Source: https://www.bronxcare.org/es/sobre-nosotros/compliance-policy/
Timestamp: 2019-10-19 23:04:26
Document Index: 318235327

Matched Legal Cases: ['§3729', '§ 3729', '§3801', '§187', '§145', '§145', '§145', '§ 366', '§175', '§ 175', '§175', '§175', '§175']

Compliance Policy | BronxCare Health System
Compliance With Applicable Federal and State
Overview of Laws Regarding False Claims and Whistleblower Protections
The BronxCare Health System (the “Hospital”) is committed to complying with the requirements of Section 6032 of the Federal Deficit Reduction Act of 2005, and preventing and detecting any fraud, waste, or abuse in the Hospital. To this end, the Hospital maintains a compliance program and strives to educate its work force on fraud and abuse laws, including the importance of submitting accurate claims and reports to the Federal and State governments.
The Hospital has instituted various procedures, which are set forth in the our Compliance Manual, to ensure compliance with these laws and to assist us in preventing fraud, waste and abuse in federal health care programs. In furtherance of this policy and to comply with the Deficit Reduction Act, the Hospital disseminates this policy to all employees (including management, contractors and other agents) to ensure that such persons are aware of certain relevant Federal and State laws, and that submission of a false claim can result in significant administrative and civil penalties under the Federal False Claims Act and other New York State laws.
To assist the Hospital in meeting its legal and ethical obligations, any employee who reasonably suspects or is aware of the preparation or submission of a false claim or report or any other potential fraud, waste, or abuse related to a Federal or State funded health care program is required to report such information to his/her supervisor and the Compliance Officer (or Compliance Liaison). Any employee who reports such information will have the right and opportunity to do so anonymously and will be protected against retaliation for coming forward with such information both under our internal compliance policies and procedures and Federal and State law. However, the Hospital retains the right to take appropriate action against an employee who has participated in a violation of Federal or State law or Hospital policy or intentionally and maliciously reports a false claim.
The Hospital commits itself to investigate any suspicions of fraud, waste, or abuse swiftly and thoroughly and requires all employees to assist in such investigations. If an employee believes that the Hospital is not responding to his or her report within a reasonable period of time, the employee shall bring these concerns about the Hospital’s perceived inaction to the Corporate Compliance Officer or Compliance Liaison. Failure to report and disclose or assist in an investigation of fraud and abuse is a breach of the employee’s obligations to the Hospital and may result in disciplinary action, up to, and including termination.
RELEVANT LAWS RELATING TO FILING FALSE CLAIMS:
A. The Federal False Claims Act (31 USC §§3729-3733)
(C) conspires to commit [the above violations]; . . . or
is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person...
(1) the terms "knowing" and "knowingly"
(B) require no proof of specific intent to defraud; and
(2) the term “claim”
(ii) is made to a contractor, grantee, or other recipient, if the money or property is to be spent or used on the Government's behalf or to advance a Government program or interest, and if the United States Government (I) provides or has provided any portion of the money or property requested or demanded; or
(4) the term “material” means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property. 31 U.S.C. § 3729.
In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government or a contractor of the federal government that he or she knows (or should know) is false. An example may be a physician who submits a bill to Medicare for medical services she knows she has not provided.
The False Claims Act also imposes liability on an individual who may knowingly submit a false record in order to obtain payment from the government. An example of this may include a government contractor who submits records that he knows (or should know) are false and that indicate compliance with certain contractual or regulatory requirements.
The third area of liability includes those instances in which someone may obtain money from the federal government to which he may not be entitled, and then uses false statements or records in order to retain the money. An example of this so-called “reverse false claim” may include a hospital who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare program.
B. Administrative Remedies for False Claims (31 USC §§3801– 3812)
1. NY False Claims Act (State Finance Law, §§187-194) -- The NY False Claims Act closely tracks the federal False Claims Act. It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. The penalty for filing a false claim is $6,000 -$12,000 per claim and the recoverable damages are between two and three times the value of the amount falsely received. In addition, the false claim filer may have to pay the government’s legal fees.
2. Social Services Law §145-b -- False Statements It is a violation to knowingly obtain or attempt to obtain payment for items or services furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment or other fraudulent scheme or device. The State or the local Social Services district may recover three times the amount incorrectly paid. In addition, the Department of Health may impose a civil penalty of up to $2,000 per violation. If repeat violations occur within 5 years, a penalty up to $7,500 per violation may be imposed if they involve more serious violations of Medicaid rules, billing for services not rendered or providing excessive services.
3. Social Services Law §145-c -- Sanctions If any person applies for or receives public assistance, including Medicaid, by intentionally making a false or misleading statement, or intending to do so, the person’s, the person’s family’s needs are not taken into account for 6 months if a first offense, 12 months if a second (or once if benefits received are over $3,900) and five years for 4 or more offenses.
1. Social Services Law §145 -- Penalties Any person who submits false statements or deliberately conceals material information in order to receive public assistance, including Medicaid, is guilty of a misdemeanor.
2. Social Services Law § 366-b -- Penalties for Fraudulent Practices
(a) Any person who obtains or attempts to obtain, for himself or others, medical assistance by means of a false statement, concealment of material facts, impersonation or other fraudulent means is guilty of a Class A misdemeanor.
(b) Any person who, with intent to defraud, presents for payment and false or fraudulent claim for furnishing services, knowingly submits false information to obtain greater Medicaid compensation or knowingly submits false information in order to obtain authorization to provide items or services is guilty of a Class A misdemeanor.
3. Penal Law Article 155, Larceny -- The crime of larceny applies to a person who, with intent to deprive another of his property, obtains, takes or withholds the property by means of trick, embezzlement, false pretense, false promise, including a scheme to defraud, or other similar behavior. It has been applied to Medicaid fraud cases.
(a) Fourth degree grand larceny involves property valued over $1,000. It is a Class E felony.
(b) Third degree grand larceny involves property valued over $3,000. It is a Class D felony.
(c) Second degree grand larceny involves property valued over $50,000. It is a Class C felony.
(d) First degree grand larceny involves property valued over $1 million. It is a Class B felony.
4. Penal Law Article 175, False Written Statements --Four crimes in this Article relate to filing false information or claims and have been applied in Medicaid fraud prosecutions:
(a) §175.05, Falsifying business records involves entering false information, omitting material information or altering an enterprise’s business records with the intent to defraud. It is a Class A misdemeanor.
(b) § 175.10, Falsifying business records in the first degree includes the elements of the §175.05 offense and includes the intent to commit another crime or conceal its commission. It is a Class E felony.
(c) §175.30, Offering a false instrument for filing in the second degree involves presenting a written instrument (including a claim for payment) to a public office knowing that it contains false information. It is a Class A misdemeanor.
(d) §175.35, Offering a false instrument for filing in the first degree includes the elements of the second degree offense and must include an intent to defraud the state or a political subdivision. It is a Class E felony.
5. Penal Law Article 176 -- Insurance Fraud Applies to claims for insurance payment, including Medicaid or other health insurance and contains six crimes.
(a) Insurance Fraud in the 5th degree involves intentionally filing a health insurance claim knowing that it is false. It is a Class A misdemeanor.
(b) Insurance fraud in the 4th degree is filing a false insurance claim for over $1,000. It is a Class E felony.
(c) Insurance fraud in the 3rd degree is filing a false insurance claim for over $3,000. It is a Class D felony.
(d) Insurance fraud in the 2nd degree is filing a false insurance claim for over $50,000. It is a Class C felony.
(e) Insurance fraud in the 1st degree is filing a false insurance claim for over $1 million. It is a Class B felony.
(f) Aggravated insurance fraud is committing insurance fraud more than once. It is a Class D felony.
6. Penal Law Article 177 -- Health Care Fraud Applies to claims for health insurance payment, including Medicaid, and contains five crimes:
(a) Health care fraud in the 5th degree is knowingly filing, with intent to defraud, a claim for payment that intentionally has false information or omissions. It is a Class A misdemeanor.
(b) Health care fraud in the 4th degree is filing false claims and annually receiving over $3,000 in aggregate. It is a Class E felony.
(c) Health care fraud in the 3rd degree is filing false claims and annually receiving over $10,000 in the aggregate. It is a Class D felony.
(d) Health care fraud in the 2nd degree is filing false claims and annually receiving over $50,000 in the aggregate. It is a Class C felony.
(e) Health care fraud in the 1st degree is filing false claims and annually receiving over $1 million in the aggregate. It is a Class B felony.
The New York State False Claim Act also provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the Act. Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.