WILLCARE is committed to detecting and preventing fraud, waste and abuse in the Medicare, Medicaid and other payor programs. As part of our Corporate Compliance Program, we are providing you with information required by the Deficit Reduction Act of 2005. This information tells you about: 1) how to report any compliance concerns internally; 2) federal and state fraud and abuse laws; and 3) whistleblower protections.
If you believe fraud, waste, abuse, or other improper conduct has occurred, you are required to:
Employees are expected to first report their concerns directly to WILLCARE to allow the company the opportunity to quickly address potential issues. Any employee who reports a concern in good faith will have the right to do so anonymously and will be protected against retaliation. The company will investigate any good faith allegations of fraud, waste, or abuse or other improper conduct. Employees are required to fully cooperate in the investigation. Such concerns may also be brought to the government. However, if an employee fails to report his/her concerns to WILLCARE, he/she will be in breach of this policy. Further, if an employee has participated in a violation of law or company policy, WILLCARE has the right to take appropriate action against him/her.
Laws Regarding the Prevention of Fraud, Waste and Abuse
I. Federal Laws
Federal False Claims Act. The federal False Claims Act (“FCA”) imposes liability on any person who submits a claim to the federal government that he/she knows (or should know) is false. The FCA also imposes liability on an individual who: i) knowingly submits a false record to obtain payment from the government; or ii) obtains money from the federal government to which he/she may not be entitled, and then uses false statements or records in order to keep the money. Honest mistakes or mere negligence are excluded. Civil penalties include five thousand five hundred dollars to eleven thousand dollars per false claim plus three times the amount of damages that the government sustains. Individuals may bring a civil action for a violation of this Act and may share in a percentage of the recovery. However, if an individual brings a case for the purpose of harassing WILLCARE, and/or the case has no merit, the individual may have to pay WILLCARE for its legal fees and costs to defend the case.
Administrative Remedies for False Claims and Statements. If a person submits a claim that the person knows is false or contains false information, or omits material information, then the agency receiving the claim may impose a penalty of up to five thousand dollars for each claim and may also recover twice the amount of the claim. These cases are handled by federal agencies (not courts) and individuals do not share in the recovery.
Federal Anti-Kickback Law: Individuals and entities may not knowingly offer, pay, solicit, or receive remuneration in exchange for referring, furnishing, purchasing, leasing, or ordering any good, facility, service or item that is paid for in whole or in part by Medicare, Medicaid, or other federal health care program. Some practices do not violate the law and are called “safe harbors”. Criminal or civil penalties include repayment of damages, fines, imprisonment, and exclusion from participation in federal programs.
II. New York State Laws
False Claims Act. The NY False Claims Act closely tracts the federal False Claims Act. It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. The penalty for filing a false claim is six thousand to twelve thousand dollars per claim plus two to three times the amount of damages the government sustains. Individuals may file a civil action in state court in the name of the government and may share in a percentage of the recovery.
False Statements Law. 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. Such conduct may result in civil penalties and damages.
Social Services Law. It is illegal for a person or corporation to obtain public assistance, including Medicaid, based on false information. Such conduct is punishable as a criminal misdemeanor.
Penal Law (Larceny, False Written Statements, Insurance Fraud, and Health Care Fraud). New York Penal Law prohibits an individual from improperly obtaining payment from the Medicaid program or filing a false statement or claim in order to receive payment from the Medicaid or other health insurance program, These crimes range from Class A misdemeanors to Class E felonies.
Anti-Kickback Law. Medicaid providers shall not accept or give (or agree to accept or give) anything in exchange for the referral of Medicaid services or to purchase, lease or order any Medicaid good, facility, service or item.
Self-Referral Prohibitions. Certain practitioners are not allowed to refer patients to health care providers when the practitioner, or the practitioner’s immediate family member, has a financial relationship with such health care provider. There are a number of exceptions to this prohibition which may make such referrals acceptable.
Professional Misconduct. It is misconduct for licensed professionals to engage in certain activities including: 1) Willfully or grossly negligently failing to comply with substantial provisions of Federal, state or local laws or regulations governing the profession; or 2)Willfully making or filing a false report, or failing to file a report required by law or by the Education Department, or willfully impeding or obstructing such filing, or inducing another person to do so.
III. Ohio State Laws
False Claims Act. Under Ohio law, providers may be civilly liable for obtaining or attempting to obtain payments to which the provider is not entitled pursuant to the provider agreement, or the rules of the federal government or the Department of Job and Family Services. Penalties include payment of civil penalties up to three times the amount wrongfully paid plus interest, a fine in the amount of five to ten thousand dollars for each false filing, and termination of the Medicaid provider agreement. In some circumstances, a provider or any other person who has to repay funds because they provided a false statement to the Medicaid program may also be criminally liable for Medicaid fraud.
Medicaid Fraud. Anyone who files a false claim or in some way participates in a scheme to file false claims for Medicaid funds can be charged with fraud, even if such person is not a provider. Medicaid fraud is a misdemeanor or felony charge depending on the amount of money received fraudulently. If convicted, the individual could go to jail and be ordered to pay fines and restitution. Additionally, a licensed medical provider found guilty of Medicaid fraud may lose his/her license. Medicaid fraud is defined as:
IV. Connecticut State Laws
Vendor Fraud. A vendor may not submit, with intent to defraud, a claimfor goods or services to the Medicaid program that is false, accept payment or additional compensation from the state or anyone else higher than the amount due or allowed by law, attempt to provide services or sell goods knowing that the recipient does not need them or without prior authorization from the Department of Social Services when required. Penalties include imprisonment, monetary penalties, exclusion from the Medicaid program and/or revocation of a state license.
Health Insurance Fraud. A person may not make or assist or conspire with another to make a written or oral statement in an application for health insurance or a claim for payment to an insurer knowing the statement is false, incomplete, deceptive or misleading. Penalties include imprisonment, fines, exclusion from the Medicaid program and/or loss of license.
Larceny. A person may not authorize, certify, attest, or file a claim for benefits or reimbursement with a local, state or federal agency knowing it is false; or knowingly accept the benefits from a claim he/she knows is false. Larceny is punishable by imprisonment and/or fines.
V. Whistleblower Protections
Federal Whistleblower Protection. The False Claims Act offers protection for employees from retaliation. An employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against because of his/her lawful acts conducted in furtherance of a FCA action may bring an action seeking reinstatement, two times back pay plus interest, and other costs, damages, and fees. However, if the employee brings an action against an employer that has no basis in law or fact, or is primarily for harassment, the employee bringing the lawsuit may have to pay the employer its fees and costs.
New York Whistleblower Protection. Similar to Federal Whistleblower Protections in that it prohibits retaliation against those that bring forth good faith knowledge of false claims. Also allows whistleblowers to share ina percentage of the proceeds from a flase clamins action or settlement.
Ohio Whistleblower Protection. Provides protections and prohibits employees who follow the statutory procedures in reporting any violations or the misuse of public resources that the employee becomes aware of in the course of their employment.
Connecticut Whistleblower Protection. Employees who report suspected violations of state or federal law or who participate in an investigation, hearing or inquiry when requested by a public body may not be discharged, disciplined or otherwise penalized.