Corporate Compliance

Any physician, hospital staff member, patient or visitor may report potentially disruptive behavior. Any persons who believe they are the object of or affected by disruptive or disrespectful behavior are encouraged to let the offending individual know that their behavior is unwelcome and against hospital policy. Individuals wishing to report an incident of potentially disruptive behavior by an employee or volunteer must do so to the Vice President or Director of Human Resources. Individuals wishing to report an incident of potentially disruptive behavior by a physician must do so to the Medical Staff President or the Director of Medical Affairs. The report must be in writing and include the date and time of the incident, the circumstance surrounding the incident, a factual and objective description of the questionable behavior, the consequences, if any, to patient care or hospital operations, and any action taken to remedy the situation. Individuals may file a complaint anonymously. False or malicious reports subject the individual to disciplinary action.  For complaints that involve employed physicians, the Vice President of Human Resources, Director of Medical Affairs, and the President of the Medical Staff, and if necessary the President of the Hospital shall determine who is responsible for leading any investigation and whether to utilize the Human Resources process or the Medical Staff process or both.

SCOPE:

Rutland Regional Medical Center

PURPOSE:

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.  

POLICY

1. 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.
2. 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.
3. 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.   
4. 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. 

DEFINITIONS

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

REFERENCES:

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.