As recipients of federal health care program funds, including Medicare and Medicaid, healthcare organizations are required by law to provide all employees, agents and contractors information regarding the federal False Claims Act, the federal Program Fraud Civil Remedies Act, and any applicable state laws intended to prevent and detect fraud, waste and abuse in federal health care programs.
What is the False Claims Act (FCA)?
The FCA is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim with the government for payment. “Knowingly” includes having actual knowledge that a claim is false, or acting in “deliberate ignorance” or “reckless disregard” as to whether a claim is false. Examples of possible false claims include billing Medicare for services that were not provided, billing for a higher-level service than the service actually furnished (upcoding), or billing for services that were not ordered by a physician.
The FCA contains provisions that allow individuals with original information (i.e., information not already the subject of legal proceedings or activities that have already been publicly disclosed) concerning fraud involving government programs to file a lawsuit on behalf of the government and, if the lawsuit is successful, to receive a portion of recoveries received by the government.
New York passed its False Claims Act in 2007.
Penalties for Violating the False Claims Act
Financial penalties to the organization for submitting a false claim can total as much as three times the amount of the claim plus fines up to $50,000 per claim. In addition to fines and penalties, an individual or organization that violates the False Claims Act is subject to exclusion from participation in federally funded healthcare programs. New York’s False Claims Act provides for a penalty of between $6,000 and $12,000 and recoverable damages between 2 and 3 times the value of the amount of money falsely received.
Protections Under the False Claims Act
There is a qui tam, or whistleblower, provision in the Federal and NYS False Claims Acts, as well as the Pennsylvania Whistleblower Law. This provision allows a private citizen (referred to as a relator), to file a lawsuit against an organization or an individual on behalf of the government if the relator is aware of a potential false claim. A relator/whistleblower can receive a portion of the settlement dollars recovered. Relators/whistleblowers also have special protection under the qui tam provision of the Federal, NYS and Pennsylvania statutes. The provision protects employees from retaliation by an employer or employee for reporting potentially fraudulent activity.
Pennsylvania Medicaid Fraud and Abuse Control Law
The Pennsylvania Medicaid Fraud and Abuse Control Law (“Medicaid Fraud Control Act”) provides a criminal remedy for the submission of false or fraudulent claims to the Pennsylvania Medicaid program. 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;
- Knowingly submitting false information for the purpose of obtaining or furnishing services or merchandise under the Medicaid program.
Program Fraud Civil Remedies Act
The Program Fraud Civil Remedies Act ("PFCRA") provides federal agencies, including the agencies responsible for federally funded health care programs, with administrative remedies against individuals and organizations that knowingly submit a false claim for payment, or knowingly make or use a false record or statement to get a false claim paid. The PFCRA is limited to situations where a false claim, or a group of related false claims, does not exceed $150,000. The PFCRA provides civil penalties up to $6,000 per false claim, plus an assessment equal to twice the amount of the false claim.
Guthrie’s Commitment to Corporate Compliance
The Guthrie Clinic is committed to fully complying with all laws and regulations that apply to our organization. The Corporate Compliance Program is evidence of the commitment to operating with the highest degree of integrity. The Compliance Program includes the Code of Conduct, policies and procedures, training and education, auditing and monitoring, and mechanisms for individuals to raise issues and concerns without fear of retaliation.
We ask that you:
- Act with honesty and integrity in all your business activities
- Follow all laws and regulations that apply to your work activities, including requirements of the Medicare, Medicaid and other federal health care programs. These requirements generally include maintaining complete and accurate medical records, and submitting only complete and accurate claims for services provided
- Contact one of the following resources available within Guthrie if you have knowledge or concern regarding a potential false claim:
- Director Internal Audit/Compliance – Roger Lathrop, 570-887-5803
- Compliance Officer – Carol Sager, 570-887-5350
- Compliance Officer – Tricia Liechty, 570-887-4644
- Compliance Hotline – 1-800-841-4644
The Guthrie Clinic policy strictly prohibits retaliation, in any form, against an individual reporting an issue or concern in good faith.
Thank you for your commitment to operating with integrity and the highest standards of ethical behavior.