FEDERAL AND STATE FALSE CLAIMS ACTS


Policy
Royale Care will comply with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal and state health care programs, including Medicare and Medicaid.  Every Royale Care employee, as well as employees of Royale Care Contractors will receive education and information regarding these regulations.
 
Purpose
This policy describes the manner in which Royale Care employees and contractors are compliant with the Deficit Reduction Act of 2005 (DRA), provides an overview of state and federal false claims acts, and describes Royale Care’s internal mechanisms to help prevent and detect fraud, waste and abuse in the federal and state health care programs.  Under the DRA, any entity which receives Medicaid payments of $5 million or more is required to provide information to its employees, contractors and agents about the federal and applicable state false claims acts, the rights of employees to be protected as whistleblowers, and the organization’s policies and procedures for detecting and preventing fraud, waste and abuse.
 
Scope:
Applies to all employees and contractors who, are actively employed or associated in the operation or billing of any program funded by the Department of Medical Assistance.
 
False Claims Laws
 
 
  • Federal False Claims Act:  The Federal False Claims Act:
    • Prohibits knowingly submitting (or causing to be submitted) to the federal government a false or fraudulent claim for payment or approval.
    • Prohibits knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved by a state Medicaid program, the federal government or its agents, such as a fiscal intermediary or other claims processor.
    • Prohibits making or using (or causing to be made or used) a false statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the U.S. government.
    • Prohibits conspiring to defraud the federal government by getting a false or fraudulent claim allowed or paid.
    • This law applies to claims filed by Royale Care for reimbursement for services provided to beneficiaries under the Medicare or Medicaid programs. 
    • Civil penalties can be imposed on any person or entity that violates the federal False Claims Act, including monetary penalties of $5,500 to $11,000 as well as damages of up to three times the federal government’s damages resulting from each false claim. 
 
  • Federal Fraud Civil Remedies:  The federal Program Fraud Civil Remedies Act of 1986 allows the government to impose civil penalties against any person who makes, presents or submits (or causes to be made, presented or submitted) false, fictitious or fraudulent claims or written statements to designated federal agencies, including the U.S. Department of Health and Human Services.
 
  • Massachusetts False Claims Act: The Massachusetts False Claims Act (MFCA) prohibits knowingly presenting (or causing to be presented) to Massachusetts a false or fraudulent claim for payment or approval. The MFCA also:
 
  • Prohibits knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved by Massachusetts or any political subdivision thereof.
  • Prohibits conspiring to defraud Massachusetts or any political subdivision thereof through the allowance or payment of a fraudulent claim, and knowingly making or using (or causing to or to be made or used) a false record or statement to conceal, avoid, or decrease an obligation to pay or to transmit money or property to Massachusetts or any political subdivision thereof.
  • Anyone who enters into an agreement or contract with Massachusetts or a political subdivision, knowing that the information contained therein is false, violates the MFCA.
  • In addition, anyone who benefits from a false claim that was mistakenly submitted violates the MFCA if he or she does not disclose the false claim within a reasonable time after he or she discovers it.
  • This law applies to claims filed by Royale Care for reimbursement for services provided to beneficiaries under the Massachusetts Medicaid program (MassHealth). 
  • Civil penalties can be imposed on any person or entity that violates the MFCA, including monetary penalties of $5,000 to $10,000 as well as damages of up to three times Massachusetts’ damages resulting from each false claim. 
 
  • “Whistleblower” and Whistleblower Protections:  The federal False Claims Act and the MFCA permit private citizens with knowledge of fraud or attempted fraud against the U.S. or Massachusetts state or local government to file suit on behalf of the federal or Massachusetts government against the person or business that committed or attempted the fraud. If the action is successful, the individual who brought the lawsuit – known as a “qui tam” relator or a “whistleblower” – is entitled to a percentage of the amount recovered.  The federal False Claims Act and the MFCA prohibit retaliation against any employee for taking lawful action in investigating, filing or participating in a whistleblower action. The MCFA prohibits an employer from enforcing any rule or policy that prohibits an employee from disclosing information to a government or law enforcement agency regarding false claims or from initiating a false claims action. 
 
Procedure
1.  Employees’ Responsibilities: 
  1. Employees will comply with Royale Care Federal and State False Claims Acts Policy which:
    1. Prohibits the submission of false claims and engaging in fraudulent or abusive activities or transactions,
    2. Requires the reporting of any suspected misconduct, including suspected violations of Royale Care policies or procedures or federal or state laws, as required by the Corporate Compliance Program.
      1. Reports of potential improper activities can be made by an employee to the Compliance Officer, Human Resources department, senior management, a supervisor, or to the Compliance Integrity Hot Line at 508-667-5953.
 
Royale Care expressly prohibits retaliation against employees who, in good faith, report or participate in the investigation of any compliance concerns, or who, in good faith, investigates, files or participates in a whistleblower action as permitted by the federal False Claims Act or the MFCA.
 
  1. Managers’ Responsibilities:
    1. All Royale Care managers must inform their employees that Royale Care does not tolerate or condone activities that result in or contribute to the submission of false claims to any federal or state health care programs, including Medicare and Medicaid.
    2. Managers must take appropriate action if he or she learns about possible fraudulent or abusive activities or transactions.
    3. Managers must also educate and train all employees on Royale Care’s policies about detecting fraud and abuse and prohibiting the filing of false claims. 
      1. Federal False Claims Act.
      2. MFCA.
      3. Massachusetts false and fraudulent claims laws.
      4. Federal Program Fraud Civil Remedies Act of 1986.
      5. All whistleblower protections available under these laws.
 
  1. Royale Care Responsibilities:
    1. Royale Care policy on Suspected Fraud, Misconduct and Dishonesty provides specific details regarding internal policies, procedures and individuals’ responsibilities to prevent and detect fraud, waste and abuse.
    2. Additionally, the policy provides for internal investigations and prompt resolution of alleged violations. 
      1. Depending on the nature of the violation, investigations of integrity or compliance issues may be performed by Human Resources, legal counsel and/or other appropriate staff or consultants.
    3. Royale Care provides training for new and current employees, to educate all Royale Care employees about the federal False Claims Act, MFCA, Massachusetts false and fraudulent claims laws, the federal Program Fraud Civil Remedies Act of 1986 and all whistleblower protections available under these laws.
    4. Royale Care’s makes available to all employees this Policy in the Personnel Policy Manual.
 
  1. Agents’ and Contactors’ Responsibilities:
    1. Each contractor that supplies services to Royale Care is required to demonstrate that its employees are educated and trained on the federal False Claims Act, MFCA, Massachusetts false and fraudulent claims laws, the federal Program Fraud Civil Remedies Act of 1986 and all whistleblower protections available under these laws, either by agreeing to provide this Policy and Royale Care materials to its employees, or by demonstrating to Royale Care satisfaction that it has equivalent policies and training programs in place.
 


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