide such ignorance of the truth or falsity of the information; or (3) acts in office with all information related to such belief. Such person also reckless disregard of the truth or falsity of the information. While must cooperate with the Integrity-Compliance Office in any audit or these false claims laws impose liability only when the claimant acts investigation instituted by Covenant related to any compliance "knowingly," they do not require that the person submitting the matters or other actions taken pursuant to Covenant's compliance claim have actual knowledge that the claim is false, and no proof of program. Covenant prohibits any form of retaliatory conduct or specific intent to defraud is required. A person who acts in reckless action against any employee or person who reports any compliance disregard or in deliberate ignorance of the truth or falsity of the violation or concern pursuant to the program. information also can be found liable under the laws. In sum, the

    false claims laws impose liability on any person who submits a [Covenant DRA Policy 6.26.07]

    claim to the federal government or to the state Medicaid program

    (including TennCare) when the person knows (or should know) the In addition to their substantive provisions, the false claims laws claim is false. An example may be a physician who submits a bill to provide that private parties may bring an action on behalf of the Medicare for medical services he/she knows has not been provided. government. These private parties are known as “qui tam relators.

    The false claims laws also impose liability on an individual who The purpose of bringing the suit is to recover the funds paid by the may knowingly submit a false record in order to obtain payment governmental health program as a result of the false claims. from the government. An example of this may include a Sometimes the government decides to join the suit. If the suit is government contractor who submits records that he/she knows (or ultimately successful, the relator who initially brought the suit may should know) are false and that indicate compliance with certain be awarded a percentage of the funds recovered. Subject to some contractual or regulatory requirements. exceptions and depending on the facts of the situation, including

     whether the relator contributes substantially to the prosecution and The third area of liability includes those instances in which whether the government intervenes in the suit, a qui tam relator may someone may obtain money from the federal government or the receive between 15 and 30 percent of the proceeds of the false TennCare program to which he may not be entitled, and then uses claims act action. However, a court may reduce the qui tam false statements or records in order to retain the money. An relator’s share of the proceeds if the court finds that the relator example of this so-called "reverse false claim" may include a planned and initiated the false claims violation. Further, if the hospital who obtains interim payments from Medicare throughout relator is convicted of criminal conduct related to his or her role in the year, and then knowingly files a false cost report at the end of the preparation or submission of the false claims, the whistleblower the year in order to avoid making a refund to the Medicare program. may be dismissed from the civil action without receiving any

     portion of the proceeds. Also, if the government does not intervene The State of Tennessee imposes criminal penalties in connection in the action, the defendant prevails, and the court finds that the with false claims and statements when: claim of the individual bringing the action was clearly frivolous, clearly vexatious, or brought primarily for the purposes of (a)(1)(A) A person, including an enrollee, recipient, or applicant, knowingly harassment, a court may award the defendant its reasonable attorney obtains, or attempts to obtain, or aids or abets any person to obtain, by means fees and expenses. of a willfully false statement, representation, or impersonation, or by concealment of any material fact, or by any other fraudulent means, or in any The false claims laws contain provisions that protect a qui tam manner not authorized by any rule, regulation, or statute governing TennCare: (i) Medical assistance benefits or any assistance provided pursuant to any relator from retaliation by his or her employer. These provisions rule, regulation, procedure, or statute governing TennCare to which such apply to any employee who is discharged, demoted, suspended, person is not entitled, or of a greater value than that to which such person threatened, harassed, or in any other way discriminated by his/her is authorized; or employer in the terms and conditions of employment as a result of (ii) Benefits by knowingly making a willfully false statement, or the employee’s lawful acts in furtherance of a false claims action. concealing a material fact relating to personal or household income, thereby resulting in the assessment of a lower monthly premium than the Remedies include reinstatement with comparable seniority, two person would be required to pay if not for the false statement or times the amount of back pay, interest on the back pay, and concealment of a material fact. compensation for any special damages as a result of the * * * discrimination, such as litigation costs and reasonable attorney fees. (2)(A) A person, firm, corporation, partnership or any other entity, including a vendor, other than an enrollee, recipient, or applicant, commits an offense who knowingly obtains, or attempts to obtain, or aids 3. Contractor and Agent Responsibilities. Contractors and or abets any person or entity to obtain, by means of a willfully false Agents must abide by this policy as to the work the Contractor or statement, report, representation, claim or impersonation, or by Agent performs for Covenant and make this policy available to their concealment of any material fact, or by any other fraudulent means, employees who are involved in performing that work. including knowingly presenting or causing to be presented to TennCare or any of its contractors, subcontractors or vendors a false or fraudulent claim for payment or approval, or in any manner not authorized by any 4. Covenant Responsibilities. Covenant Health shall ensure that rule, regulation, procedure, or statute governing TennCare, medical this policy is available to all employees, including management. assistance payments pursuant to any rule, regulation, procedure, or statute Covenant Health shall ensure that all Contractors and Agents: (1) governing TennCare to which such person or entity is not entitled, or of a are provided with this policy, (2) disseminate the same to their greater value than that to which such person or entity is authorized. For employees, and (3) agree to abide by the same as to the work the purposes of this subsection (a), "attempts to obtain" includes making or presenting to any person a claim for any payment under any rule, Contractor or Agent performs for Covenant. Further, Covenant regulation, procedure, or statute governing TennCare, knowing such shall include the substance of this policy in any employee handbook claim to be false, fictitious or fraudulent. or equivalent document. The Covenant Integrity-Compliance Office * * * will include this policy in its compliance training of Covenant (3)(A) A person, firm, corporation, partnership or any other entity employees. commits an offense when providing a willfully false statement regarding another's medical condition or eligibility for insurance, to aid or abet another in obtaining or attempting to obtain medical assistance payments, 5. Definitions. For purposes of this policy, the term Contractors medical assistance benefits or any assistance provided under any rule, and Agents” includes any contractor, subcontractor, agent, or other regulation, procedure, or statute governing TennCare to which the person person that, on behalf of Covenant, furnishes or authorizes the is not entitled or to a greater value than that to which such person is furnishing of Medicaid health care items or services, performs authorized. For purposes of this subsection (a), "attempting to obtain" includes making or presenting to any person a claim for any payment billing or coding functions, or is involved in the monitoring of under any rule, regulation, procedure, or statute governing TennCare, health care provided by Covenant. Contractors and Agents that knowing such claim to be false, fictitious or fraudulent. Tenn. Code Ann. furnish Medicaid health care items and services include, without ? 71-5-2601. limitation, all contract therapists, physicians (including, but not limited to, house staff, hospitalists, and independent contractors), There also are federal and state administrative remedies for false pharmacies, and supply vendors (even if the contract with the claims and statements. These remedies may be imposed by a supply vendor has not been reduced to a writing). “Contractors and governmental agency as an administrative matter, after a Agents” do not include individuals, businesses, or organizations hearing. Remedies include civil monetary penalties ranging form that perform functions not associated with the provision of $5,000 to $25,000 per false claim, and double or treble damages. 42 Medicaid health care items or services, such as copy or shredding U.S.C. ? 3802; Tenn. Code Ann. ? 71-5-182. services, grounds maintenance, and hospital cafeteria or gift shop services. [Covenant DRA Policy 6.26.07]

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