Compliance information for employees, contractors and agents.
Aging in America (AIA) and its charitable subsidiaries are committed to the prevention and detection of any fraud, waste, and abuse in its organization. To this end, AIA maintains a comprehensive compliance program geared in part to educating our community and staff on fraud and abuse laws and the importance of submitting accurate claims and reports to all Federal, State and local government programs, including Medicare and Medicaid.
Policy Statement: AIA prohibits the knowing submission of a false claim, or production of a record to generate or conceal a false claim for payment to a Federally or State funded health care program. Such submissions are a violation of Federal and State law and can result in significant administrative and civil penalties under the Federal False Claims Act and New York State Fraud & Abuse laws. See reverse for detailed information on applicable laws.
What we expect from our employees, contractors and agents: To assist AIA in meeting its legal and ethical obligations, we rely on you to be our “eyes and ears” and to alert management to all potential fraud, waste or abuse. Toward that end, anyone who is aware of the preparation or submission of a false claim or report, or who suspects any potential fraud, waste, or abuse is required to report such information to senior management. Alternatively, anyone can make a confidential report to the Human Resource Development Department (Ext. 8265) or to the Executive Vice President (Ext. 8215) who serves as the compliance officer for the organization. Alternatively, you may use our toll-free HelpLine to make a confidential or anonymous report by calling 1-866-232-9395.
No retaliation for reporting: We are committed to investigate all reports swiftly and thoroughly through our internal compliance mechanisms including Quality Assurance, Ethics and Finance & Audit Committees. Employees are protected against retaliation under Federal and State law (see reverse for specific “whistleblower” protections). Employees, contractors and/or agents will be disciplined, terminated and/or held liable for their own knowing participation in a fraudulent scheme.
Reporting to government agencies: If an employee believes the organization’s response is either deficient or unresponsive, the employee must bring his/her concerns to the Compliance Officer. If such follow-up still does not trigger an appropriate response, then, after a reasonable period of time, employees can either contact the President (ext 8214) or have the ability to bring concerns to the appropriate government agency under Federal and/or State law.
Other Important Information for Contractors and Agents working for or on behalf of Morningside: Contractors and agents must use one of our internal compliance processes to report suspected fraud, waste or abuse. If you have a reasonable suspicion and do not report it, or if you refuse to participate in an investigation involving a report of suspected activity, be aware that you may be in breach of your contractual duties and obligations to AIA. This information is being provided to all contractors and agents involved with the provision, monitoring or billing for Medicaid services. Contractors and Agents must acknowledge receipt, read and understand this information and hold themselves to a similar standard.
You must report internally first. Employees must use one of our internal compliance processes to report suspected fraud, waste or abuse. If you have a reasonable suspicion and do not report it, or if you refuse to participate in an investigation involving a report of suspected activity, be aware that you may be in breach of your duties and obligations to your employer.
This information is being provided to all organization employees and employees of contractors or agents of our organization. We expect your full cooperation and support.
Applicable Laws Below is a discussion of some of the specific laws addressing false/fraudulent claims for payment for health care services (including claims to Medicare, Medicaid and private health plans). While not exhaustive, these are the laws primarily used by the government to prosecute and prevent fraud, waste and abuse in its taxpayer financed health programs.
The Federal Civil False Claims Act (31 U.S.C. § 3729 et seq.) The “grand-daddy” of fraud statutes, the False Claims Act (“FCA”) was originally enacted during the Civil War to address the problem of fraud among defense contractors. The current version of the FCA (c. 1982-1986) was designed to enhance the government’s ability to detect and recover losses due to fraud. The FCA prohibits the:
· knowing submission (actual knowledge or deliberate ignorance) of a false or fraudulent claim for payment and/or knowingly making a false record or statement to secure government payment and/or conspiring with others to get such a claim allowed or paid. Employees who report potential violations of the FCA may not be discharged, demoted, harassed or discriminated against as a consequence of reporting. This aspect of the FCA is known as “whistleblower” protection.
Civil and Administrative penalties under the FCA include but are not limited to:
· A fine of $5,500 to $11,000 per claim
· Up to 3 times the amount of actual damages (losses) sustained
· Payment of all costs incurred by the government to recover losses.
· Exclusion from participating in Federal Health insurance programs
· Remedies may be sought under the Program Fraud Civil Remedies Act 31U.S. §3810Private individuals, called qui tam relators, may bring lawsuits for violations of the FCA and may be awarded a portion (15-25%) of the proceeds if the government takes the case. If the government does not take the case, a qui tam relator can still bring a lawsuit on his/her own, and if successful may be awarded 25-30% of the proceeds. But if unsuccessful, and if the lawsuit is frivolous, then a qui tam relator may be responsible for the defense costs of the provider.
New York State False Claims Law & Whistleblower Protections
In addition to Federal law, New York State makes it a crime to knowingly and willfully submit false information or conceal a material fact for the purpose of obtaining greater compensation than is otherwise permitted under a public or private health plan. “Health Care Fraud” may be a misdemeanor, or Class E – A felony, depending on the amount of payment wrongfully sought.
See NYS Penal Law Article 177. See also NY Social Service Law §366-b(2) which sets forth requirements for compliance programs. Also, NY Social Service Law §145-b provides for civil penalties for fraudulent claims which include fines of 3 times the amount of falsely overstated charges and civil monetary payments of $2,000 for each item or service paid as restitution to the Medical Assistance Program ($7,500 for repeat offenders). NY Finance Law §187 et.seq. includes qui tam provisions similar to the FCA.
NYS Labor Law §740 prohibits employers from taking retaliatory action against an employee who discloses (or threatens to disclose) a violation of law. An employee who is discharged, demoted, disciplined or otherwise discriminated against can bring a lawsuit against his/her employers but will only receive NYS “whistleblower” protection if he/she brought the issue to the attention of his/her employer and afforded the employer a reasonable opportunity to correct the problem.