Your duty to report
Safeguarding our commitment to Integrity requires everyone’s help. The purpose of this Code of Conduct is to encourage you to report your questions or concerns. We rely on you to tell us if you believe that someone is violating the law. We also rely on you to tell us if you believe that a process or practice violates the law.
- All possible violations of the law, regulations, this Code of Conduct or a compliance policy must be reported.
- Staff will seek clarification from their supervisor or the Compliance Officer if they are unsure about the regulatory requirements for performing their job.
This Code of Conduct makes all of us accountable for compliance with legal and ethical standards. Anyone who violates such standards, including a failure to report, shall be subject to appropriate discipline.
Any retaliation or threat of retaliation against a person who reports in good faith is strictly prohibited. Any person who believes that they are being retaliated against shall report their concerns to the Compliance Officer. Reporting in good faith means that you are reporting a concern truthfully and factually.
How to report your concerns
You may choose how to report your concerns. You may report
The Hotline allows you to leave a confidential voicemail message.
Reports will be treated confidentially. You can choose to report anonymously and your identity will not be disclosed unless such disclosure is ordered by a Court or other lawful authority. The Compliance Officer will investigate all reported concerns. Anonymous callers must provide sufficient information to allow for a reasonable investigation. When calling, you should identify your work area, describe the specific practice or behavior, and describe what you believe to be illegal about the activity.
Rutland Regional Medical Center
The purpose of this policy is to inform employees, volunteers, members of the Medical Staff, contractors, and agents of Rutland Regional’s efforts to prevent Fraud, and Abuse so that potential concerns are immediately reported. This policy is intended to ensure that Rutland Regional provides information about the federal False Claims Act, the Vermont Medicaid fraud statute and whistleblower protections under both state and federal law, as required by section 1902 of the Social Security Act as amended by the Deficit Reduction Act of 2005.
- Commitment to compliance – Rutland Regional has a Corporate Compliance Plan, Code of Conduct, and other policies that are intended to prevent, detect, and remedy fraud, waste and abuse, and other forms of noncompliance. The Code of Conduct states that the organization is committed to (1) complying with laws, regulations, and ethical standards, (2) promoting a culture of prevention, detection, and resolution of potential wrongdoing; and (3) strictly prohibiting retaliation against individuals who report concerns in good faith.
- Education and communication – Rutland Regional provides education, training, and communication about laws such as the False Claims Act to ensure that potential concerns are immediately reported and resolved as expeditiously as possible.
- Obligation to prevent and report – All staff are responsible for ensuring that they prevent, and report potential problems that can lead to payment errors. It is critical to identify, and respond to potential payment errors to prevent the organization from being subject to severe financial penalties.
- Identifying potential overpayments – The False Claims Act requires that providers identify, report, and return to Medicare or Medicaid overpayments within 60 days of identification. The failure to promptly return an identified overpayment would be considered a false claim.
4.1. The False Claims Act prohibits:
4.1.1. knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval;
4.1.2. knowingly making or using, or causing to be made or used, a false record or statement that is material to an obligation to pay or transmit money or property to the Government;
4.1.3. to defraud the government by getting a false or fraudulent claim allowed or paid; and
4.1.4. Knowingly concealing or improperly avoiding or decreasing an obligation to pay or transmit money of property to the Government.
4.1.5. Knowingly failing to return an identified overpayment within 60 days after the overpayment was identified.
4.2. Sanctions include:
4.2.1. Excluding the provider or individual from participating in Medicare and Medicaid;
4.2.2. Criminal penalties including imprisonment for up to five years; and
4.2.3. Civil monetary penalties from $5,500 to $11,000 per claim, plus triple damages;
4.3. Enforcement: The United States Attorney General may bring a civil or criminal action for violations of the False Claims Act, and the Vermont Attorney General may file a civil action for violation of the State false claims statute. The federal False Claims Act also includes a qui tam provision, which allows an individual who is the “original source” of information about the falsity of a claim to file a claim as a relator on behalf of the Federal Government, and the relator may share in the government’s recovery of damages.
4.4. Protection for “Whistleblowers”: The False Claims Act protects employees from retaliation when they pursue a False Claims Act related action. As stated in the Code of Conduct, Rutland Regional strictly prohibits retaliation of any kind.
4.5. Reporting Concerns about Potential Overpayments – The Code of Conduct requires that all staff and contractors report all possible violations of the law. If staff or a contractor has knowledge or information that may have resulted in or may result in the submission of a false claim, or the receipt of an overpayment, they shall notify their supervisor, the Chief Compliance Officer at 802.772.2557, or call the Compliance Hotline at 866.403.5245.
4.5.1. The Chief Compliance Officer is responsible for ensuring that a reasonable inquiry is conducted to determine if the organization has received any overpayments. The department that provided the service, or manages the relevant process, is responsible for providing information that is necessary to determine the potential cause of an overpayment, and implementing corrective action to prevent future errors. The Patient Financial Services and Finance Departments are responsible for assisting in the quantification, and timely repayment of all overpayments.
4.5.2. Exception to reporting – There is no requirement to report errors that occur within the Patient Financial Services Department that are part of routine claims processing, or within the Finance Department associated with cost report issues provided that the errors are resolved promptly.
Abuse means practices that, either directly or indirectly, result in unnecessary costs to the Medicare or Medicaid Programs where it is not possible to establish that abusive acts were committed knowingly, willfully, and intentionally.
Fraud means 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 some unauthorized benefit to himself/herself or some other person.
Knowingly means that a person, with respect to information: (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.
OTHER POLICIES AND FORMS
Replaces Providing Information About the False Claims Act
Code of Conduct
Corporate Compliance Plan
Providing and Documenting Services that are paid by the Federal Healthcare Programs
42 U.S.C. § 1396a(a)(68)(Medicaid requirement for a policy on the False Claims Act)
31 U.S.C. §§ 3729-33 (False Claims Act)
31 U.S.C. §§ 3801-12 (Program Fraud Civil Remedies Act)
18 U.S.C. § 1347 (Criminal Health Care Fraud)
21 V.S.A. §§ 507-09 (Vermont health care employee whistleblower protection law)
13 V.S.A § 3016 (Vermont criminal false claim)
33 V.S.A. § 141 (Vermont Medicaid fraud)
APPENDIX – EXAMPLES THAT MAY RAISE A FALSE CLAIMS ACT CONCERN
- Billing for services that were not provided.
- Duplicate payments.
- Billing the wrong number of units.
- Misrepresenting the services that were provided as another service that carries a higher payment (often referred to as “upcoding” or “unbundling”).
- Incorrect use of CPT codes, HCPCS codes, Modifiers, and diagnosis codes.
- Payments for noncovered services
- Receiving payments from Medicare for a noncovered service such as a service that was inconsistent with a Local Coverage Decision (LCD), or National Coverage Decision (NCD).
- Receiving payments from Medicaid for a noncovered services such as service that was inconsistent with a Medicaid Medical Policy.
- Receipt of Medicare payments when another insurance had the primary responsibility for payment.
- Failing to properly document a billable service when the documentation is a condition for payment.
- Providing and billing for a service without a required physician order.
- Receiving a payment for a service with the wrong date of service such as when are patient died prior to the date of service that was reported on a claim.
- Billing for services that were performed by an unlicensed or excluded individual.
- Billing for a service that was not appropriately supervised by a physician or nonphysician practitioner.
- Billing Medicare for outpatient services provided to a resident of a skilled nursing facility where the service should have been covered as part of a SNF stay.