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Policy Regarding False Claims Laws for Federal and
State Health Care Programs
Overview
Washington
University is committed to complying with the requirements of
federal and state laws, including Section 6302 of the Federal
Deficit Reduction Act of 2005, and to preventing and detecting
fraud, waste, or abuse in its organization in connection with
federal and state health care programs.
The intention
of this document is to supplement the University’s Code of
Conduct and other policies and procedures and to provide
information to employees and contractors and agents of the
University about the provisions of federal and state false
health care claims laws, penalties for violating the laws, and
how to report suspected violations of the false claims laws.
Following is
a summary of federal and state laws regarding health care
programs and an overview of the related compliance activities in
the University.
Federal
False Claims Act
The federal
False Claims Act (FCA) is intended to prevent and detect fraud,
waste, and abuse of government funds. It is a violation of the
federal FCA for anyone to knowingly submit, or cause another
person to submit, a false health care claim and receive
government funds. Examples of actions that could violate the
federal FCA include overcharging the government for services
rendered; filing a claim with the government for services that
were not rendered; or filing a claim with the government with
information known to be false. Anyone who knowingly or
intentionally submits a false claim to the federal government is
liable for civil penalties of $5,500 to $11,000 per claim, plus
three times the amount of damage caused by the false claim.
State False Claims - Missouri
Missouri law
contains civil and criminal false claims provisions for
combating Medicaid fraud. Specifically, Missouri’s false claim
statute prohibits: (1) knowingly presenting a claim for payment
that falsely states the health care provided was medically
necessary; (2) knowingly concealing an event affecting initial
or continued payments by a medical assistance program for
providing care; (3) knowingly concealing or failing to disclose
any information in order to obtain a payment from a medical
assistance program to which the health care provider is not
entitled or improperly increasing the amount of any such payment
to which the health care provider is entitled; or (4) knowingly
making a claim for payment for health care that was provided
that has a lesser value than the amount of the claim. Criminal
penalties range from imprisonment up to seven (7) years,
restitution and civil penalties of $5,000 to $10,000 per
violation plus treble damages measured as three (3) times the
amount of damage sustained by the Medicaid program as a result
of the false claims activity. Alternatively, Missouri law
authorizes the attorney general to initiate civil actions for
violations of Missouri’s false claims laws and recover up to two
times the amount of payments received by the person as a result
of making false statements or false representations, as well as
the state’s costs in pursuing the action.
Reporting
Violations and Whistleblower Protection
Anyone who
suspects a violation of the FCA or any other federal, state, or
local law, a University policy, or the University’s Code of
Conduct is required to promptly report it to University
management. Anyone who, in good faith, reports a suspected or
actual violation of law, regulation, or University Code of
Conduct or policy will be protected from retaliation and
retribution as a result of such reporting, regardless of whether
or not, after investigation, a violation is found to have
occurred. As outlined in the University’s Code of Conduct, any
one of the following three channels may be used for informing
University management of the suspected violations:
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Report it
directly to your supervisor or department head or chair.
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Report
it to the related area-specific compliance office. For
health care related matters, contact the Director of the
Physician Billing Compliance Office at (314) 747-7666 or
opbc@msnotes.wustl.edu
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Call the
University hotline at (314) 362-4998. Reports may be made
anonymously.
If issues
related to misuse of government funds are not addressed and
resolved by the above reporting channels, the federal FCA
contains “whistleblower” provisions that allow citizens with
evidence of false claims against the government to sue, on
behalf of the government, in order to recover the improperly
charged funds. If the suit ultimately ends in a monetary
judgment, the citizen may share in the damages recovered. The
federal FCA extends protections to employees who report false
claims from retaliation or discrimination by an employer and
University policy provides protection from retaliation and
retribution as a result of such reporting, regardless of whether
or not, after investigation, a violation is found to have
occurred.
Policies and Procedures for Detecting and Preventing Health Care
Fraud, Waste, and Abuse
Washington
University has a wide variety of policies, procedures, and
activities related to detecting and preventing health care
fraud, waste, and abuse, including the following:
The
Washington University Code of Conduct expresses the commitment
by Washington University to carry out its educational, research,
and health care activities in compliance with all relevant laws
and regulations and with the highest integrity. All employees
are expected to adhere to it.
The
University’s Physician Billing Compliance Office provides
mandatory annual training for all faculty and staff who
participate in patient care or reimbursement-related
activities. The training includes information about how to
report false claims. The Physician Billing Compliance Office
also educates and works closely with billing personnel in each
department to address billing questions or concerns that may
arise. They also create and publish periodic educational and
informative newsletters related to billing matters. They also
perform monitoring and auditing of billing compliance.
The
University Compliance Office maintains the University’s hotline
and investigates or partners with appropriate personnel to
investigate all hotline calls and ensure appropriate corrective
action occurs. This Office also performs audits of compliance
with various federal regulations.
The Internal
Audit Office performs internal audits throughout the University,
which includes reviewing compliance with University policies and
procedures and adequacy of internal controls, including internal
controls related to health care, such as in the areas of billing
processes, cash receipts, payment posting, write-offs, refunds,
etc. The Controller’s Office issues a Guide to Internal
Controls document annually to all business managers and requires
them to certify annually that they have received it and
understand they are responsible for having adequate internal
controls in their areas.
University links related to detecting and preventing
fraud, waste, and abuse:
Code
of Conduct
Physician
Billing Compliance Office
Washington
University Compliance Office
Office
of Internal Audit
University’s
Guide to Internal Controls
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