University Compliance

False claims laws for federal and state health care programs

 

False Claims Laws

Washington University in St. Louis is committed to complying with the requirements of federal and state laws, including Section 6302 of the Federal Deficit Reduction Act of 2005, and to preventing and detecting fraud, waste or abuse in its organization in connection with federal and state health care programs.

Overview

Washington University is committed to complying with the requirements of federal and state laws, including Section 6302 of the Federal Deficit Reduction Act of 2005, and to preventing and detecting fraud, waste or abuse in its organization in connection with federal and state health care programs.

The intention of this document is to supplement the university’s Code of Conduct and other policies and procedures and to provide information to employees and contractors and agents of the university about the provisions of federal and state false health care claims laws, penalties for violating the laws, and how to report suspected violations of the false claims laws.

Following is a summary of federal and state laws regarding health care programs and an overview of the related compliance activities in the university.

Federal False Claims Act

The Federal False Claims Act (FCA) is intended to prevent and detect fraud, waste and abuse of government funds. It is a violation of the federal FCA for anyone to knowingly submit, or cause another person to submit, a false health care claim and receive government funds. Examples of actions that could violate the federal FCA include overcharging the government for services rendered; filing a claim with the government for services that were not rendered; or filing a claim with the government with information known to be false. Anyone who knowingly or intentionally submits a false claim to the federal government is liable for civil penalties of $5,500 to $11,000 per claim, plus three times the amount of damage caused by the false claim.

State False Claims - Missouri

Missouri law contains civil and criminal false claims provisions for combating Medicaid fraud. Specifically, Missouri’s false claim statute prohibits:

  1. knowingly presenting a claim for payment that falsely states the health care provided was medically necessary;
  2. knowingly concealing an event affecting initial or continued payments by a medical assistance program for providing care;
  3. knowingly concealing or failing to disclose any information in order to obtain a payment from a medical assistance program to which the health care provider is not entitled or improperly increasing the amount of any such payment to which the health care provider is entitled; or
  4. knowingly making a claim for payment for health care that was provided that has a lesser value than the amount of the claim. Criminal penalties range from imprisonment up to seven years, restitution and civil penalties of $5,000 to $10,000 per violation plus treble damages measured as three times the amount of damage sustained by the Medicaid program as a result of the false claims activity. Alternatively, Missouri law authorizes the attorney general to initiate civil actions for violations of Missouri’s false claims laws and recover up to two times the amount of payments received by the person as a result of making false statements or false representations, as well as the state’s costs in pursuing the action.

Reporting Violations and Whistleblower Protection

Anyone who suspects a violation of the FCA or any other federal, state or local law, a university policy or the university’s Code of Conduct is required to promptly report it to university management. Anyone who, in good faith, reports a suspected or actual violation of law, regulation, or University Code of Conduct or policy will be protected from retaliation and retribution as a result of such reporting, regardless of whether or not, after investigation, a violation is found to have occurred. As outlined in the University’s Code of Conduct, any one of the following three channels may be used for informing university management of the suspected violations:

  • Report it directly to your supervisor or department head or chair.
  • Report it to the related area-specific compliance office. For health care related matters, contact the Director of the Physician Billing Compliance Office at (314) 747-7660 or opbc@msnotes.wustl.edu
  • Call the university hotline at (314) 362-4998. Reports may be made anonymously.  

If issues related to misuse of government funds are not addressed and resolved by the above reporting channels, the federal FCA contains “whistleblower” provisions that allow citizens with evidence of false claims against the government to sue, on behalf of the government, in order to recover the improperly charged funds. If the suit ultimately ends in a monetary judgment, the citizen may share in the damages recovered. The federal FCA extends protections to employees who report false claims from retaliation or discrimination by an employer and university policy provides protection from retaliation and retribution as a result of such reporting, regardless of whether or not, after investigation, a violation is found to have occurred.

Policies and Procedures for Detecting and Preventing Health Care Fraud, Waste and Abuse

Washington University has a wide variety of policies, procedures and activities related to detecting and preventing health care fraud, waste and abuse, including the following:

The Washington University Code of Conduct expresses the commitment by Washington University to carry out its educational, research and health care activities in compliance with all relevant laws and regulations and with the highest integrity. All employees are expected to adhere to it.

The university’s Physician Billing Compliance Office provides mandatory annual training for all faculty and staff who participate in patient care or reimbursement-related activities. The training includes information about how to report false claims. The Physician Billing Compliance Office also educates and works closely with billing personnel in each department to address billing questions or concerns that may arise. They also create and publish periodic educational and informative newsletters related to billing matters. They also perform monitoring and auditing of billing compliance.

The University Compliance Office maintains the university’s hotline and investigates or partners with appropriate personnel to investigate all hotline calls and ensure appropriate corrective action occurs. This Office also performs audits of compliance with various federal regulations.

The Internal Audit Office performs internal audits throughout the university, which includes reviewing compliance with university policies and procedures and adequacy of internal controls, including internal controls related to health care, such as in the areas of billing processes, cash receipts, payment posting, write-offs, refunds, etc. The Controller’s Office issues a Guide to Internal Controls document annually to all business managers and requires them to certify annually that they have received it and understand they are responsible for having adequate internal controls in their areas.

University links related to detecting and preventing fraud, waste and abuse:

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