Source: https://ukhealthcare.uky.edu/staff/corporate-compliance/false-claims-policy
Timestamp: 2020-01-19 13:37:07
Document Index: 439661286

Matched Legal Cases: ['§ 205', '§ 3801', '§ 3729', '§ 3729', '§ 205', '§ 61']

False Claims Policy | UK HealthCare
UNIVERSITY OF KENTUCKY HOSPITAL - FIRST ISSUED: 08/07
CHANDLER MEDICAL CENTER Corporate Compliance POLICY - CURRENT AS OF: 08/07
SUBJECT: False Claims
SEE ALSO: Corporate Compliance, Ky. Rev. Stat. Ann. §§ 205.8451, .8463, .8465, & .8467, 31 U.S.C. §§ 3801-3812, 31 U.S.C. §§ 3729-3733, Deficit Reduction Act of 2005, Sections 6031, 6032
PURPOSE: The purpose of this policy is to satisfy certain requirements or anticipated requirements in connection with provisions of Deficit Reduction Act of 2005.
PROCEDURE: UK/KMSF shall make this policy available to all employees, including management, and of any contractors and agents. UK/KMSF shall also revise this policy as necessary to comply with changes in the law.
What are the false claims laws, qui tam provisions, and whistleblower protections provided to UK/KMSF employees, including management, and of any contractors and agents?
Fraud and Abuse are Legal terms and are defined below:
Fraud is defined as "intentional deception or misrepresentation that individuals make, knowing it to be false, and that could result in some unauthorized benefit to them."
Abuse is defined as "incidents or practices that are inconsistent with accepted sound medical practices. Abuse may directly or indirectly result in unnecessary costs to the program, improper reimbursement, or payment for services that fail to meet professionally recognized standards of care, or that are medically necessary."
Originally enacted in 1865 by Congress, the federal Civil False Claims Act, 31 U.S.C. § 3729, et seq. ("FCA"), uncovered several instances of fraud among defense contractors during the Civil War. President Abraham Lincoln wanted this legislation during the Civil War to address widespread abuse by military contractors who were selling defective products and materials to the Union Army and charging excessively high prices for their services.
The current FCA, which was amended in 1986, provides the government with authority to identify and recover monies paid out fraudulently. The government has had billions of dollars returned to it because of the current FCA. Corporations and individuals have, either through litigation or settlement, returned monies or paid fines because of allegations of improperly obtaining federal health care program finds. FCA is a proven means to detect fraud, by encouraging individuals, called "whistleblowers" or "relators," to uncover and report fraud to the government. The ability for whistleblowers to report fraud creates a strong incentive for UK/KMSF to continue its vigilance in their pursuit of compliance and avoid liability for multiple damages and penalties under the FCA.
The federal FCA prohibits any individual or entity from knowingly submitting false or fraudulent claims, causing submission of such claims, making a false record or statement in order to secure payment from the federal government for such a claim, or conspiring to get coverage for such a claim so it is paid. Under the statute the terms "knowing" and "knowingly" mean that a person:
3. Qui Tam & Whistleblower Protection Provisions
The Commonwealth of Kentucky has not adopted any false claims acts or statutes that contain qui tam or whistleblower provisions that are similar to those found in the federal False Claims Act. It has adopted, however, a generally applicable Medicaid anti-fraud statute that makes it unlawful for a person to submit false and fraudulent claims to the Kentucky Medicaid program. The statute also makes it unlawful for any person to present false information regarding an institution or facility so the Commonwealth may license or recertify it as a Medicaid provider. Violations of the statute are both civil and criminal offenses and are punishable by substantial fines and imprisonment. Kentucky Revised Statutes ("KRS") §§ 205.8451, 205.8463, 205.8465, and 205.467.
The Commonwealth's Office of the Inspector General of the Cabinet for Health and Family Services ("State OIG") is responsible for investigating and detecting the existence of fraud and abuse and exercising oversight of Medicaid provider participants. The State OIG works with the federal government. Federal agencies that the State OIG works with may include federal OIGs, the US Attorney's Office, the Department of Health and Human Services, the Federal Bureau of Investigation, and the Kentucky Attorney General's Office. The State OIG toll-free hot line to report instances of Medicaid fraud is (800) 372-2970.
The Commonwealth of Kentucky recognizes a public policy exception to the "employment at will doctrine" when its courts review cases involving whistleblowers and their employers. Under this exception, an employer could not terminate an employee for bringing to its attention, or the attention or federal or state authorities, issues such as up-coding, lack of medical necessity, etc. In addition, KRS § 61.102, which is designed to protect certain public employees from reprisal, may be applicable.
In addition, Kentucky's criminal code has various laws for prosecuting fraud including the provisions of KRS Chapter 514 (theft and related offenses), KRS Chapter 516 (forgery and related offenses), Chapter 517 (business and commercial frauds), Chapter 518 (miscellaneous crimes affecting businesses, occupations and professions), Chapter 519 (obstruction of public administration) and Chapter 523 (perjury and related offenses). Also, there are other criminal statutes that the Commonwealth Attorney General may be able to use to prosecute individuals and entities for actions that are fraudulent or in some way jeopardize the future financial integrity of the Medicare or Medicaid program.
UK/KMSF Policies & Procedures for Detecting & Preventing Fraud, Waste, & Abuse
UK/KMSF Prohibitions Against Retaliation & Whistleblower Rights & Protections