Policy AD-106 False Claims Recovery Education 2021-07-16

Purpose

The purpose of this policy is to comply with the requirements of the Federal False Claims Act (Title 31, United States Code), the Delaware False Claims and Reporting Act (Title 6, Delaware Code), and the Federal Deficit Reduction Act of 2005, Section 6032 (DRA), which requires (1) an employee education policy regarding false claims recovery for entities receiving annual payments of at least 5 million dollars under a state Medicaid plan; and (2) procedures for detecting and preventing fraud, waste and abuse.

Policy

Westside recognizes and meets the requirements of the Federal Deficit Reduction Act (DRA) by providing written policies and procedures and educating all employees and contractors on:

• The federal False Claims Act;
• Activities that constitute false claims against state and federal funds (for example Medicaid eligibility and Medicaid reimbursement);
• Relief and whistleblower protections to which plaintiffs (employees who report fraud) are entitled through federal and state law; and
• Procedures for detecting, preventing, and reporting fraud, waste and abuse.

Scope

This policy applies to Westside employees and all contracted providers.

Definitions

False Claims – False claims occur when any person knowingly:

• Presents or causes to be presented a false or fraudulent claim for payment to the state or federal government. An example would be a physician who submits a bill to Medicare for services that he or she knows were not provided.
• Makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid by the state or federal government. An example would be an organization that submits records that are known to be incorrect that indicate compliance with contractual or regulatory requirements.
• Conspires with other persons to make a false claim or get a false claim paid by the state or federal government.
• Makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to repay overpayments to the state or federal government. An example would be an organization that obtains interim payments from Medicare during the year and at year-end files a false report to avoid paying a refund to the Medicare program.

Knowingly – A person acts “knowingly” when that individual:

• Has actual knowledge of that claim information is false;
• Acts in deliberate ignorance of the truth or falsity of the claim information; or
• Acts in reckless disregard of the truth or falsity of the claim information.

Plaintiff (also referred to as the Qui Tam Relator) – A private person who brings an action against an organization on behalf of a government entity to redress false claims. Such persons may share in a percentage of the proceeds from a false claim action or settlement and are afforded whistleblower protections.

Whistleblower Protections – An employee who proves he or she has been discharged, demoted, suspended, threatened, harassed or in any way discriminated against by his or her employer because of involvement in a false claims disclosure is entitled to relief. Such relief may include:

• Reinstatement with the same seniority status that the employee would have had but for the discrimination;
• Two times the amount of back pay plus interest; and
• Compensation for any special damage sustained because of the discrimination (including litigation costs and reasonable attorney's fees).

Procedures

Employee education about false claims recovery is implemented as follows:

• 1. Training and notification of Westside employees
     1. Annual mandatory HealthStream Corporate Compliance course, and
     2. New employee Corporate Compliance presentation.
  2. Policies and procedures shared on the intranet site and policy spreadsheet
     1. AD-106 False Claims Recovery Education (this policy)
     2. HR-102 Whistleblower (State), and
     3. HR-103 Whistleblower (Federal).

Procedures used by Westside for detecting and preventing fraud, waste and abuse include:

• 1. Routine internal audits of patient charts and submitted claims to verify accuracy and appropriateness of billing;
  2. Segregation of duties and reviews of internal control processes;
  3. Annual financial audit performed by independent auditors;
  4. Internal Compliance and Risk Management Committee that meets routinely to prevent and address compliance issues;
  5. Periodic process reviews performed by external consultants; and
  6. Periodic audits/reviews performed by state and federal auditors.

Employees who are uncertain about the validity of claims (for instance, those related to Medicaid eligibility or Medicaid reimbursement) shall review the relevant requirements to determine their validity and/or discuss their questions with their manager.

If Westside or its employees suspect or become aware of fraud, waste, or abuse, they shall report their concerns to their manager.

• 1. The manager must notify the Corporate Compliance Officer about the suspected fraud, waste or abuse so that the concern can be investigated and any necessary corrective actions taken.
  2. The Corporate Compliance Officer will notify the Chief Operating Officer (COO) and Chief Executive Officer (CEO).

References

1. Federal Deficit Reduction Act of 2005, Section 6032 (DRA) (https://www.cms.gov/regulations-and-guidance/legislation/deficitreductionact/downloads/checklist1.pdf)

Federal False Claims Act, Title 31, United States Code (https://www.law.cornell.edu/uscode/text/31/3729)

Delaware False Claims and Reporting Act, Title 6, Chapter 12, Delaware Code (https://delcode.delaware.gov/title6/c012/index.html)

Whistleblower Rights and Protections, U.S. Department of Justice Office of the Inspector General (OIG) https://oig.justice.gov/hotline/whistleblower-protection

Relevant Standard from The Joint Commission (TJC):

• 1. Standard LD.04.01.01 The organization complies with law and regulation. The Joint Commission (TJC). Leadership (LD) Comprehensive Accreditation Manual for Ambulatory Health Care (CAMAC), January 1, 2021.