FalseClaims Memo.doc

DEPARTMENT OF MENTAL HEALTH

INFORMATION ABOUT THE FALSE CLAIMS ACTS

Topics:

· The Federal and State False Claims Acts

· DMH Billing Practices – duty to comply with all applicable laws, regulations, policies and billing practices

· Employees/contractors with knowledge of the filing of a false claim have the duty to report Federal law requires the Department to regularly inform its employees and contractors about the Federal and State False Claims Acts and other similar laws and the role that such laws play in preventing and detecting fraud, waste, and/or abuse in government programs, particularly Medicare and Medicaid.

Pursuant to these and other laws, the Department seeks to ensure that claims made and/or payments received for services provided by or on behalf of the Department reflect only those services provided and reimbursement amounts allowed by the applicable payors, including but not limited to Medicaid and Medicare. Department employees, contractors and agents (hereinafter collectively referred to as “employees”) must comply with all applicable laws, regulations, policies and procedures when:

· Preparing and submit any bill, claim or otherwise seek reimbursement for the Department from Medicare, Medicaid and others.

· Completing any documentation that could be used by the Department to prepare bills or claims.

Employees are prohibited form knowingly making false or misleading entries or statements on any bills, claims forms or other request for reimbursement submitted to the federal government, another state agency or any other payor (false claim). Similarly, employees are prohibited from knowingly making false or misleading entries or statements in any documentation which may be used to support such bills, claim forms, etc.

Examples of what constitutes a false claim include the following:

· Knowingly billing for procedures not performed

· Knowingly falsifying information in the medical record

· Knowingly double-billing

· Falsely indicating that a particular health care professional attended a procedure

· Characterizing the service differently than the service actually rendered

· Billing separately for services that should be a single service.

The Federal and State False Claims Acts impose substantial civil penalties on entities and individuals who file false claims affecting respectively, the Federal or State governments. Besides the payment of damages, an entity or individual may also have to pay civil penalties in the range of $5,000 to $11,000 per false claim. Actions under these Acts may be initiated by the respective government or by individuals having actual knowledge of false claims being filed. As an incentive for individuals to file actions, individuals who file successful action are entitled to between 15 and 30% of the final judgment.

In addition to the False Claims Acts, there are other Federal and State laws that could be applicable when a false claim is filed. Below are examples of these laws:

HIPAA (Health care fraud)

Criminal (fines and imprisonment)18 USC §1347; 18 USC §669)

Civil (penalties and damages) 18 USC §§1035 and 1518.

Medicaid False Claims Statute

Criminal (fines and imprisonment) M.G.L. c. 118E §§39 and 40)

Social Security Act Criminal (fines and imprisonment) 42 USC §1320a-7b False Health Care Claims Act

Criminal (fines and imprisonment) M.G.L. c.175H, §§2-4

Program Fraud Civil Remedies Act

Administrative remedies (penalties and damages) 31 USC §3801 et seq.

Insurance fraud

Criminal (fines and imprisonment) M.G.L. c. 266, §111

Employees with knowledge about the Department making improper claims based on false claim data, or for other reasons, must report such to their supervisor, the applicable administrator-in-charge, or to:

Anne Vacca, DMH Internal Control Officer

Department of Mental Health

25 Staniford Street, Boston, MA 02114

(617) 626-8069 Fax (617) 626-8014

Email: Anne.Vacca@state.ma.us

Director of Privacy and Compliance

Department of Mental Health

25 Staniford Street

Boston, MA 02114

(617) 626-8160

Fax (617) 626-8077

Email: DMHPrivacyOfficer@state.ma.us

Similarly, the Department strongly encourages employees with any concerns about a particular claim(s) or the Department’s billing and/or documentation practices or who may have questions about the applicable laws, regulations, policies or procedures, to discuss such with their supervisor or administrator-in-charge.

Both the Federal and State False Claims Laws prohibit employers from retaliating against employees who disclose information to government or law enforcement agencies or file false claim actions. Employees may not be discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their taking action to report false claims information.

If you have any questions regarding this memorandum, please consult with your agency’s legal counsel.