OBJECTIVE:
Sage Memorial Hospital is committed to following all applicable laws and regulations, those that address healthcare fraud, waste and abuse, and the proper billing of Medicare, Medicaid, IHS, and other government funded healthcare programs. This includes the Federal False Claims Act (FCA) and the Program Fraud Civil Remedies Act (PFCRA).
POLICY:
It is the policy of Sage Memorial Hospital that all personnel (including employees, management, physicians, consultants, contractors, and other agents) shall comply with the False Claims Act (FCA) and the Program Fraud Civil Remedies Act (PFCRA).
Reporting Possible Violations
A report of suspected fraud can be made directly to the Office of the Inspector General or the Arizona Health Care Cost Containment System (AHCCCS) without the threat of retaliation.
What should you do if you believe that your organization may have made a false claim? You should immediately contact:
- The Office of the Inspector General directly by calling 800-447-8477 or submitting a complaint at https://oig.hhs.gov/fraud/report-fraud/
If you suspect fraud or financial misconduct, click the button below:
The Arizona Health Care Cost Containment System (AHCCCS), suspected fraud report on AHCCCS members and providers by calling 888-ITS-NOT-OK (888-487-6686) or AHCCCSFraud@azahcccs.gov
If you suspect fraud or financial misconduct, click the button below:
Federal Laws
The Federal False Claims Act (FCA)
The False Claims Act (FCA) is a federal law that prohibits a person or entity, such as the Hospital from “knowingly” presenting or causing to be presented a false or fraudulent claim for payment or approval to the Federal government, and from “knowingly” making, using, or causing to be made a false record or statement to get a false or fraudulent claim paid or approved by the Federal government. The FCA also prohibits a person or entity from conspiring to defraud the government by getting a false or fraudulent claim allowed or paid. These prohibitions extend to claims submitted to Federal health care programs, such as Medicare or Medicaid.
The FCA covers fraud involving any federally funded contract or program, except for tax fraud.
The FCA broadly defines the terms “knowing” and “knowingly.” Specifically, knowledge will have been proven for purposes of the FCA if the person or entity:
(i) has actual knowledge of the information
(ii) acts in deliberate ignorance of the truth or falsity of the information; or
(iii) acts in reckless disregard of the truth or falsity of the information.
The law specifically provides that a specific intent to defraud is not required to prove that the law has been violated.
A person or entity found guilty of violating this law is obligated to repay all of the falsely obtained reimbursement and will be liable for a civil penalty between $12,537 to $25,076, plus three times the amount of damages sustained by the government as a result of the prohibited conduct for each violation of the Act. In addition to being liable for damages and civil penalties, violating the FCA can subject a person or entity to exclusion from participation in Federal health care programs, such as Medicare and Medicaid.
Whistleblower (Relators) Protection
Private persons are permitted to bring civil actions for violations of the FCA on behalf of the United States (also known as “qui tam” actions) and are entitled to receive percentages of monies obtained through settlements, penalties and/or fines collected. Persons bringing these claims (also known as “relators” or “whistleblowers”) are granted protection under the law. Specifically, any whistleblower who is discharged, demoted, suspended, threatened, harassed, or discriminated against because of lawful acts by the employee in furtherance of an action under the act is entitled to all relief necessary to make the employee whole. Such remedies may include reinstatement with seniority, double back pay, interest, special damages sustained as a result of discriminatory treatment, and attorneys’ fees and costs.
The Program Fraud Civil Remedies Act (“PFCRA”)
This Federal law makes it illegal for a person or entity to make, present or submit (or cause to be made, presented or submitted) a “claim” (i.e., a request, demand or submission) for property, services, or money to an “authority” (i.e., an executive department of the Federal Government, e.g., the U.S. Department of Health and Human Services, which oversees Medicare and Medicaid programs) when the person or entity “knows or has reason to know” that the claim:
(i) is false, fictitious, or fraudulent; or
(ii) includes or is supported by any written statement which asserts a material fact which is false, fictitious, or fraudulent; or
(iii) includes or is supported by any written statement which omits a material fact, is false, fictitious, or fraudulent because of the omission and is a statement in which the person or entity has a duty to include such material fact; or
(iv) is for the provision of items or services which the person or entity has not provided as claimed.
In addition, it is illegal to make, present or submit (or cause to be made, presented, or submitted) a written “statement” (i.e., a representation, certification, affirmation, document, record, or accounting or bookkeeping entry made with respect to a claim or to obtain the approval or payment of a claim) if the person or entity “knows or has reason to know” such statement:
(i) asserts a material fact which is false, fictitious, or fraudulent or
(ii) omits a material fact making the statement false, fictitious, or fraudulent because of the omission.
The Program Fraud Civil Remedies Act (“PFCRA”)
Similar to the FCA, the PFCRA broadly defines the terms “knows or has reason to know” as
(i) having actual knowledge that the claim or statement is false, fictitious, or fraudulent;
(ii) acting in deliberate ignorance of the truth or falsity of the claim or statement; or
(iii) acting in reckless disregard of the truth or falsity of the claim or statement.
The law specifically provides that a specific intent to defraud is not required to prove that the law has been violated.
The PFCRA provides for civil penalties of not more than $12,537 for each false claim paid by the government, and, in certain circumstances, an assessment of twice the amount of each claim.
In addition, if a written statement omits a material fact and is false, fictitious or fraudulent because of the omission and is a statement in which the person or entity has a duty to include such material fact and the statement contains or is accompanied by an express certification or affirmation of the truthfulness and accuracy of the contents of the statement, the law provides for a penalty of not more than $12,537 to be imposed for each such statement.
Arizona State Laws
The state of Arizona does not have its own FCA but following are state laws that apply to filing fraudulent claims with the government.
1. §§36-2918, 36-2957, A.R.S.
It is unlawful for a person to make a claim to the state, the AHCCCS administration, or a contractor for an item or service the person knows was not provided, is false or fraudulent, or may not be made by the health care system for specified reasons such as medical necessity.
2. §§13-2310, 13-2311, 36-2918, 36-2957, A.R.S.
Making a claim as described above may be subject to both criminal and civil penalties.
3. §23-1501, A.R.S.
An employee can make a claim against an employer if that employee is terminated in retaliation for disclosing information in a reasonable manner that the employer or an employee of the employer has violated the law.
4. §13-3713, A.R.S.
It is a felony offense for a person to knowingly offer, deliver, receive or accept compensation in any form for referring a patient, client or customer to any individual, pharmacy, laboratory, clinic or health care institution providing medical or health-related services or items.