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The Federal False Claims
Act…
… and how it affects You
(as impacted by the Deficit Reduction Act of 2005)
Updated 11/20/06
Purpose of Presentation
• To provide a general overview of the Federal False
Claims Act
• To provide information to Tulane University
Faculty and Staff Employees about their rights to
protection under the Deficit Reduction Act of 2005
• To describe Tulane University’s policies and
procedures for detecting and preventing fraud,
waste, and abuse
As Medicare and Medicaid programs grow increasingly complex,
laws and regulations governing them become more complicated,
and require increasing organizational resources to ensure
compliance with their requirements.
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This comes at a time when these programs become more strained by
the health care needs of retiring baby boomers.
Nearly 36 million (86%) of today’s beneficiaries receive benefits paid
as fee-for-service
Over 1 billion claims are paid each year to over 1 million providers
In 2004, more than $1 trillion went to Medicare, Medicaid, and Social
Security programs
These figures illustrate the government’s need for enhanced diligence
in identifying and targeting fraudulent activities and recovering funds
under the False Claims Act.
The Medicaid Program
• originated in 1965 to ensure health care
coverage and services for low-income and
financially needy people
• is administered by the states, but is jointly
funded by federal and state governments
• reimburses providers directly for services to
its beneficiaries
The state’s fraud control units investigate
Medicaid fraud and abuse issues.
The Medicare Program
• was established in 1965 by Title XVIII of the
Social Security Act
• is a federally-funded health insurance program
for citizens 65 or older, and persons with longterm disability or end-stage renal disease
• consists of four parts, for various health care
items and services
Medicare Part A
• provides coverage for institutional providers
• generally pays under the Prospective Payment System
(PPS), but may also reimburse institutional providers
(including hospitals) for services they provide under Part B
such as hospital outpatient services
• is financed through payroll taxes paid by employees and
employers through FICA, by self-employed individual
contributions, and the Railroad Retirement Board
• currently makes payment through contracted insurance
companies (Fiscal Intermediaries), but will move to a new
contracting model, Medicare Administrative Contractor
(MAC) by 2011
Medicare Part B
• covers services provided by suppliers: physicians, nurse
practitioners, home health care, ambulance, clinical and
diagnostic labs, durable medical equipment
• bases payment on Medicare fee schedules developed by the
Centers for Medicare and Medicaid Services
• carries a deductible and co-insurance paid by the beneficiary
• is financed through premiums paid by enrollees, general
revenue, and interest earned on the Part B trust fund
• payments are generally made by contracted insurance
companies (carriers), which will be replaced with the MAC
contracting model
Medicare Part C
• was originally established in 1997 as “Medicare Choice” to
offer managed care services to Medicare beneficiaries
• was amended in 2003 to become “Medicare Advantage”, and
beneficiaries receive Part A and Part B services through
enrollment in a managed care organization (HMOs, PPOs)
• may also include wellness and preventative health programs
• is financed by payments made by CMS to Medicare
Advantage contractors that would have otherwise been paid
under Parts A and B to providers and suppliers
Medicare Part D
• is a prescription drug benefit for Medicare beneficiaries, added
as of January 1, 2006
• includes coverage for outpatient prescription drugs, prescribed
biological products, insulin (including supplies), and vaccines
• is administered by private Prescription Drug Plans
• is financed by premiums paid by Medicare beneficiaries
• generally carries a deductible, co-insurance, and a monthly
premium
Medicare and Medicaid programs are administered by
the Centers for Medicare and Medicaid Services (CMS),
which provides operational direction and policy
guidance to health care providers and suppliers. Find
them online at www.cms.gov.
The Office of Inspector General (OIG), within the Department
of Health and Human Services, is charged with oversight of
the Medicare program, and investigates suspected fraud and
abuse. It imposes civil monetary penalties and administrative
actions, including program exclusion, against health care
providers for fraud and abuse misconduct; and refers cases
of fraud to the Department of Justice and other federal
agencies for further criminal and/or civil action.
The Federal False Claims Act
31 USC § 3279
The False Claims Act
• is a federal statute that covers fraud involving any
federally funded contract or program (including
Medicare and Medicaid)
• is commonly known as the “Lincoln Law” because it
was first enacted to counter fraudulent activities
involving military procurement during the Civil War
• establishes liability for any person who knowingly
presents or causes to be presented a false or
fraudulent claim to the U.S. government for payment
The term “knowingly” is defined to mean
that a person, with respect to information:
• has actual knowledge of falsity of information
in the claim
• acts in deliberate ignorance of the truth or
falsity of the information in a claim
• acts in reckless disregard of the truth or
falsity of the information in a claim
The act does not require proof of specific
intent to defraud the government. Health
care providers can be prosecuted for a
wide variety of conduct that leads to the
submission of fraudulent claims to the
government, such as knowingly making
false statements, double-billing for items
or services, billing for services never
performed, falsifying records, or otherwise
causing a false claim to be submitted.
For purposes of the False Claims Act, a “claim”
includes any request or demand for money that is
submitted to the U.S. government or its contractors.
• Health care providers and suppliers who violate the False
Claims Act can be subject to civil monetary penalties
ranging from $5500 to $11000 for each false claim
submitted.
• Providers and suppliers can also be required to pay 3
times the amount of damages sustained by the
government.
• If a provider or supplier is convicted of a False Claims Act
violation, the OIG may seek to exclude him/her/it from
participation in federal health care programs.
Examples of Health Care Fraud:
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Billing for services not rendered or goods not provided
Falsifying certificates of medical necessity and billing for services
not medically necessary
Billing separately for services that should be a single service (unbundling)
Falsifying treatment plans or medical records to maximize
payments
Failing to report overpayments or credit balances
Duplicate billing
Unlawfully giving health care providers inducements in exchange
for referrals
Physician billing for services provided by interns, residents, and
fellows in a teaching hospital
Qui Tam “Whistleblower” Provisions
• Designed to encourage individuals to report
misconduct involving False Claims Act
• Allows any person with actual knowledge of
allegedly false claims to the government to file a
lawsuit on behalf of the government
• Resulted in more than $1.4 billion in settlements
and judgments in 2004-2005
• Recovered $1.1 billion through “whistleblower”
lawsuits
Qui Tam Procedure: The whistleblower must file his/her lawsuit
on behalf of the government in a federal district court, and kept “under
seal” (confidential) during governmental review and investigation of the
allegations
• Rights of Parties:
If the government
determines that the lawsuit
has merit and decides to
intervene, the prosecution of
the lawsuit will be directed
by the Department of
Justice. If the government
decides not to intervene, the
whistleblower may continue
with the lawsuit on his or her
own.
• Awards to Qui Tam
Whistleblowers:
If the lawsuit is successful,
and certain legal
requirements are met, the
whistleblower may receive
an award ranging from 15
to 30 percent of the amount
recovered, and may be
entitled to reasonable
expenses for bringing the
lawsuit.
Furthermore….
• The False Claims Act entitles
whistleblowers to additional relief,
including employment reinstatement,
back pay, and any other compensation
arising from retaliatory conduct against
the whistleblower for filing an action
under the False Claims Act or
committing other lawful acts in a False
Claims Act action.
The Deficit Reduction Act of 2005 offered an
incentive to states to enact their own False
Claims Act requirements. At present, only a
handful of states has enacted their own.
LOUISIANA
IS ONE OF THEM!
Maintains a “hotline” for reporting incidents involving
Billing Practices and Procedures and other fraudulent
activity.
Call 504-988-5142 to report
violations.
Tulane University
Code of Conduct
Compliance with Federal Law for Billing and
Reimbursement of Health Care Services
This Code of Conduct evidences the commitment of Tulane
University (“Tulane”) and its employees, agents, and
contractors to full compliance with all laws and regulations
regarding billing for health care services. Tulane is
committed to ensuring that billing to and reimbursement
from the Medicare program, Medicaid program, and all other
federal health care programs is in compliance with the
regulations and guidance for billing such programs. It is
Tulane’s policy to educate our employees, agents and
contractors about the provisions of the federal and state
laws that prohibit the submission of false claims and false
statements as well as about the whistleblower protections
contained in these laws and the role that these laws play in
detecting and preventing fraud, waste, and abuse.
Tulane University Code of Conduct
• Applicability
• This Code of Conduct applies to all Tulane
employees, agents and contractors, however,
health care providers and individuals supporting
health care providers are more likely to
encounter the situations described in this Code
of Conduct. Those employees, agents and
contractors who provide health care services,
are members of Tulane University Medical
Group, or who provide administrative,
managerial, financial or other support for
Tulane’s health care functions should ensure
that they fully understand this Code of Conduct.
Tulane University Code of Conduct
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State and Federal Laws
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Both federal and Louisiana law prohibit Tulane from knowingly
presenting a false or fraudulent claim to Medicare, Medicaid, or other
federal health care programs. Federal law defines a “false claim” as
knowingly presenting false or fraudulent claims for payment or making
or using a false record or statement to receive payment for a claim.
Louisiana law defines a “false or fraudulent claim” as a claim that a
health care provider (or his agent) submits knowing the claim to be
false, fictitious, untrue, or misleading in regard to any material
information. Examples of false claims could include billing for services
not rendered or goods not provided, falsifying certificates of medical
necessity, falsifying medical records, unauthorized use or unauthorized
assignment of provider billing numbers, and failing to report
overpayments or credit balances. All of the data elements that must be
included in submissions for reimbursement from Medicare, Medicaid
and other federal health care programs must be accurate. Violations of
these federal and state laws can subject Tulane to significant fines and
penalties.
Tulane University Code of Conduct
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Protection of Whistleblowers
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The federal and state laws contain certain protections for
“whistleblowers” who alert the appropriate governmental
authority of a violation of the false claims acts. Under these
laws, any person with actual knowledge of an allegedly false
claim, including employees, agents and contractors, may,
under certain conditions, become a whistleblower under
these statutes and is free to notify the appropriate state or
federal governmental authorities if he/she does not believe
that Tulane is responding appropriately when notified about
potential violations. Employers are prohibited from taking
adverse or retaliatory action against a whistleblower who in
good faith notifies the appropriate governmental authority of
an alleged violation. Whistleblowers may also be entitled to
relief, including employment reinstatement, back pay, and
other compensation arising from retaliatory conduct against
the whistleblower.
Tulane University Code of Conduct
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Tulane’s Policies and Procedures
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Tulane University is committed to promoting ethical practices and to
preventing and detecting fraud, waste, and abuse. Tulane
systematically reviews its compliance with the rules and regulations of
Medicare, Medicaid, and other federal payors. Tulane also has in place
compliance procedures for audits, personnel training and continuing
education. Tulane’s compliance personnel regularly apprise themselves
and the organization of current state and federal statutory and
regulatory developments to ensure that Tulane is compliant with the
rules governing federal and state health care programs claims
submissions.
In addition, Tulane relies on its employees to notify it of any potential
inaccurate billing so that we are not accused of violating the laws that
prohibit the submission of false claims to the government. Tulane
makes it a part of the duty of all employees to assist it this commitment
to accurate billing by reporting any potential improprieties without fear of
retaliation. Tulane employees may report potential billing violations
directly to their supervisor or to the “hotline” maintained by Tulane for
this purpose, which can be reached at 504-862-8698. Alternatively,
information on the hotline and reporting any potential improprieties can
be found at http://www.tulane.edu/%7Eaudit/hotline.shtml.
•
Download the test at
,
answer the questions, and fax it to
the University Privacy and
Contracting Office, 504-988-7777.
http://tulane.edu/counsel/upco/upload/Quiz.pdf
Completion of this material is
MANDATORY, and carries one (1)
Compliance Training Unit credit.