False Claims Act Policy

Compliance Hot Line (800) 472-5827

Date: July 25, 2007

Purpose

The purpose of this policy is to comply with the requirements of the Deficit Reduction Act of 2005 with regard to federal and state False Claims laws as they apply to Penn Highlands Elk Health System and its affiliates (collectively, "Penn Highlands Elk Health System").

Definitions

For the purposes of the False Claims Act laws, a "claim" includes, but is not limited to any request or demand for money or property that is submitted to the U.S. Government or to a contractor, grantee, or other recipient, if any portion of the request is to be funded or reimbursed by the government.

Policy

It is the policy of Penn Highlands Elk Health System that all employees, including management, and contractors and agents representing Penn Highlands Elk Health System are educated regarding the federal and state False Claims laws and the roles of these laws in preventing and detecting fraud, waste and abuse in federal health care programs.

Federal False Claims Act, 31 U.S.C. §§ 3729 - 3733: The federal False Claims Act ("FCA") assists the federal government in combating fraud and recover damages resulting from fraud in a federally funded program, purchases, or contracts. The act establishes significant liability for any person or entity that knowingly presents or causes to be presented, a false or fraudulent claim to the U.S. Government for payment.

  • The term "knowingly" is defined to mean that a person, with respect to information:
    Has actual knowledge of false information in the claim
  • Deliberately ignores the truth or falseness of the information in a claim
OR

  • Acts in reckless disregard of the truth or falseness of the information in a claim.
  • The act does not require proof of a specific intent to defraud the U.S. government for the act.

Actions That Violate

Actions that violate the FCA include, among other things:

  • Knowingly submitting a false claim for payment
  • Knowingly making or using a false record or statement to obtain payment for a false claim
  • Conspiring to make a false claim or get one paid
  • Knowingly making or using a false record to avoid payments owed to the U.S. Government

Enforcement

The United States Attorney General may bring civil actions for violations of the FCA. As with most civil actions, the government must establish its case by presenting a preponderance of the evidence rather than by meeting the higher burden of proof that applies in criminal cases. Proof of intent is not a requirement to determine whether an act is a violation of the FCA.

Private or Qui Tam Actions/Whistleblower Provisions

An individual (or qui tam plaintiff) can file a civil suit for himself and for the government for violations of the FCA. Individuals who report fraud may be awarded a percentage by the courts depending upon a number of circumstances, including, whether the government prosecutes the case, the factual bases, and/or the whistleblower's involvement in the act.

Under federal law, an employee who has been discharged, demoted, suspended, threatened, harassed, or in any way discriminated or retaliated against by his employer because of involvement in a FCA disclosure is entitled to reinstatement of status, back pay and compensation for any special damages sustained because of the discrimination or retaliation.

State FCA

The state of Pennsylvania does not yet have a state false claims act, however the state's Medicaid Fraud Control Units investigates, monitors and prosecutes Medicaid fraud and abuse issues. Both the state's Medicaid program and the Attorney General's Office have Medicaid Fraud Units.

Distribution

Penn Highlands Elk will distribute this Policy to all employees (including management), all members of Penn Highlands Elk medical staff, and on a going forward basis, to all new and renewing contractors and agents of Penn Highlands Elk. In addition, this policy will be placed on Penn Highlands Elk website.

Reporting Concerns regarding Fraud, Abuse and False Claims

Penn Highlands Elk takes issues regarding fraud, abuse and false claims seriously. As per the Penn Highlands Elk’s Compliance Plan, the fundamental policy is that all of its business and practices be conducted at all times in compliance with all applicable federal and state laws, rules and regulations. As per Penn Highlands Elk’s Code of Conduct and applicable policies, it is the obligation of any individual to report any suspected violation of the Code of Conduct or Compliance Program, and any uncorrected error in billing, accounting, financial; or other business matter, even if unintentional, to both their manager and the Compliance Officer at (814) 788-8848.

References:

  • 31 U.S.C. §§ 3801-3812
  • 31 U.S.C. §§ 3729-3733
  • Deficit Reduction Act of 2005, Sections 6031, 6032
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