False Claims and Payment Fraud Prevention

The purpose of this policy is to inform employees, contractors, volunteers and agents of Yale New Haven Health System of the Federal False Claims Act (referenced in this policy as "FCA") the Federal Program Fraud Civil Remedies Act, the Connecticut False Claims Act (“CFCA”), and all other State False Claims Acts; to provide general information regarding YNHHS’s efforts to combat fraud, waste, and abuse; and to describe the remedies and fines for violations that can result from certain types of fraudulent activities.

In addition, this policy conforms to The Deficit Reduction Act (DRA) “Employee Education Provision” intended to bolster Medicaid fraud and abuse enforcement with the following:

a) Establish fraud and abuse policies and an effective and comprehensive education plan; Included in annual Health Stream training “Corporate Compliance: A Proactive Stance Course”.

b) Provide detailed explanation of administrative remedies pertaining to civil or criminal penalties for false claims.

c) Provide specific discussion to the rights of employees regarding whistleblower protection under such laws.

d) Ensure the entity has a non-retaliation policy available to all employees.

All employees, contractors, agents, and volunteers of YNHHS must not create any false or misleading documents or financial or electronic records for any purpose. No one may instruct you to so.

 

 

All employees, contractors, agents, and volunteers of YNHHS must immediately report any suspicion of fraud, waste, or abuse in connection with the business of YNHHS to the Office of Privacy and Corporate Compliance. YNHHS engages in specific compliance efforts to detect and prevent fraud, waste, and abuse, such as the Corporate Compliance Program.

If you would like more information on the Corporate Compliance Program and specific compliance policies or on how to report any concerns, please contact the Office of Privacy and Corporate Compliance (203-688-8416). Compliance Policies may also be found on the YNHHS Intranet..

 

 

The Federal False Claims Act (FCA) imposes civil penalties on people and companies who knowingly submit a false claim or statement to a federally-funded program or otherwise conspire to defraud the government in order to receive payment. Failure to report and return overpayments from Medicare and Medicaid within certain timeframes might also constitute a violation of the FCA. The FCA also protects people who make efforts to stop the suspected fraud.

 

The FCA is not confined to healthcare claims, but extends to any payment requested of the federal government or the federal government’s contractor, grantee, or other party, if the payment is to be spent or used on the government’s behalf or to advance a government program or interest and the government provides any portion of the payment or will reimburse the contractor, grantee, or other party. The FCA applies to billing and claims sent from YNHHS to any government payor program, including Medicare and Medicaid.

 

It is the policy of YNHHS that an employee, contractor, or agent of YNHHS who knowingly and intentionally submits a false claim will be reported to the necessary authorities. Anyone or any company that submits a false claim or statement to the government may be fined under the FCA between $5,500 and $11,000 for each such claim submitted, regardless of the size of the false claim, and the person or company could be required to pay an additional fine of three times the value of any charges. Where a person who violated the FCA reports the violation to the government under certain conditions, the FCA provides that the person shall be liable for not less than double damages.

Part of the FCA's purpose is to create an environment where employees and others feel safe reporting concerns about fraud. Any person, who lawfully attempts to stop any FCA violations or reports information about false claims or suspected false claims that are submitted by others, may not be retaliated against, demoted, suspended, threatened, or harassed for such actions.

 

The FCA also protects individuals who assist in an investigation, provide testimony, or participate in the government's handling of a false claim. Individuals have the right to FCA whistle blower protection from retaliation in any form as to the result of their whistle blowing. These protections include reinstatement without loss of seniority if fired, recovery of two times lost wages plus interest and recovery of attorney fees and other reasonable costs in connection with pursuing retaliation claim. Confidentiality will be maintained to the extent possible.

 

The FCA’s provisions are generally enforced by the U.S. Department of Justice. The FCA provides that an individual may initiate a formal claim under certain circumstances. If any funds are recovered, a portion of the funds may be paid to the person who initiated the formal claim, at the discretion of a federal court. This amount, if awarded, generally is between 15% and 30% of the total damage amount.

 

If a person wishes to file a claim regarding fraud or suspected fraud related to a healthcare payment directly with the government, he or she must first present a formal complaint, along with all material evidence relating to the alleged fraud, to the authorities at the U.S. Department of Justice. The authorities have 60 days to investigate, during which time the complaint is kept confidential. Upon completion of the investigation, the government will decide either to pursue the case on its own or decline to proceed with the case. If the federal government declines the case, the individual may still proceed with the case on his or her own, but without the government's assistance, and at his or her own expense.

 

A private legal action under the FCA must be brought within six years from the date that the false claim was submitted to the government. (A government-initiated claim may be brought up to ten years after the false claim, depending on the circumstances.)

 

 

Persons or companies that commit fraud on the federal government, by false claim or statement, can be assessed monetary penalties in addition to the penalties of the False Claims Act because of a law called the Program Fraud Civil Remedies Act (referenced in this policy as "PFCRA"). Specifically, PFCRA penalties of $5,000 per false claim or statement apply if a person or company submits a claim to the federal government that: the person or company knows or has reason to know is false, fictitious, or fraudulent; includes or is supported by written statements containing false, fictitious, or fraudulent information; includes or is supported by written statements that omit a material fact, which causes the statements to be false, fictitious, or fraudulent and the person submitting the statement has a duty to include the omitted fact; or is for payment of property or services that are not provided as claimed.

 

The $5,000 penalty also applies if a person or company provides written back-up or materials relating to the claim in which the person or company asserts a material fact that is false, fictitious, or fraudulent; or omits a fact that the individual had a duty to include, the omission causes the statement to be false, fictitious, or fraudulent, and the statement contains a certification of accuracy.