Uintah Health Care Special Service District

DEFICIT REDUCTION ACT POLICY

PURPOSE

Uintah Health Care Special Service District is committed to its role in preventing health care fraud and abuse and complying with applicable state and federal laws related to health care fraud and abuse.  The Deficit Reduction Act of 2005 requires information about both the Federal False Claims Act and other laws, including state laws, dealing with fraud, waste, and abuse and whistleblower protections for reporting those issues.  To ensure compliance with suck laws, Uintah Health Care Special Service District has policies and procedures in place to detect and prevent fraud, waste, and abuse, and also supports the efforts of federal and state authorities in identifying incidents of fraud and abuse.  This policy sets forth Uintah Health Care Special Service District policies and procedures for detecting and preventing fraud, waste, and abuse and an overview of the Federal Civil False Claims and Program Fraud Civil Remedies Acts and applicable state laws.

POLICIES AND PROCEDURES

[The Provider] takes health care fraud and abuse very seriously.  It is our policy to provide information to all employees, contractors and agents about the federal and state false claims act, remedies available under these provisions and how employees and others can use them, and about whistleblower protections available to anyone who claims a violation of the federal or state false claims act.  We also advise our employees, contractors and agents of the steps Uintah Health Care Special Service District has in place to detect health care fraud and abuse.

FEDERAL AND STATE FALSE CLAIM LAWS

The Role of Federal and State Laws in Preventing Fraud, Waste and Abuse: The Centers of Medicare & Medicaid Services (CMS) defines “fraud” as the intentional deception or misrepresentation that an individual knows to be false (or does not believe to be true) and makes, knowing that the deception could result in an unauthorized benefit to himself or another person.  CMS defines “abuse” as incidents or practices of providers that are inconsistent with sound medical practice and may result in unnecessary costs, improper payment or the payment for services that either fail to meet professionally recognized standards of care or are medically unnecessary.

The Federal Government and the State of Utah have enacted criminal and civil laws pertaining to the submission of false or fraudulent claims for payment or approval to the federal and state governments and to private payers.  The false claims laws, which provide for criminal, civil, and administrative penalties, provide governmental authorities with broad authority to investigate and prosecute potentially fraudulent activities, and also provide anti-retaliation provisions for individuals who make good faith reports of fraud, waste, and abuse.

The Federal Civil False Claims and Program Fraud Civil Remedies Acts, applicable State Laws, and anti-retaliation provisions are summarized in the following sections.

1.   FEDERAL CIVIL FALSE CLAIMS ACT

The Civil False Claims Act (31 U.S.C. §3729 et seq.) is a statute that imposes civil liability on any person who:

∙ knowingly presents, or causes to be prevented, a false or fraudulent claim, record or statement for payment or approval,

∙ conspires to defraud the government by getting a false or fraudulent claim allowed or paid,

∙ uses a false record or statement to avoid or decrease an obligation to pay the Government,

                  and

                  ∙ other fraudulent acts enumerated in this statute.

The term “knowingly” as defined in the Civil False Claims Act (“FCA”) includes a person who has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information.  No proof or specific intent to defraud is required.

The term “Claim” includes any request or demand for money or property of the United States Government provides any portion of the money requested or demanded.

Potential civil liability under the FCA currently includes penalties of between five thousand and eleven thousand per claim, treble damages, and the costs of any civil action brought to recovery such penalties or damages.

The Attorney General of the United States is required to diligently investigate violations of the FCA, and may bring civil action against a person.  Before filing suit the Attorney General may issue an investigation demand requiring production of documents and written answers and oral testimony.

The FCA also provides for Action by Private Persons (qui tam lawsuits) who can bring a civil action in the name of the government for a violation of the Act.  Generally, the action may not be brought more than six years after the violation, but in no event more than ten.  When the action is filed it remains under seal for at least sixty days, The United States Government may choose to intervene in the lawsuit and assume primary responsibility for prosecuting, dismissing or settling the action. If the Government chooses not to intervene, the private party who initiated the lawsuit has the right to conduct the action.

In the event the Government proceeds with the lawsuit, the qui tam plaintiff may receive fifteen to twenty-five per cent of the proceeds of the action or settlement.  If the qui tam plaintiff proceeds with the action without Government, the plaintiff may receive twenty-five percent to thirty per cent of the recovery.  In either case, the plaintiff may also receive an amount for reasonable expenses plus reasonable attorneys’ fees and costs.

If the civil action if frivolous, clearly vexatious, or brough primarily for harassment, the plaintiff may have to pay the defendant its fees and costs. If the plaintiff planned or initiated the violation, the share of proceeds may be reduced and, if found guilty of a crime associated with the violation, no share will be awarded to the plaintiff.

WHISTLEBLOWER PROTECTION

The Civil False Claims Act also provides for protection for employees from retaliation.  An employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against in terms and conditions of employment because of lawful acts conducted in furtherance of an action under FCA may bring an action in Federal District Court seeking reinstatement, two times the amount of back pay plus interest, and other enumerated costs, damages, and fees.

2.    FEDERAL PROGRAM FRAUD CIVIL REMEDIES ACT OF 1986

The Program Fraud Civil Remedies Act of 1986 (“Administrative Remedies for False Claims and Statements” at 38 U.S.C §3801 et seq.) is a statute that establishes an administrative remedy against any person who presents or causes to be presented a claim or written statement that the person knows or has reason to know it to be false, fictitious, or fraudulent due to an assertion or omission to certain federal agencies (including the Department of Health and Human Services).

The term “knows or has reason to know” is defined in the Act as a person who has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.

The term “claim” includes any request or demand for property or money, e.g., grants, loans, insurance, or benefits, when the United States Government provides or will reimburse any portion of the money.

The authority, i.e., federal department, may investigate and with the Attorney General’s approval commence proceedings if the claim is less than one hundred and fifty thousand dollars.  A hearing must begin within six years from the submission of the claim.  The act allows for civil monetary sanctions to be imposed in administrative hearings, including penalties of five thousand five hundred dollars per claim and an assessment, in lieu of damages, of not more than twice the amount of the original claim.

3.    EXAMPLES OF A POSSIBLE FALSE CLAIM

The following are examples of a possible false claim, but are not limited to these alone:

1.    Making false statements regarding a claim for payment;

2.    Falsifying information in the medical record;

3.    Double-billing for items or services;

4.    Billing for services or items not preformed or never furnished.

WHAT SHOULD BE DONE IF A POSSIBLE FALSE CLAIM HAS BEEN MADE

1.    If an employee discovers an event that is similar to one of the examples of a false claim above, and employee is encouraged to;

a.    Report to the Uintah Health Care Special Service District administrator for further investigation.  If the employee is not comfortable doing this;

b.    The employee should contact his/her immediate supervisor.

2.    An employee is not required to report a possible FCA violation to the Uintah Health Care Special Service District first.  A report may be made directly to Adult Protective Service, 800-371-7897 or the Utah Attorney General’s Office; Medicaid Fraud and Elder Patient Abuse Unit, 877-613-7283.  However, in many instances Uintah Health Care Special Service District believes that the use of its internal reporting process is a better option because it allows Uintah Health Care Special Service District to quickly address potential issues.  Uintah Health Care Special Service District encourages employees to consider first reporting suspected false claims to the Uintah Health Care Special Service District administrator but the choice is up to the employee.

3.    Uintah Health Care Special Service District will not retaliate against any employee for informing the Uintah Health Care Special Service District or the federal or state government of a possible FCA violation.

An employee with question regarding this policy should contact Alicen Hatch at 435-781-3505

Deficit Reduction Act of 2005 (“DRA”) Education Requirements for Employees

Dear Employee:

The DRA requires providers such as ours to provide information to all of its employees regarding the Federal False Claims Act (“FCA”), administrative remedies for false claims and statements, applicable state false claims provisions and whistleblower protections under these laws.

You will find a copy of our policy which address our role in preventing healthcare fraud, waste and abuse at https://www.uintahhealthcaressd.org/

Please sign in the space provided below to acknowledge that you will review the information.

Thank you very much,

Sincerely,

Alicen Hatch

Administrator

ACKNOWLEDGED AND AGREED this________ day of ________________ 20_____

By: _____________________________________ (PRINT)

_________________________________________ Signature