Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-820 - Employee education about false claims recoveries

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The following words and terms
				  when used in this part shall have the following meanings unless the context
				  clearly indicates otherwise:
"Contractor" or "agent" includes any contractor,
					 subcontractor, agent, or other person that or who, on behalf of the entity,
					 furnishes, or otherwise authorizes the furnishing of, Medicaid health care
					 items or services, performs billing or coding functions, or is involved in the
					 monitoring of health care provided by the entity.
"Employee" means any officer or employee of the
					 entity.
"Entity" means a governmental agency, organization, unit,
					 corporation, partnership, or other business arrangement (including any Medicaid
					 managed care organization, irrespective of the form of business structure or
					 arrangement by which it exists), whether for-profit or not-for-profit, which
					 receives or makes payments, under a state plan approved under title XIX or
					 under any waiver of such plan, totaling at least $5,000,000 annually. A
					 governmental component providing Medicaid health care items or services for
					 which Medicaid payments are made would qualify as an "entity" (e.g., a state
					 mental health facility or school district providing school-based health
					 services). A government agency that merely administers the Medicaid program, in
					 whole or part (e.g., managing the claims processing system or determining
					 beneficiary eligibility), is not, for these purposes, considered to be an
					 entity.
B. The Medicaid
				  agency meets the requirements regarding establishment of policies and
				  procedures for the education of employees of entities covered by §
				  1902(a)(68) of the Social Security Act (the Act) regarding false claims
				  recoveries and methodologies for oversight of entities' compliance with these
				  requirements.
C. Provider
				  requirements.
1. If an entity furnishes items
				  or services at more than a single location or under more than one contractual
				  or other payment arrangement, the provisions of § 1902(a)(68) of the Act
				  apply if the aggregate payments to that entity meet the $5,000,000 annual
				  threshold. This applies whether the entity submits claims for payments using
				  one or more provider identification or tax identification numbers.
2. An entity will have met the $5,000,000
				  annual threshold as of January 1, 2007, if it received or made payments in that
				  amount in federal fiscal year 2006. Future determinations regarding an entity's
				  responsibility stemming from the requirements of § 1902(a)(68) of the Act
				  will be made by January 1 of each subsequent year based upon the amount of
				  payments an entity either received or made under the state plan during the
				  preceding federal fiscal year.
3.
				  The entity must establish and disseminate written policies that must also be
				  adopted by its contractors or agents. Written policies may be on paper or in
				  electronic form, but must be readily available to all employees, contractors,
				  or agents. The entity need not create an employee handbook if none already
				  exists.
4. An entity shall
				  establish written policies for all employees (including management), and of any
				  contractor or agent of the entity, that include detailed information about the
				  False Claims Act and the other provisions named in § 1902(a)(68)(A) of the
				  Act, including the Virginia Fraud Against Taxpayers Act (§ 8.01-216.1 et
				  seq. of the Code of Virginia). The entity shall include in those written
				  policies detailed information about the entity's policies and procedures for
				  detecting and preventing waste, fraud, and abuse. The entity shall also include
				  in any employee handbook a specific discussion of the laws described in the
				  written policies, the rights of employees to be protected as whistleblowers and
				  a specific discussion of the entity's policies and procedures for detecting and
				  preventing fraud, waste, and abuse.