Prevention of Fraud, Waste, and Abuse (Policy Number: 132.03)
Policy No: 132.03
Original Issue Date: 4/9/2019
Revision Date: 2/16/2021
Title: Prevention of Fraud, Waste, and Abuse
Applicability: Jefferson Health System and its Controlled Affiliates (Jefferson)
The purpose of this policy is to provide all members of the Jefferson community, including but not limited to employees, contractors, vendors, students, and agents (“Jefferson”) with clear guidance regarding their responsibilities to prevent, identify, and report all actual or potential activities or instances that may relate to fraud, waste, and abuse.
Jefferson’s Code of Conduct and Ethical Behavior emphasizes honesty and integrity. All members of the Jefferson community must comply with federal, state, and local laws and must exercise their duty to prevent fraud, waste and abuse at Jefferson. Such duties include, but are not limited to, reporting all concerns and suspicions regarding fraud, waste, abuse, or suspected false claims act violations to appropriate parties or authorities.
Abuse: practices that, either directly or indirectly, result in unnecessary costs, including but not limited to practices that result in providing patients with medically unnecessary services that do not meet professionally recognized standards.
Fraud: the intentional or deliberate misrepresentation made by an individual that could result in some unauthorized benefit, including but not limited to:
- Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a federal health care or other payment for which no entitlement would otherwise exist;
- Knowingly soliciting, receiving, offering, and/or paying remuneration to induce or reward referrals for items or services reimbursed by federal health care or other programs; or
- Making prohibited referrals for certain designated health services.
- Plagiarizing publications, fabrication of data, misrepresentation of historical sources and presenting false references.
Good Faith Report: A disclosure of misconduct made with a belief in the truth of the report based upon the facts. A report may be initiated in good faith regardless of whether the complaint is ultimately founded or unfounded. A report is not in good faith if made with reckless disregard for or willful ignorance of facts that would disprove the report.
Jefferson Community: includes Board of Trustees, senior leadership, faculty, clinicians, researchers, administrators, employees, volunteers, contractors, vendors, and students of Thomas Jefferson University, Jefferson affiliated hospitals, outpatient services and ambulatory practices, and outpatient service practices. Patients and students are an integral part of the Jefferson Community, and although not required to report using this mechanism for reporting, they are invited to disclose instances of potential Fraud, Waste, and Abuse.
Retaliation: Any adverse action or credible threat of an adverse action by TJU and its controlled affiliates taken against anyone for having made a good-faith report of misconduct.
Waste: the overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including Medicare, Medicaid, or other programs. Waste is a misuse of resources.
- Jefferson engages in risk-based auditing and monitoring activities designed to ensure that its practices, including claims for reimbursement submitted to government and private payers, align with laws, regulations, contractual obligations, and its internal policies and procedures.
- Every member of the Jefferson community is encouraged to report potential concerns about activities that may not align with Jefferson’s stated policies and procedures governing honesty and integrity. Reporting allows Jefferson the opportunity to correct deficiencies for the benefit of the community. Methods for reporting are outlined in Section III of this policy.
- All members of the Jefferson Community must complete mandatory Code of Conduct training, at least annually. In addition, certain individual members of the Jefferson Community must complete the Centers for Medicare and Medicaid Services’ (“CMS”) fraud, waste, and abuse training modules at least annually or within the time prescribed by CMS.
- Targeted training and education to support lawful business activities shall be provided to all members of the Jefferson community with a frequency and intensity necessary to promote understanding and appropriate application.
- Members of the Jefferson Community must report all suspected illegal, unethical, or improper activities. Similar to the reporting of violations of the Code of Conduct, members of the Jefferson Community have a duty to report all instances of suspected fraud, waste or abuse in federal and state health care programs.
- Suspicions of fraud, waste or abuse, or suspected false claims act violations must be reported immediately through the appropriate channels:
- Reports to the Enterprise Office of Corporate Compliance may be made via telephone at (215) 503-6300 or electronic mail at ComplianceQuestions@jefferson.edu;
- If an anonymous report is preferable to the reporter, one can be made by using the Jefferson Alert Line by calling 1-833-ONE-CODE (1-833-663-2633) or completing a report online at http://jefferson.mycompliancereport.com. Reports to the Alert Line may be made at any time and from any location.
- An outside company that is not related to Jefferson manages the Alert Line 24 hours a day, seven days a week. For additional information, please refer to the Alert Line Policy #132.02
- Where to Find Help:
- Immediate Supervisor – Speaking with your immediate supervisor is usually the best place to get answers to your questions.
- A Higher-Level Manager or Leader – If your immediate supervisor is unable to address your concern, raise the issue with a higher-level manager or leader in your department.
- Human Resources – Your local Human Resources professionals can assist you with workplace issues and concerns.
- Office of Legal Affairs – Contact the Office of Legal Affairs at (215) 955-8585 when you need guidance about legal matters involving Jefferson.
- Enterprise Corporate Compliance Department – The Corporate Compliance Department is responsible for operation of Jefferson’s compliance and integrity program. Contact 215-503-6300 or at ComplianceQuestions@jefferson.edu to discuss concerns, report issues, and obtain answers to your questions.
- Your Regional Compliance Officer - Please visit the Compliance Community online at myJeffHub for information regarding contact with a local compliance representative.
- You do not have to be sure that you are right in order to raise concerns about potential violations of the Code of Conduct, Jefferson’s policies, laws, or regulations. Jefferson will investigate all good faith reports of possible misconduct.
- Non-Retaliation (Whistleblower Protections)
- Jefferson strictly prohibits retaliation against any person who reports, in good faith, an actual or perceived violation of law, regulation, or any associated policies and procedures.
- Anyone who engages in retaliatory activity against a reporter or whistleblower will be subject to disciplinary action, up to and including termination. Reports of suspected retaliation shall be investigated in accordance with relevant Jefferson policies and procedures.
- Failure to comply with this policy is a violation of Jefferson’s Code of Conduct and persons violating the policy will be subject to appropriate disciplinary action, up to and including termination.
- Jefferson will follow all internal policies and procedures as well as regulatory guidelines to meet external reporting requirements related to fraud, waste, and abuse or suspected false claims.
Related Policy Notes:
- This policy supersedes all prior and existing Fraud Waste and Abuse (FWA) policies at Thomas Jefferson University and its controlled affiliates. Retirement of any prior or existing FWA policies shall be effective as of the Effective Date listed above, unless otherwise indicated within this policy.
- Identified conflicts between other Jefferson policies related to Fraud, Waste, and Abuse shall be construed to be consistent with this policy. All conflicts shall be brought to the attention of the Enterprise Corporate Compliance Department for review.
References and Citations:
- Deficit Reduction Act of 2005 (S. 1932) §§ 6031-6034 (DRA)
- The False Claims Act, 31 U.S.C. §§ 3729-3733
- Administrative Remedies 31 U.S.C. §§ 3801, et seq
- 62 P.S. §§ 1407(a) (c),1408
- 55 Pa. Code §1101.75
- N.J. Stat. Ann. §§ 2A:32C-1—32C-18
- 6 Del. Code Ann. § 1203
- Enterprise Compliance Policy 132.02 – Alert Line
- Jefferson’s Code of Conduct and Ethical Behavior
Original Issue Date: 4/9/2019
Revision Date(s): 12/4/2020, 02/16/2021