Thursday, April 24, 2014

Deficit Reduction Act , False Claims Act and Employee Protection

The Deficit Reduction Act and the False Claims Act combine to offer employee protection against fraud and waste and whistle blower protection, too. Compliance with these acts is key to health care program funding and keeping medical care and medical care givers both safe and sound.

First, an overview: the 2005 Deficit Reduction Act set up a new Medicaid Integrity Program quite similar to the Medicare Integrity Program. Vastly increased funding means vastly increased scrutiny of Medicare and Medicaid. This has become an increasingly vivid hot spot for government regulation, and is exactly what the False Claims Act is intended for.

When an organization is on the radar of the Medicaid Integrity Program, one area in particular that will be studied is whether the organization properly and adequately communicated all the information about the False Claims Act, and about the whistle blower protections communicating the details of the False Claims Act (FCA) and the whistle blower protections.

Concerned as to whether or not you’ve handled these details, assessed and addressed them? MedTrainer can help. Our training program is designed to ensure compliance in a wide spectrum of areas for medical, dental, and veterinary care givers. Unsure or overwhelmed about all the detailed information to be imparted? We can offer the comprehensive information coverage you need to keep your staff focused and knowledgeable - without the hassle.

After all, the False Claims Act requires knowledge to successfully implement. As a recipient of federal health care program funds, such as Medicare and Medicaid, you’re legally required to include all of its policies and provide thorough information about the federal False Claims Act to all employees and contractors. You also need to provide information about all state civil and criminal laws dedicated to the prevention and detection of fraud and waste in health care programs.

A federal law that makes it a crime for any one to make a false record or file a false claim knowingly to a federal health care program, The False Claims Act includes any plan that provides health benefits funded directly by the federal government or a state health care plan.

In short, knowing that a claim is false, or disregarding evidence that a claim may be false, is illegal: whether that false claim involves over billing Medicare for services, submitting inaccurate claims for provided services, or billing for services that were not provided. The False Claim Act deals with both patient fraud and care giver fraud and waste. Other examples include billing twice for the same service; billing for medically unnecessary services or creating false certificates indicating  medical necessity; billing for services separately that could be billed as one; creating false medical records or treatment plans designed to increase payments; failing to report and refund over payments. Other situations could include a physician billing for services rendered by medical students, interns, residents or fellows in teaching hospitals; and giving or receiving unlawful inducements for referrals for services from other health care providers.

The False Claims Act has provisions built in so that individuals with information about fraud in government health care programs can file a lawsuit on behalf of the government. These individuals can, should the lawsuit succeed, receive a portion of the recovered amount received by the government.

In most states, it is a crime to obtain a Medicaid payment or benefit by providing false information. Like the federal government, most states have laws on the books that allow individuals to file a lawsuit for false claims filed for payment.

Penalties for violating the False Claims Act are steep indeed. Financial costs can add up to as much as three times the cost of the claim made plus fines of between $5500 and $11,000 per claim. And fines and penalties aren’t the only substantial downside. Courts can impose criminal penalties too - against individuals who violated the act and against organizations who perpetrated willful or reckless violations.

Making sure your staff knows the tremendous implications of ignoring fraud or pleading ignorance to fraud and abuse is vitally important.

Along with the penalties and enforcement, the False Claim Act also offers protection - for anyone who files a lawsuit under the act. This protection serves to prevent an employee from firing, demotion, threats, and harassment incurred if the employee files a False Claims Act lawsuit.

Being fully committed to complying with health care organization laws and regulations means establishing a compliance program that clearly states your cooperation with and commitment to the legal program.

Such a compliance program includes a statement that outlines the conduct standards expected within your organization, including appropriate policies and procedures. In includes training and educating all staff members, setting up systems for auditing and monitoring, and having in place the proper channels for individuals to present any issues or concerns - without retaliation. All of these compliance materials should be easily accessible online, in employee handbooks, and handouts, and as a company policy to work with honesty and integrity.

Providing employees with information is a requirement of the Deficit Reduction Act. Signed into law in 2006 by then President Bush, the law requires states who participate in Medicaid to demand that providers who receive or make a minimum of $5 million under that state’s Medicaid program, will set up written policies for employees, contractors, and any agents to review. These written policies must give detailed information the False Claims Act, the federal Program Fraud Civil Remedies Act, whistle blower protections, and any additional or supplemental federal and state laws regarding both criminal and civil penalties for false claims and statements. Information must also be provided about the way these laws prevent and can detect waste, fraud, and abuse. And, procedures and policies must be established by the provider to prevent and detect waste, fraud, and abuse. Finally, to be in compliance with the DRA, any employee handbook
of a covered entity must include both a discussion of these laws and the rights of employees protected as whistle blowers.

Yes, there’s that word again, compliance. It is as much a part of health care and the medical profession today as the treatment of patients. Failure to comply with education requirements may cause ineligibility to receive Medicaid payments. A knowing violation of the education requirements can also result in strong penalties for submitting false claims under the False Claims Act for non-compliance.

Along with the Deficit Reduction Act, False Claims Act, medical practices of all kinds need to adhere to OSHA standards, developed to reduce hazards in the work place and successfully implement both safety and health programs. The OSHA act of 1970, like the DRA and the False Claims Act, stop an employer from discrimination against or discharging of an employee who has made a complaint, exercised a right, or participated in an investigation. HIPAA, the Health Insurance Portability and Accountability Act which  serves to establish standards of security and privacy, must also be adhered to, as does the Patient Safety and Quality Improvement act of 2005, which ensures a confidential reporting system for health care professionals to report errors and safety compromises.

In summary, from the DRA and False Claims Act to HIPAA, new laws, rules, and regulations have been established by the federal government and by state governments, to protect patients, and to prevent waste and fraud. Being in compliance with these rules and regulations, adhering to these federal laws, means educating all medical staff, and implementing written guidelines, training, and education programs. This is a lot to have on any care givers plate. MedTrainer can help you with training and education, achieve compliance, improve your efficiency, and help you to prevent the very things these laws were designed to prevent: waste, fraud, and abuse.

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