Jefferson University Hospitals

Preventing Fraud, Waste and Abuse and the Federal in Connection with University Activities (Policy Number: 107.24)

Policy No: 107.24
Original Issue Date: 11/27/2006
Review Date: 1/1/2007
Revision Date: 1/1/2007

Category: Compliance Administration
Title: Preventing of Fraud, Waste and Abuse and the Federal in Connection with University Activities
Applicability: Thomas Jefferson University


Policy

Thomas Jefferson University (TJU) is committed to promoting a culture which encourages and assists employees to conduct their activities, related to the University’s educational, research, and clinical missions, with integrity and in compliance with all applicable laws, regulations and University policies and procedures.  Employee familiarity with federal and state laws addressing fraud, waste and abuse in government-funded health care and research programs is required under federal law and is the first step towards ensuring compliance. The purpose of this policy is to provide all employees, contractors and agents of TJU with detailed information regarding these laws, including protection of whistleblowers, and information on preventing and detecting fraud, waste and abuse in the delivery of health care services and the conduct of research at TJU.

Laws Designed to Address Fraud, Waste and Abuse

The following summarizes the key provisions of several major federal and state laws which are commonly used by the government to combat fraud and abuse.

A. The Federal Civil False Claims Act

The Civil False Claims Act (“Act”) was enacted during the Civil War to combat fraud committed by companies that supplied the government with war materials. Currently, the government has used the Act to combat fraud in connection with the provision of health care services and the conduct of federally funded research. The Act allows the government to recover money from individuals or companies that knowingly submit false claims for payment to the government.  Its provisions also permit private citizens or “whistleblowers” to file lawsuits (“QuiTam”  suits) on behalf of the government and to receive a portion of the proceeds.

Elements of a false claims offense:

  • any person who “knowingly” submits or causes the submission of a false or fraudulent claim to the government (or uses a false record to support the claim) will be liable for

  • a civil penalty of $5,500 to $11,000 per false claim

  • plus three times the amount of damages (amount that was overpaid) incurred by the government.

Knowingly means that the person has actual knowledge of the information and acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information (no proof of specific intent to defraud is required).

Claim is a request or demand for payment by the federal government, such as a claim form submitted to Medicare or Medicaid for patient services.

Examples of false or fraudulent claims:

  • Billing for services not performed

  • Upcoding (billing for a higher level of service than was performed and /or documented)

  • Billing more than once for the same service

  • Certifying effort on a research project that was not performed

Who may file a lawsuit under the Act?

Under the Act’s Qui Tam provisions, a private person (“Relator”) may bring a lawsuit on behalf of the government.  The government may decide whether to take over the lawsuit or allow the Relator to pursue the case alone.  If the government takes over the case and obtains a settlement or favorable verdict at trial, the Relator may receive between 15 and 25 percent of the proceeds, and from 25 to 30 percent if the Relator proceeds alone. However, if the Relator planned or initiated the violation that is the subject of the lawsuit, the Relator’s share of the proceeds may be reduced, or eliminated in the event the Relator is convicted of a criminal violation in connection with the lawsuit.

Protection for the Relator

Relators are protected under the Act from any  type of retaliation (including, but not limited to, being discharged, demoted, suspended, threatened, harassed, or discriminated against) by his or her employer as a result of any lawful acts done by the employee serving as a Relator, or by assisting and/or providing information related to a lawsuit under the Act.

B. Program Fraud Civil Remedies Act

Federal law provides the government with remedies in addition to those available under the Civil False Claims Act, including recovery of overpayments, imposition of civil monetary penalties, and exclusion from federal health care (e.g. Medicare and Medicaid) and research programs.

C. Pennsylvania Provider Fraud Law and Regulations

Under the Medicaid program, a healthcare provider may not knowingly or intentionally present a false or fraudulent claim to the state for payment. False or fraudulent claims include, but are not limited to, medically unnecessary services, duplicate claims for the same service, claims for services not rendered, undocumented or falsely documented services, upcoding, and soliciting or receiving kickbacks in relation to the provision or referral of services paid by Medicaid. Penalties for violation of this law include repayment of amounts paid plus interest, restitution, exclusion from participation as a Medicaid provider, and criminal penalties with a maximum penalty of $25,000 and 10 years imprisonment.

 

TJU's Corporate Compliance Program

The University’s Corporate Compliance Program is designed to establish effective internal controls that foster adherence to the numerous laws, regulations, and University policies and procedures governing academic health centers.  These controls are aimed at the prevention, detection and resolution of noncompliance with these laws, regulations, policies and procedures (“noncompliance”).

A. The University’s Code of Conduct (See also TJU Policy No. 107.02)

The Code of Conduct establishes the framework for the University’s Corporate Compliance Program.  The Code “provides the foundation for the actions we take and the decisions we make in furtherance of our goals while upholding the laws and regulations and the standards of ethics in our community and our professions.” The Code articulates a set of standards for proper conduct, reinforces each individual’s responsibility to report violations, provides examples of violations of the Code, and references the University’s disciplinary policies. 

B. Compliance Hotline – Employees (See also, TJU Policy No. 107.01)

In order to facilitate reports concerning any real or potential noncompliance with applicable federal, state and local laws, or University policies and procedures, the University has established a confidential compliance hotline in which employees may in good faith report concerns related to fraud, waste and abuse.  Generally, any concerns should be shared with your immediate supervisor.  If that is not an option, employees should contact the TJU Corporate Compliance Administration office.  Alternately, an anonymous report may be made by calling ComplyLine: 1-888-5COMPLY. ComplyLine is available 24 hours a day, 7 days a week.  Employees are strongly encouraged to use any or all internal reporting mechanisms to resolve compliance concerns.

C. Prohibition Against Retaliation for Good Faith Reporting of Noncompliance (See also, TJU Policy No. 107.06)

In addition to ComplyLine, all employees are forbidden from engaging in retaliation, retribution or harassment directed against any individual who in good faith reports a concern regarding noncompliance to a University official or public body. If an adverse personnel or academic action is taken against a University employee, student or other individual in retaliation for his or her good faith disclosure of information to a designated University official or public body concerning alleged wrongful conduct, and if the employee’s or student’s conduct or performance did not otherwise warrant such action, the adverse personnel or academic action will be reversed and the individual engaging in the prohibited behavior may be subject to discipline under this policy.

D. Compliance Monitoring

Corporate Compliance Administration (“CCA”) conducts scheduled and unscheduled audits of TJU’s programs and services with particular emphasis on risk areas identified by the federal government.  Overpayments identified through audit are returned promptly and corrective action plans approved by the CCA are required when deficiencies are identified.

E. Policies and Procedures

Generally, employees are responsible for knowledge of all University policies and procedures which are relevant to their job responsibilities. In addition to the above-referenced policies, the following are policies and procedures designed to prevent and detect fraud, waste and abuse in relation to federal and state health care programs:

  • Provider Identification Number (PIN) for Claims Submission   TJU Policy No. 107.10

  • Collection of Co-payment (At the Time of Service)                    TJU Policy No. 121.04

  • Billing Encounter Forms and Documentation Templates           TJU Policy No. 121.02

F. Educational Programs

Because compliance depends in large part on an employee’s knowledge and understanding of applicable regulations, rules, and policies with respect to his or her responsibilities, emphasis is placed on continued development and implementation of comprehensive, educational programs. For employees involved in coding and billing functions for patient services, CCA has developed programs to help ensure that all services billed to third party payors and patients comply with applicable payor regulations and contracts, are properly documented, and correctly reflect the services provided. 

See Policy No:

  1. Education and Training Requirement for All JUP Personnel Involved in the Coding Process – TJU Policy No. 107.12;

  2. Sanctions for Failure to Attend Mandatory Educational Programs – TJU Policy No. 107.07

  3. Documentation Training Policy for New JUP Physicians and Non-Physician Practitioners – TJU Policy No. 107.05


References

  1. Deficit Reduction Act of 2005 (S. 1932) §§ 6031-6034 (DRA)
  2. The Federal Civil False Claims Act, 31 U.S.C. §§ 3729-3733
  3. Administrative Remedies 31 U.S.C. §§ 3801, et seq
  4. 62 P.S. § 1407(a) – (c)
  5. 55 Pa. Code §1101.74-76

Responsibility for maintenance of policy: Compliance & Privacy Officer