All providers of long term supports and services, and other health care provider organizations, receiving Medicaid funding of more than $5,000,000 annually are required to inform contractors, agents, and staff about: Federal and State False Claim Acts; protections for whistleblowers; and the provider organization’s efforts to prevent and detect fraud and abuse.
This Policy serves to inform Community Bridges’ contractors, agents, and employees of the provisions, penalties, and whistleblower protections associated with Federal and State False Claims Acts, to remind contractors of our good faith efforts to prevent and detect false claims, and to remind employees and inform agents of our Compliance Program.
III. FEDERAL FALSE CLAIMS ACT
The Federal False Claims Act is the primary enforcement mechanism employed by the Federal Government to combat health program fraud. The False Claims Act allows the Government to bring civil or criminal actions in cases where false claims are made with actual knowledge, reckless disregard, or conscious disregard for the falsity of the claim. Specific intent to defraud is not required. The penalties for such false claims can be substantial.
Illegal Actions under the Federal False Claims Act
The Federal False Claims Act prohibits any person or organization from:
Persons or organizations violating the Act are subject to liability 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 as a result of the illegal act/s. In addition, since violations of the law are defined as felonies, those responsible may also be prosecuted and subject to applicable Federal criminal penalties. The Federal Government decides in each case whether to pursue civil and/or criminal remedies based on the situation.
Federal Whistleblower Protections related to False Claims
The Federal False Claim Act includes a provision that allows employees or other private citizens to file a civil lawsuit on behalf of the Government and to request that the Government join in the suit. In return, the citizen may share a percentage of any recovery or settlement provided to the Government. These types of actions are referred to as “qui tam” (who as well) actions, and the individual is a “whistleblower” who brings forward evidence of the alleged wrongdoing. The purpose of qui tam is to provide an incentive for whistleblowers to come forward to help the Government discover and avoid paying fraudulent claims by awarding whistleblowers a percentage of the recovery.
The Federal False Claims Act also provides protections to employees who may be discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against by an employer because of lawful whistleblower activity engaged in by the employee. The Act entitles employees to relief to “make them whole,” including reinstatement with the same seniority status they would have had but for the discrimination, twice the back pay, interest on back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.
IV. NEW HAMPSHIRE MEDICAID FRAUD AND FALSE CLAIMS ACT
New Hampshire has a Medicaid Fraud and False Claims Act that is similar to the Federal False Claims Act, and that provides both civil and criminal penalties for violators. Major prohibitions in the Act are as follows.
Prohibited Acts under the New Hampshire Medicaid Fraud and False Claims Act
New Hampshire’s Medicaid Fraud and False Claims Act provides that no person shall:
Any person or organization that violates the New Hampshire Medicaid Fraud and False Claims Act is subject to a State civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages that the State sustains as a result of the illegal action/s. Any such person may also be subject to State criminal prosecution and liability for a felony.
New Hampshire Whistleblower Protections
The New Hampshire “Whistleblowers’ Protection Act” affords legal protections to employees who report violations of State or Federal law, such as the Federal False Claims Act or the State Medicaid Fraud and False Claims Act, or who refuse to execute illegal directives, or who participate in governmental investigations or hearings.
An employer is prohibited from discharging, threatening, or discriminating against any employee who:
In the event of employer violation of New Hampshire’s Whistleblowers’ Protection Act, an aggrieved employee’s legal remedies may include reinstatement with back pay and benefits, restoration of seniority rights, other appropriate injunctive relief, compensation for special damages, and an award of attorneys’ fees and costs.
V. CONTRACTOR MONITORING
Community Bridges, in collaboration with the NH Department of Health and Human Services, engages in good faith review and monitoring of contractor submissions and other items – including but not limited to: contractor service / progress notes, reported attendance / hours, and billings; consumer, family, or other complaints; and related information or reports – to identify potential inconsistencies or deficiencies, to engage in appropriate communication with relevant parties, as needed, and to help ensure false claims prevention and detection.
VI. CORPORATE COMPLIANCE
Community Bridges is committed to conducting our business ethically and in conformity with all applicable Federal and State statutes and regulations. Our Corporate Compliance Program is intended to assure compliance with relevant Federal and State standards, to minimize any potential risk of fraud or abuse, and to affirm the key organizational themes of quality, customer service, and ethical business practice.
Community Bridges’ Compliance Program has the following core elements: (1) Corporate Compliance Manual and Code of Conduct; (2) Employee Handbook; (3) Whistleblower Policy; (3) Designated Corporate Compliance Officer; (4) Designated External Whistleblower Complaint Officer;(5) Open lines of communication; (4) Training and education; (5) Monitoring and auditing; (6) Response to detected deficiencies; and (7) Enforcement of contract standards and disciplinary standards.
1. Medicaid State Plan Requirements, 42 USC §1396a(a)(68) 2. Federal False Claims Act, 31 USC §3729 to §3733 3. New Hampshire Medicaid Fraud and False Claims Act, RSA167:58 to 167:61-e 4. New Hampshire Whistleblowers’ Protection Act, RSA 275-E