FALSE CLAIMS ACT INFORMATIONNumber:
Version 1/December 2006
- Purpose. The purpose of SPP-001 is to provide:
- Information, in accordance with 42 U.S.C. § 1396a(a)(68), regarding the federal civil False Claims Act, 31 U.S.C. § 3729, et seq., (“FCA”), the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. § 3801, et seq., (“PFCRA”), state laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws; and
- Procedures to ensure that WVHCS’s practices are consistent with its stated policies.
- Scope. This policy applies to all WVHCS-affiliated entities and departments including, but not limited to: WVHCS, Inc., WVHCS-Hospital, WVHCS-Hospital Transitional Care Unit, UHHS, Rural Health Corporation, Heritage House, VNA and Behavioral Health Services.
- General Procedure for Detecting and Preventing Fraud, Waste and Abuse. WVHCS operates under a Compliance Program, promotes Compliance Program Standards of Conduct and Policies and Procedures, and maintains departmental policies and procedures that support good business practices — all of which (1) govern how the health care system does business in compliance with all applicable laws and regulations and (2) are essential elements in WVHCS’s ongoing efforts to detect and prevent fraud, waste and abuse in federal and state health care programs. The WVHCS Compliance Program Standards of Conduct and Policies and Procedures, and departmental policies and procedures, are posted on the WVHCS Intranet. Compliance Program Policies and Procedures that specifically relate to the detection and prevention of fraud, waste and abuse include, but are not limited to, this Policy and the others referenced herein.
In order to facilitate WVHCS’s commitment to the detection and prevention of fraud, waste and abuse, as required by 42 U.S.C. § 1396a(a)(68), the information set forth below shall be:
Any employee who has knowledge or information of any potential false claims or other wrongdoing has a duty to report such suspected misconduct in accordance with policy CS-170. An employee may fulfill this duty by making a report to the Compliance Officer, to the employee’s direct supervisor, or through Community Health System's Compliance Line at (800) 495-9510. Reports of suspected misconduct may be made anonymously in accordance with policy CS-120.
- Distributed to all WVHCS employees, contractors and agents; and
- Included in WVHCS’s employee handbooks.
- False Claims Act Information.
- Overview. The FCA is a law aimed at preventing fraud against the federal government, including fraudulent billing and submission of claims to all federal health care programs (e.g., Medicare and Medicaid). The FCA is the federal government’s primary civil remedy for false claims and statements.
- Prohibited Conduct Under the False Claims Act. The FCA prohibits any person or entity from:
- Knowingly presenting, or causing to be presented, to the government a false or fraudulent claim for payment or approval;
- Knowingly making or using, or causing to be made or used, a false record or statement in order to have a false or fraudulent claim paid or approved by the government;
- Conspiring to defraud the government by getting a false or fraudulent claim allowed or paid;
- Falsely certifying the type or amount of property to be used by the government;
- Certifying receipt of property used (or to be used) by the government on a document without completely knowing that the information is true;
- Knowingly buying or receiving government property from an unauthorized agent; or
- Knowingly making or using, or causing to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government.
- In the context of the FCA, the term “knowingly” means that the entity or individual committing the prohibited act:
- 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 the government is required.
- The U.S. Attorney General may bring civil actions for violations of the FCA. An action must be brought within three years of the date when material facts are known or should have been known to the government, but in no event more than ten years after the date on which the violation was committed.
- A private person also may file a FCA suit in the name of the United States for false or fraudulent claims submitted by individuals or entities. Commonly known as “qui tam” actions, such lawsuits by a private person are commenced when a “relator” (also referred to as a “whistleblower”) files a civil complaint in federal court, under seal, and discloses material evidence to the U.S. Attorney General. A qui tam action must be brought within six years after a violation. Whistleblowers who file a qui tam action may receive a reward of 15-30 percent of the monies recovered for the government, plus attorneys’ fees and costs. (This amount may be reduced, however, if, for example, the court finds the whistleblower planned and initiated the violation.)
- Penalties. Individuals or entities found to have violated the FCA are liable for a civil penalty for each false claim of not less than $5,500 and not more than $11,000, plus up to three times the amount of damages sustained by the federal government.
- “Whistleblower” Protections.
- Whistleblowers are afforded certain protections against retaliation for bringing an action under the FCA. An employee who is discharged, demoted, suspended, threatened, harassed, or confronts discrimination in furtherance of such an action or as a consequence of whistleblowing activity is entitled to all relief necessary to make the employee whole. Such relief may include reinstatement, double back pay, and compensation for any special damages, including litigation costs and reasonable attorneys’ fees.
- Consistent with the FCA, WVHCS’s policy is to protect employees from any retaliation or retribution for reporting suspected violations of the law to law enforcement officials or to WVHCS management, or for filing “whistleblower” lawsuits on behalf of the government. Specifically, policy CS-170 prohibits retaliation in any manner or retribution against an employee who has made or intends to make a report of an activity, practice or arrangement that the employee believes violates or may violate a law (including the FCA), a regulation, or Compliance Program Standards of Conduct or Policies or Procedures.
- Program Fraud Civil Remedies Act of 1986
- Overview. The PFCRA provides for administrative remedies against persons and entities that make, or cause to be made, a false claim or written statement to certain federal agencies, including the U.S. Department of Health and Human Services (“HHS”).
- Prohibited Conduct Under PFCRA. The conduct prohibited by the PFCRA is similar to that prohibited by the FCA, but the PFCRA was enacted as a means to address lower dollar frauds and, as such, generally applies to claims of $150,000 or less. The PFCRA makes it unlawful for any person or entity to make, present or submit, or to cause to be made, presented, or submitted, a claim that the person or entity knows or has reason to know:
- Is false, fictitious or fraudulent;
- Includes or is supported by any written statement which asserts a material fact which is false, fictitious or fraudulent;
- Includes or is supported by any written statement that –
- omits a material fact;
- is false, fictitious or fraudulent as a result of such omission; and
- is a statement in which the person or entity making, presenting, or submitting such statement has a duty to include such material fact; or
- Is for payment for the provision of property or services which the person or entity has not provided as claimed.
- Enforcement. Violations in the health care sector typically are investigated by the HHS Office of Inspector General, and enforcement actions must be approved by the U.S. Attorney General. PFCRA enforcement can begin with a hearing before an administrative law judge. A subpoena can be issued to further the investigation, or the matter can be referred to the Department of Justice for proceedings under the FCA.
- Penalties. Individuals or entities found to have violated the PFCRA are liable for a civil penalty of not more than $5,000 for each false claim, plus an assessment of up to two times the amount of such claims, or the portion of such claims, that are determined to violate the PFCRA. Penalties may be recovered through a civil action brought by the U.S. Attorney General or through an administrative offset against “clean” claims.
- Pennsylvania’s Medicaid Fraud and Abuse Control Law
- Overview. Pennsylvania’s Medicaid Fraud and Abuse Control Law, 62 P.S. § 1407, (“Medicaid Fraud Control Act”) provides a criminal remedy for the submission of false or fraudulent claims to Pennsylvania’s medical assistance (i.e., Medicaid) program.
- Prohibited Conduct Under the Medicaid Fraud Control Act. The Medicaid Fraud Control Act prohibits any person from, among other things:
- Knowingly or intentionally presenting for allowance or payment any false or fraudulent claim or cost report for furnishing services or merchandise under the Medicaid program;
- Knowingly presenting for allowance or payment any claim or cost report for medically unnecessary services or merchandise under the Medicaid program;
- Knowingly submitting false information, for the purpose of obtaining greater compensation than that to which he or she is legally entitled, for furnishing services or merchandise under the Medicaid program; or
- Knowingly submitting false information for the purpose of obtaining or furnishing services or merchandise under the Medicaid program.
- Enforcement. The Pennsylvania Office of the Attorney General and the county district attorneys have concurrent authority to institute criminal proceedings under the Medicaid Fraud Control Act.
- Penalties. In general, a person who violates provisions of the Medicaid Fraud Control Act is guilty of a felony of the third degree for each such violation with a maximum penalty of fifteen thousand dollars ($15,000) and seven years imprisonment.
- State “Whistleblower” Protections. The Pennsylvania Whistleblower Law, 43 P.S. §§ 1421-1428, provides protection from discrimination and retaliation to any person who witnesses or has evidence of wrongdoing or waste while employed by a public body (e.g., state, county or city agency, department, division or council, etc.) and who makes a good faith report of the wrongdoing or waste, verbally or in writing, to one of the person’s superiors, to an agent of the employer or to an appropriate authority. No employer may discharge, threaten or otherwise discriminate or retaliate against an employee regarding the employee’s compensation, terms, conditions, location or privileges of employment because the employee, or a person acting on behalf of the employee, makes a good faith report or is about to report, verbally or in writing, to the employer or appropriate authority an instance of wrongdoing or waste.
- Dissemination of Information. Employees and, to the extent determined by the Chief Compliance Officer in consultation with the Corporate Compliance Committee, Covered Contractors shall receive information on procedures for detecting, preventing and reporting fraud, waste and abuse, the FCA, the PFCRA, Pennsylvania’s Medicaid Fraud Control Act and whistleblower protections. This information may be disseminated through WVHCS’s annual mandatory education program, WVHCS Orientation, a special mailing or other such method.
- VIII. Questions. Any questions regarding this Policy, the FCA, the PFCRA, or Pennsylvania’s Medicaid Fraud Control Act, should be directed to WVHCS’s Chief