Summary of Relevant Laws: The False Claims Act (31 U.S.C. §§ 3729-3733)
The False Claims Act is a federal law designed to prevent and detect fraud, waste and abuse in federal healthcare programs, including Medicaid. Under the False Claims Act, anyone who “knowingly” submits false claims to the Government is liable for damages up to three times the programs' loss plus $11,000 per claim filed. Under the civil FCA, each instance of an item or a service billed to Medicaid counts as a claim, so fines can add up quickly. False Claims suits can be brought against individuals and entities. The False Claims Act does not require proof of a specific intent to defraud the Government. Providers can be prosecuted for a wide variety of conduct that leads to the submission of a false claim.
Some examples include:
· Knowingly making false statements;
· Falsifying records;
· Submitting claims for services never performed or items never furnished;
· Using false records or statements to avoid paying the Government;
· Falsifying time records used to bill Medicaid; or
· Otherwise causing a false claim to be submitted.
Whistleblower/Non-Retaliation or “Qui Tam” Provisions:
In order to encourage individuals to come forward and report misconduct involving false claims, the False Claims Act contains a “Qui Tam” or whistleblower/non-retaliation provision. The Government, or an individual citizen acting on behalf of the Government, can bring actions under the False Claims Act. An individual citizen, referred to as a whistleblower or “Relator,” who has actual knowledge of allegedly false claims may file a lawsuit on behalf of the U.S. Government. If the lawsuit is successful, and provided certain legal requirements are met, the whistleblower may receive an award ranging from 15% - 30% of the amount recovered.
The False Claims Act prohibits discrimination and/or retaliation by RHG against any employee for taking lawful actions under the False Claims Act. Any employee who is discharged, demoted, harassed, or otherwise discriminated against because of lawful acts by the employee in False Claims actions is entitled to all relief necessary to make the employee whole. Such relief may include, but is not limited to reinstatement, double back pay, and compensation for any special damages, including litigation costs and reasonable attorney fees.
Administrative Remedies for False Claims (31 USC Chapter 38. §§3801-3812):
This federal statute allows for administrative recoveries by federal agencies including the Department of Inspector General and Department of Health and Human Services, which operates the Medicare and Medicaid Programs. The law prohibits the submission of a claim or written statement that the person knows or has reason to know is false, contains false information or omits material information. RHG may impose a monetary penalty of up to $5,000 per claim and damages of twice the amount of the original claim. Unlike the False Claims Act, a violation of this law occurs when a false claim is submitted, not when it is paid. Also unlike the False Claims Act, the determination of whether a claim is false, and imposition of fines and penalties is made by the administration of RHG, and not by prosecution in the federal court system.
New York State False Claims Act (State Finance Law §§187-194):
The New York State False Claims Act closely tracks the Federal False Claims Act. It imposes penalties on parties that file false and fraudulent claims for payment from any state or local government, including Medicaid. Penalties are $6,000 – $12,000 per claim and the recoverable damages are three times the value of the amount falsely received including consequential damages sustained by state or local government.
The law also allows for qui tam lawsuits by individuals.
Social Service Law §145-b False Statements
It is a violation to knowingly obtain or attempt to obtain payment for items or services furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment or other fraudulent scheme or device. The State or the local Social Services district may recover up to three times the amount of the incorrectly paid claim. In the case of non-monetary false statements, the local Social Service district or State may recover three times the amount incorrectly paid. In addition, the Department of Health may impose a civil penalty of up to $2,000 per violation. If repeat violations occur within five years, a penalty up to $7,500 may be imposed if they involve more serious violations of the Medicaid rules, billing for services not rendered, or providing excessive services.
Social Service Law § 366-b, Penalties for Fraudulent Practices
Any person who, with intent to defraud, presents for payment any false or fraudulent claim for furnishing services or merchandise, knowingly submits false information for the purpose of obtaining Medicaid compensation greater than that to which he/she is legally entitled to, or knowingly submits false information in order to obtain authorization to provide items or services shall be guilty of a Class A misdemeanor. Any person who obtains or attempts to obtain, for himself or others, medical assistance by means of a false statement, concealment of material facts, impersonation, or other fraudulent means is guilty of a Class A misdemeanor.
Penal Law Article 155, Larceny
The crime of larceny applies to a person who, with intent to deprive another of property, obtains, takes or withholds the property by means of a trick, embezzlement, false pretense, false promise, including a scheme to defraud, or other similar behavior. This law has been applied to Medicaid fraud cases.
Penal Law Article 175, Written False Statements
There are four crimes in this Article that relate to filing false information or claims. Actions include falsifying business records, entering false information, omitting material information, altering RHG’s business records, or providing a written instrument (including a claim for payment) knowing that it contains false information. Depending upon the action and the intent, a person may be guilty of a Class A misdemeanor or a Class E felony.
Corporate Compliance Plan
The Rockland Hospital Guild, Inc. receives funds to provide residential and restorative services to individuals living with a serious and persistent mental illness. This Corporate Compliance Policy has been designed and implemented to detect and prevent fraud, waste, and abusive practices within the agency, and to provide guidance to employees, Board members, and persons associated with the Rockland Hospital Guild in preventing fraud, waste, and abuse.
The Rockland Hospital Guild Corporate Compliance Program is a systematic program that was implemented to prevent, detect, address, and report violations of the law within the agency. The purpose of the plan is to ensure that employees/volunteers, Board members, and persons associated with the Rockland Hospital Guild conduct themselves according to all applicable ethical and legal requirements.
The Rockland Hospital Guild conducts business in an ethical manner and is committed to complying with federal, state and local regulations. As part of this commitment, we educate and train employees, Board members, volunteers and persons associated with RHG, on the compliance program’s standards, assist them in complying with its provisions, and provide an environment in which all can comply without fear of retaliation.
Corporate Compliance Plan
Implementation of Written Policies and Code of Conduct
Written policies, including a Code of Conduct and a Code of Ethics, have been developed and implemented to convey expected behaviors and practices that are to be followed by all employees, in keeping with our commitment to conducting business with integrity and in compliance with all applicable federal and state laws and regulations.
The Rockland Hospital Guild provides each employee with their own copy of the Code of Conduct, Code of Ethics, and the Employee Handbook that each is expected to adhere to. Each employee signs for their copy and agrees in writing to adhere to the Codes of Conduct and the Code of Ethics while in the Rockland Hospital Guild's employ.
Corporate Compliance Officer
A Corporate Compliance Officer has been designated by Rockland Hospital Guild (RHG), and is responsible for overseeing the Compliance Program; reviewing and updating agency policies and procedures; overseeing the risk assessment related to Compliance and recommending changes in procedures as a result of Risk Assessment; overseeing/conducting internal audit procedures relative to Compliance issues; maintaining agency policies and procedures; facilitating the implementation of Compliance training; investigating matters related to Compliance issues, including hotline reports, employee, consumer, and/or payor complaints; and coordination of the Compliance Committee duties.
The Rockland Hospital Guild's Compliance Officer reports directly to the Executive Director, and to the Board of Directors at quarterly Board meetings. Any communication to the Executive Director and Board of Directors remains confidential.
All compliance concerns are forwarded to the Compliance Officer, who reviews and investigates any issues as they are reported.
The Corporate Compliance Officer acts as a liaison with consultants and governmental agencies in the event of an audit or investigation.
Johanna Bowen is the assigned Corporate Compliance Officer for RHG. She can be contacted at the Guild's administrative offices, 2
Corporate Compliance Committee
The Rockland Hospital Guild has a designated Compliance Committee that meets quarterly or more frequently as compliance concerns and violations are brought to the Compliance Officer. The Committee members include the Program Supervisors of each of the Rockland Hospital Guild's residential programs, a House Manager, the Finance Director, the Benefits Manager, the Administrative Assistant, and the Executive Director. The Compliance Committee is headed by the Compliance Officer, who coordinates the committee activities.
The Committee reviews any claims of fraud or abuse, and the efforts to investigate and correct the systems or issues involved. Complaints communicated to and investigated by the Compliance Officer, and reviewed by the Compliance Committee, remain confidential.
The Committee members review updates and changes in compliance issues and policy on an ongoing basis. Program Supervisors are expected to share any changes with all their employees.
Training and Education of Employees
All Rockland Hospital Guild employees, consultants, Board members, and interns/volunteers are educated about compliance requirements in the health care industry relating to the federal and state laws with which the Rockland Hospital Guild must comply. This training includes discussion of the Federal and New York State False Claims Act, Civil Monetary Penalties, Billing Issues Risk Areas and Medical Necessity Medicaid Criteria, as well as The Whistleblower Protections Act.
Rockland Hospital Guild employees are informed that any employee who violates these laws/regulations risks not only prosecution, penalties and civil actions on an individual basis, but subjects the Rockland Hospital Guild to the same legal actions. Employees who have questions about any of these laws/regulations are instructed to consult with the corporate compliance officer.
Any Rockland Hospital Guild employee who violates these laws will have also been advised during their new employee orientation and annual compliance training that a violation may lead to disciplinary action up to and including immediate termination of position. A record of this training is maintained in the Rockland Hospital Guild's administrative office in the employee's file.
Training updates and refreshers are conducted annually. Any changes will be brought to the employees by their immediate supervisor as the changes occur, and in the annual training.
Anonymous / Confidential Reporting and Communication with the Corporate Compliance Officer
Every employee at the Rockland Hospital Guild is a partner in fraud prevention and in maintaining compliance with the governing laws/regulations. All employees have a duty to report any violation of the laws and regulations, Code of Conduct, and Code of Ethics.
Each employee can report to their program supervisor, who is then responsible for bringing the report to the compliance officer.
Individuals wishing to file a report of fraud or noncompliance with agency policy can contact the Compliance Officer directly. There is no requirement that the individual making the report identify him/herself in any way. All complaints can remain anonymous and will remain confidential to the extent possible. Complaints can be made by contacting the agency compliance phone line at extension 103, by emailing the compliance officer at email@example.com, by mail to 2 Irvings Way, Orangeburg, NY, 10962, or by leaving a note in the Administration building
All of the channels available to Rockland Hospital Guild employees to report concerns can remain anonymous and confidential, and are addressed in the annual compliance training.
All Rockland Hospital Guild employees, interns, consultants, and Board members are responsible for reporting any suspected fraud or non-compliant behavior to either their immediate supervisor or to the corporate compliance officer. This includes reporting those employees who may be encouraging, directing, facilitating, or permitting non-compliant behavior. Failure to report illegal, unethical or non-compliant behavior to either their immediate supervisor or to the corporate compliance office will result in corrective and/or disciplinary action.
Once a report is made, the compliance officer will conduct an investigation maintaining employee confidentiality. When the investigation is complete, the compliance officer will bring the completed investigation report to the full compliance committee for review. The committee will then determine any follow-up or disciplinary action to be taken. The level of disciplinary action will be dependent on the situation. The Compliance committee, recognizing the seriousness of any offense in this arena, could recommend suspension or termination of employment.
No employee will be subject to any disciplinary action for good faith reporting of compliance concerns to his/her supervisor or the corporate compliance officer.
Upon completion of the investigation, the corporate compliance committee will identify and implement steps to prevent a situation of this type occurring in the future.
Internal Auditing and Monitoring
Internal auditing and monitoring the agency’s operations are key to ensuring compliance and adherence to policies and ethical business practices. Internal auditing and monitoring can also identify areas of potential risk and those areas where additional training and oversite is required.
Quality Assurance/Utilization Review
Utilization reviews of resident records are conducted to make sure there is documentation of medical necessity, billable services, and the additional care, as required by the state licensing agencies and Medicaid. The utilization review is completed at regularly scheduled intervals. Feedback is given to residential managers for correction. Training is provided where indicated to assist staff with improvement of documentation.
In any instance where it is found that billing is not supported by documentation, billing will be withheld for that service. The Finance Director will void any claim, and instances where unsupported billing has occurred, monies will be returned, adhering to protocols and process for self-disclosure.
Responding to Compliance Issues, Corrective Action, Refunding Overpayments
An allegation of non-compliance brought to the Compliance officer will trigger an investigation. Confidentiality of employee identity will be maintained during the investigation process to the extent possible. Once the investigation is completed, the Compliance committee will determine follow-up and/or disciplinary action as required. The results of the investigation will be brought by the executive director and to the Board of Directors.
When an audit or internal investigation results in a substantiated finding, it is policy to initiate corrective action promptly, including making restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting disciplinary action, and implementing systemic changes to prevent a recurrence of a similar violation.
All verified violations of the compliance plan are subject to corrective action, which may include a report to governmental agencies or referral to law enforcement authorities. Disciplinary action may include written reprimand, suspension, termination of employment, restitution, referral for criminal investigation, or civil litigation.
Non- Intimidation and Non-Retaliation
The Rockland Hospital Guild will comply with the Whistleblower Protections afforded under both federal and state law. No individual who brings a qui tam civil action against the Rockland Hospital Guild on behalf of the people of the United States or State of New York will be discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms or conditions of his/her employment due to reporting violations of the False Claims Act.
The Rockland Hospital Guild has a policy of non-intimidation and non-retaliation against individuals for good faith participation in the Compliance Program. All staff, volunteers, consultants, and Board members can freely discuss, report to, and raise questions with the Compliance officer, Supervisors. and the Executive Director about any situation they feel may be in violation of Federal and NY State law, Rockland Hospital Guild policy and/or any regulatory requirements.
No staff person, Board member, volunteer or consultant, or member of the Rockland Hospital Guild Community who reports any action or suspected action to any government agency by Rockland Hospital Guild that is illegal, fraudulent, or in violation of any policies shall suffer intimidation, harassment, discrimination, or other retaliation, or adverse employment consequences.
Any violations of this non-intimidation policy should be immediately reported to the Compliance Officer, who will administer this policy and preserve the confidentiality of any reported information. Reports may be made in person, by phone, letter, email, or by leaving a message on the designated Compliance phone line. Any violations of this policy may result in disciplinary action up to and including termination.