Bellefaire Jcb Compliance With The Deficit Reduction Act

Deficit Reduction Act. Section 6032 of the Deficit Reduction Act of 2005 (DRA) mandates that organizations/entities like Bellefaire who receive Medicaid payments of $5,000,000 or more put in place policies that educate employees, contractors and agents about the federal False Claims Act and any relevant state law that pertains to civil or criminal penalties for false claims/statements and whistleblower protections. The education is to include the role of the laws in preventing and detecting fraud, waste, and abuse in federal health care programs.

False Claims Act. The False Claims Act (hereafter, FCA) is a federal law. The purpose of the FCA is to provide the government with a vehicle for recovery of government funds received by way of fraud, waste or abuse. The FCA provides this vehicle through a mechanism that allows both the government and/or a private individual to file a civil lawsuit against anyone who commits fraud, waste or abuse in the receipt of government funds.

The FCA holds responsible anyone who 1.) submits, or 2.) causes someone else to submit, a false or misleading claim for government funds. Under the FCA, “anyone” can be an individual or a business, and a “claim” is simply a demand for money to be paid in some part by the government. Bellefaire submits a “claim” within the definition/scope of the FCA every time an employee submits a progress note to be billed to Medicaid because the service reportedly provided in the progress note is paid for in part by the federal government and in part by the state government.

Examples of fraud include, but are not limited to:

1. Billing for a service that was not provided.
2. Billing for more time than was actually spent providing the service.
3. Double billing for a single service that was provided.
4. Knowingly prescribing or delivering services that are not medically necessary.
5. Providing services to client #1 and billing client #2’s Medicaid.
6. Knowingly billing for a service different than the service you provided in order to receive an increased reimbursement rate.

Examples of Abuse include, but are not limited to:

1. Negligently providing services that are not medically necessary.
2. Negligently providing a service – failing to provide the service in accordance with the Ohio Administrative Code (OAC) standards.
3. Including non-billable services in a billing.
4. Failing to document the services you provided a.) at all, b.) in a timely manner, and/or c.) according to the OAC standards.

FCA Whistleblower Incentives. A whistleblower is a person with insider knowledge who reports misconduct to the government. The FCA provides incentives to whistleblowers for reporting fraud, waste, or abuse to the government. If the defendant is found guilty these incentives include; a portion of the money recovered from the defendant, and the payment by the defendant of the private individual’s attorney’s fees.

FCA Whistleblower Protections. The FCA also provides whistleblower protections for employees who report fraud, waste, or abuse. When a whistleblower reports misconduct, the case remains sealed for 60 days. This means that it is not accessible to the public, including the employee’s employer. Further, the FCA prohibits an employer from discriminating or retaliating against the employee for his or her involvement in a FCA action. If the employer does discriminate or retaliate against the whistleblower, the whistleblower may receive damages that could include reinstatement to his or her job, double the amount of back pay owed to the employee plus interest, and compensation for special damages that include attorney’s fees spent by the employee to enforce the whistleblower protections guaranteed under the FCA.

Ohio Law. Like the DRA, ORC §5111.10.1, entitled Fraud, Waste and Abuse Prevention and Detection, is an Ohio law that mandates providers who receive Medicaid payments of $5,000,000 or more put in place policies that educate employees, contractors and agents about the FCA and Ohio laws. This education is to include 1.) the prohibition of fraud, waste, and abuse, 2.) the penalties for committing fraud, waste, and abuse, and 3.) whistleblower protections.

The relevant state law on filing false claims is found in ORC §2913.40 entitled Medicaid Fraud. The primary difference between this law and the FCA is that in Ohio, only “providers” can be found civilly liable for Medicaid fraud, waste or abuse. A “provider” is a person or entity that has a contract with the Ohio Department of Jobs and Family Services (ODJFS) to receive Medicaid payments. Under the FCA, and individual can be prosecuted for Medicaid fraud, waste, or abuse.

Ohio Law Penalties. Penalties for providers committing Medicaid fraud, waste or abuse in Ohio include, but are not limited to, payment of civil penalties that could be as much as three times the amount wrongfully paid to them plus interest, a fine between five and ten thousand dollars for each false filing, and termination of the provider agreement with ODJFS for up to five years. Termination of the provider agreement would prohibit the provider from receiving Medicaid funding.

Further, committing fraud in Ohio could be a criminal offense that ranges from a first degree misdemeanor to a third degree felony, depending on the amount of money fraudulently received. Unlike the civil penalties, the criminal penalties in Ohio may be imposed on individuals. Those individuals who hold professional state licenses may also have their license suspended or revoked, either temporarily or permanently, should their licensing board determine that they engaged in fraudulent activity.

Ohio Whistleblower Protections. In Ohio, §4113.52 entitled, Right of Employee to Report Violation of Law by Employer or Fellow Employee, authorizes employees to report possible misconduct to their supervisor or identified responsible administrator. If the employer does not respond to the employee within 24 hours after receiving the complaint, the employee is authorized to notify any of the following: 1.) the prosecuting attorney of the county, 2.) law enforcement, 3.) any governmental organization/entity with regulatory authority over the employer, or 4.) the inspector general.

Should the employee choose to take any of the following actions, the employer is prohibited from 1.) removing or suspending the employee, 2.) withholding salary increases or other benefits to which the employee is otherwise entitled, 3.) transferring or reassigning the employee, 4.) denying the employee a promotion that otherwise would have been received, or 5.) reducing the employee in pay or position. If the employer chooses to take any of the actions listed above, the employee may file a civil action against the employer so long as it is filed within 180 days from the date the retaliatory action was taken. Remedies for the employee may include 1.) reinstatement to the same or similar position, 2.) payment of back pay and other fringe benefits denied to the employee, possible with interest, and 3.) payment of litigation costs.

At Bellefaire the responsible/authorized administrator to report possible misconduct to is the Corporate Compliance Officer. Bellefaire policy is in line with Ohio law in that all employees are encouraged to notify the Corporate Compliance Officer in the event of any possible misconduct, and any retaliation against employees is absolutely prohibited.

There is a burden on the reporting employee. The reporting employee must make a reasonable effort to ensure that the information reported is accurate. If it is demonstrated through the investigation that the employee purposely, knowingly, or recklessly reported incorrect of false information, the employee is subject to disciplinary action by the employer, up to and including termination. The employee may also face sanctions by their professional licensing board. If the determination is made at trial that the employee purposely, knowingly, or recklessly reported incorrect or false information, the employee may be responsible for payment of the employer’s litigation costs.

Should you have insider knowledge that you would like to share with the Ohio government, you may call any of the following entities charged with investigating suspected Medicaid fraud, waste, or abuse:

1. The Ohio Auditor of State (AOS) at 7-800-282-0370
2. Medicaid Fraud Control Unit (MCFU) at 1-800-642-2873
3. The Office of Research, Assessment, and Accountability (ORAA) at 614-466-7936.

Bellefaire Policies Aimed at Preventing Fraud, Waste, and Abuse. This Corporate Compliance Plan incorporates into policy the Agency practices targeted at preventing fraud, waste and abuse. In addition, the Corporate Compliance Officer, or his or her designee, conducts monthly corporate compliance audits that include record reviews and phone surveys to verify that service has occurred as documented in the client record. In addition, in-home community based staff/providers are required to obtain the signature of the client/service recipient, or the client’s guardian, at the time of service in order to verify that the service occurred. Program supervisors in the in-home programs are also required to review records and report any potential misconduct to the Corporate Compliance Officer. Finally, the Risk Management Department conducts routine audits of the clinical records in all agency programs/department. The staff members in the Risk Management Department are trained to report any potential misconduct to the Corporate Compliance Officer. It is through these practices that the Agency attempts to prevent fraud, waste, and abuse.