QUALITY ASSURANCE CORPORATE COMPLIANCE PLAN

Transcription

1 208 W. Main Street Elbridge, NY HOMECARE fax QUALITY ASSURANCE CORPORATE COMPLIANCE PLAN ElderChoice remains committed to conducting business in an ethical and professional manner at all times. This means not only following the bounds of the law, but continually striving to exceed all best practices and expectations as a home care agency. A Corporate Compliance Plan is a mechanism which is designed to detect and prevent violations of the law, as well as the likelihood of unethical and/or fraudulent activity, to stop any such behavior as soon as possible, to address (through disciplinary action) the offending employee, and to address/recognize trends and changes needed in policy. The Corporate Compliance Plan, as developed by the agency, serves three purposes: To comply with county, state and federal Medicaid laws in regards to fraud and Medicaid abuse. To provide all ElderChoice employees with a guideline for conducting business in an ethical and legal manner. To assure all ElderChoice employees protection against in regards to reporting fraudulent or unlawful activity. The principles included in the Corporate Compliance Plan, and subsequent Code of Conduct are important, and therefore any violations will be handled according to the same disciplinary standards as noted in the ElderChoice Employee Handbook. ElderChoice Statement of Values The following represent ElderChoice s organizational and behavioral principles, goals and standards that will permeate and govern our professional relationships, systems design, and daily operations. As an organization, we will strive to achieve the highest levels of QUALITY, COMPLIANCE, and EFFICIENCY. 1- Human Dignity We believe that people matter and that every interaction with another individual offers each of us an opportunity to reinforce this. At ElderChoice we will demonstrate this by; Representing ElderChoice and treating others in a professional manner. Respecting the uniqueness and individuality of each person we interact with. Relentlessly pursuing ethical, high moral standards in our work and professional relationships. Reinforcing each individual s right and responsibility to choose his or her life direction. Recognizing and rewarding efforts to improve each ones contribution to achieving the Vision, Mission and Values of ElderChoice. 2- Progress We believe that all progress requires change but that all change is not progress. Because of this, we will strive to continually identify, develop and take action on realistic goals that focus on bringing about lasting improvement for the organization and those we support. This will be demonstrated by; updated

2 Clarification of vision, direction, and organizational goals. Evaluating performance at every level and developing systems and facilitating efforts to improve it. Focusing resources on the research and development needed to identify opportunities for improvement in every system and working relationship. Decisions will be fact based and values driven. Reinforce the reality that lasting change occurs in an environment where Continuous Evaluation and Quality Improvement strategies are applied. 3- Collaboration It is clear to us that nothing of lasting value is accomplished by the efforts of one individual acting alone. Therefore we will commit ourselves to developing and sustaining the attitudes and skills required to effectively work with others to achieve lasting improvements for the people we support together. We will exhibit this by the effective use of; Working relationships to plan for the future and to solve problems Problem solving tools and skills Short and long range planning Engaged participation at every level of the organization 4- Integrity This condition exists when there is a harmony or, congruence between what is thought, said, and done by an individual or organization. ElderChoice will strive for this by; Diligently pursuing error free regulatory compliance. Performing our individual duties in a way that aligns with ElderChoice s Vision, Mission and Values. Keeping our agreements and commitments. Holding ourselves and each other accountable as it applies to these values. 5- Open, Honest, Respectful Communication In the simplest of terms an organization has been defined as anything that talks to itself. Communication is the life blood of any organization and so we will seek to enhance its effectiveness at ElderChoice by; Honoring the Chain of Command in and between departments. Seeking to fully understand and meet the needs of others whenever possible. Valuing feedback from staff regarding the systems they are members of and the professional relationships they have within ElderChoice. Communicating performance expectations in a way that can be understood in terms of motivation and behaviors. Managing conflict in a way that brings about understanding and resolution. Keeping confidences with each other. 6- Judgment When clarity fades sound judgment is required. Because there are an endless number of complexities and challenges involved in working with people and/or today s systems of care, our leaders and staff must be able to accurately interpret and apply ElderChoice values to these challenges. To prepare for these inevitable situations we will strive to develop; Informational systems that provide effective, timely input and feedback for addressing complex situations. Key measurements that provide insight into problem areas and related factors. Training that provides our staff with the tools and skills necessary to interpret and take effective action on complex situations. updated

3 7- Stewardship We believe that all assets are valuable resources to be appreciated, cared for, and respected. How we manage our staff, finances, facilities, ideas, talents, experience, property, and relationships will demonstrate our commitment to good stewardship at all times by; Limiting waste or neglect of supplies, ideas, and resources. Utilizing Green Practices including recycling, pollution prevention, and care for our natural environment. Our commitment to safety for all. Maintaining an organized and excellent physical environment. Maintaining ourselves in a way that mirrors our individual and organizational value. Being grateful and protecting what has been entrusted to us. ElderChoice will not knowingly engage in activities that would result in false, inaccurate, untimely and/or incomplete information billed to Medicaid. This includes but is not limited to enrollment, disenrollment, encounters, claims data, and provider credentials. The BENEFITS of a CORPORATE COMPLIANCE PLAN The agency recognizes that a cohesive Corporate Compliance Plan will not only benefit the agency, but the employees and the patients it supports, as well. Expected benefits of this plan are identified as: To demonstrate to employees and the community at large our strong commitment to honest and responsible provider and corporate conduct; Identify and prevent illegal and unethical conduct. Improve the quality, efficiency, and consistency of participant care; Create a centralized source for distributing information on health care statutes, regulations, and other program directives related to fraud, abuse and related issues Develop a procedure that encourages employees to report potential problems easily and anonymously; Develop procedures that allow the prompt, thorough investigation of alleged misconduct by corporate officers, managers, employees, independent contractors, consultants, nurses, and other health care professionals; Initiate immediate, appropriate, and decisive corrective action; Minimize, through early detection and reporting, the loss to the Government from false claims, and thereby reduce the agency s exposure to civil damages and penalties, criminal sanctions, and administrative remedies, such as program exclusion; Enhance the structure of agency operations and gain consistency between separate business units CODE OF CONDUCT 1. The agency will not engage in the following undesirable practices when obtaining or maintaining a contract with the state or federal government, or within any other contractual business arrangement: Falsification or failure to verify employee provider credentials. Falsified or inadequate provider network. Failure to follow, in good faith, all rendered Provider Agreements, requirements and regulations sent forth by the state/federal programs in which the agency provides services. 2. The agency will not engage in the following fraudulent marketing and enrollment activities: Offering monetary or other goods/services to potential patients or families, to encourage them to enroll with the agency. Misrepresentation to Medicaid beneficiaries, including but not limited to misleading the prospective patient and/or family into believing the employee works directly for the federal or state government. Knowingly distributing marketing materials which misrepresents or falsifies information. updated

4 3. The agency will not engage in activities to withhold or delay pre-approved services, also known as underutilization. These can include, but is not limited to: Failure to serve individuals, specifically due to their cultural/language barriers or specifically due to their HIV status. Failure to provide approved services, as noted in the individual s Service Plan/Plan of Care, unless specifically requested by the patient and/or the patient is in agreement. An ineffective and/or over burdensome complaint process, thus limiting the patient s right to appeal or grieve without fear of retaliation. Failure to provide qualified, trained personnel, specific to the service requested/approved. 4. The agency will not engage in fraudulent claims submission and billing practices. These include, but are not limited to: Billing for services that have not been rendered. Billing for services, per patient, amount and type of service, that have not been pre-approved by the appropriate authority. Billing for two Medicaid services during the same date/time for the same patient, without preapproval by the appropriate authority. Such approvals will be retained in the patient s Service Plan/Plan of Care and will be supported by service notes, outlining activities and goals. Improper Billing Coding (documentation supports a different level of code and unbundling). Falsification of time records and/or documentation pertaining to the claim submission process The agency will not knowingly and willfully offer, pay, solicit or receive payment to induce the referral of business reimbursable under in any circumstance. Employees will not offer or provide gifts, free services, or other incentives to prospective participants, families of prospective patients, physicians, hospitals, contractors, assisted living facilities, or other potential referral sources. HIGH RISK AREAS The agency recognizes that there are certain high risk areas, by virtue of the businesses operated and payor sources billed, which make the agency vulnerable to Medicaid fraud and fraudulent practices. The following is a partial list of areas considered high risk for the agency. Billing for services that were not provided. Billing without adequate documentation. Billing for unapproved services. Billing for an ineligible patient. Billing for more time than was actually provided. Falsifying documentation, including but not limited to time sheets, mileage forms, daily notes and documentation of encounters. Services provided by an employee that does not meet the qualifications to provide the service. Unethical conduct by any employee, manager, director, vendor, or associate of ElderChoice, including but not limited to waste and abuse. - waste - define as over utilization of services, or other practices that result in unnecessary costs. Generally not considered caused by criminally negligent actions but rather the misuse of resources. - abuse - define as provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. updated

5 CORPORATE COMPLIANCE OFFICER The agency Executive Director will appoint a Corporate Compliance Officer, to ensure the agency s dayto-day compliance, as outlined in this plan. The Corporate Compliance Officer will have responsibilities as outlined below: Responsible for investigating any such reports of corporate fraud or potential fraud, as outlined in the plan. Findings of all investigations, including will be reviewed with the agency Executive Director for appropriate action. Ensure the agency s Corporate Compliance Plan has been certified, on an annual basis, with the NYS Office of Medicaid Inspector General. Such certificate will be retained by the Corporate Compliance Officer. Be an active member of the agency s Quality Improvement Committee and activity participate in all state/federal audits, as they occur. The Corporate Compliance Officer will, at a minimum of an annual basis, report to the Governing Body in reference to any violations of the Corporate Compliance Plan and recommendations made by the Corporate Compliance Officer and/or Corporate Compliance Committee for changes/modifications to the plan. In the event that Self Disclosure is deemed necessary or if the Corporate Compliance officer feels the Executive Director is allowing and/or practicing fraudulent activities, the Corporate Compliance Officer will request to meet with the Governing Body, at more frequent intervals, in order to review the situation, the outcomes of the investigations and recommendations. Compile an annual report, submitted to the Corporate Compliance Committee, the agency s governing authority/owners and the agency Executive Director, outlining all activities and issue in regards to corporate compliance that were founded during the reporting period. This report will include a summary of the following: o All corporate compliance issues, as have been reported for the year, including a brief summary of issues noted, findings and suggested remediation/action. o New and annual employee training, as is related to the corporate compliance plan. o Assurances that the Corporate Compliance Plan has been certified with the NYS OMIG on an annual basis. o Recommendations for any modifications or changes in the Corporate Compliance Plan, based on findings during the reporting period. EMPLOYEE TRAINING All agency employees will be trained and oriented, upon hire, to the agency s Corporate Compliance Plan, including purpose, Code of Conduct, High Risk Areas, reporting responsibilities, disciplinary action as related to the plan and methods available to report any concerns to the Corporate Compliance Officer. The agency s Governing Board will receive additional Corporate Compliance training, to include the Board s specific ancillary fiscal duties. All Governing Board members will also receive the initial Corporate Compliance Plan training, as well as the annual re-orientation training. All agency employees will be re-trained and re-oriented, on an annual basis, to the Corporate Compliance Plan. This re-training will include, but is not limited to any changed in the plan, a review of employee responsibilities and methods available to report any concerns to the Corporate Compliance Officer. As there are changes/modifications to the Corporate Compliance Plan, the updated plan will be posted on the agency s ADP portal, for all employees to read and acknowledge the changes. The Corporate Compliance Officer will be responsible for reviewing, modifying and approving all Corporate Compliance training offered by the agency. REPORTING OBLIGATIONS and PROCEDURES Each agency employee is responsible for immediately reporting any suspected or actual wrongdoing (regardless of whether or not based on personal knowledge) of applicable federal or state laws and standards. updated

6 The suspected or actual wrongdoing is to be discussed with the employee s direct supervisor. If the employee does not wish to discuss the concern with their direct supervisor (or ancillary agency director), or the employee has already expressed their concern and feels the need for further clarification and/or action, the employee should make a report to agency s Corporate Compliance Officer (see information below). After the initial report, each employee will continue to update the report with any new information as it is obtained by the employee. All information reported will be kept confidential and can be reported anonymously, if this is the desire of the complainant. It is possible, however, that the employees name may need to be revealed in certain situations, as required by law or when government authorities intercede. Under no circumstances will the reporting of any information result in retaliation, harassment, or punitive action against the employee. All agency employees are afforded protection from reprisal and/or retaliation for reporting any fraudulent and/or suspected fraudulent activity. Policies regarding the Corporate Compliance Plan can also be found in the agency s Employee Handbook. The contact information for the agency s Corporate Compliance Officer are provided to each employee as part of the employee new hire orientation, and annually at the agency s re-training. A summary of the Corporate Compliance Plan, along with contact information, is also available in the patient s Home Binder, so to be readily accessible to all patients, employees and families. Information for reporting is noted as follows: ElderChoice Corporate Compliance Officer, Molly Goodwin can be reached by: mgoodwin@elderchoiceinc.com Main Office: ext. 311 or Toll HOMECARE Mail ; 208 W. Main Street, Elbridge, NY Confidential drop box is also available next to main door at the Elbridge location. Fax: Or by use of the ElderChoice Compliance and Complaint account: compliance@elderchoiceinc.com (link can also be found at www. elderchoiceinc.com) To file an anonymous complaint: please use the confidential drop box at the Elbridge location or, when mailing a complaint, do not sign the complaint or affix a return address on the envelope. You can also leave a voice message at the main office, outlining the concerns, with no identifying information. INVESTIGATIVE PROCESS/PROCEDURE Upon receipt of a corporate compliance complaint/concern, the Corporate Compliance Officer will review immediately available information and assign the complaint a level code. This will be noted on the Corporate Compliance Complaint Investigation coversheet and will indicate whether, based on preliminary information, the compliant is: Level 1 A complaint/concern considered a severe level and may require Self Disclosure. Level 2 - A complaint/concern at a moderate level that may include Medicaid billing that can be reconciled internally and is not at a Self Disclosure level. Level 3 A complaint/concern at a low level and may include a modification or adjustment to internal agency policy; No Medicaid billing is in question. Each complaint/concern will be investigated, utilizing the ElderChoice Corporate Compliance Investigation format, which will include a description of the complaint/issue, evidence reviewed (testimonial, documentary, digital), the investigation, conclusions and recommendations. All Corporate Compliance Complaints will be logged in on an annual data tracking form. updated

7 All investigations will be initiated within 24 hours of the initial complaint/concerns. Completed investigations will be reviewed with the Executive Director for follow up and appropriate action. In addition, the resolution/results of the investigations will be reviewed with appropriate Department Head, for further corrective action and/or follow up, as deemed by the investigation. Concerns in regards to fraudulent and/or possible fraudulent behavior/activities may be reported to the Corporate Compliance Officer by an agency employee, a previous employee, a patient, family member, community advocate and/or by an external audit and/or internal audit/mechanism. Any reports to the Corporate Compliance Officer will in be reviewed and assigned an initial level of severity, as per the Corporate Compliance Complaint Investigation cover sheet. This form will be completed by the Corporate Compliance Officer, and become part of the final investigation, with results submitted to the agency Executive Director for review. These investigative reports will include, but are not limited to the compliance issue in question, the method the concern was brought to the attention of the Corporate Compliance Officer, steps taken to immediately correct the concern and recommendations for implementing procedures, policies and systems as necessary to reduce the potential for reoccurrences. SELF DISCLOSURE Upon completion of an investigation of a concern/complaint that is determined to be a violation of the Corporate Compliance Plan, the results will be reviewed with the agency Executive Director. Each concern/complaint will be considered on an individual basis and factors to be considered will include, but are not limited to the exact issue in question, the amount (fiscal) involved, any patterns or trends identified within the agency s systems and the period of non-compliance. If it is determined, by the Corporate Compliance Officer and the agency President, that Self Disclosure to the Office for Medicaid Inspector General (OMIG) is necessary, the agency President will seek the review/advice of the agency s legal consul. If deemed necessary, Self Disclosure steps will be taken (including but not limited to submission of the completed OMIG Self Disclosure form, the agency investigative report, a specific list of all claims in question, names of individuals involved in suspected improper or illegal conduct) and agency restitution will be reviewed/agreed upon by the agency, OMIG and ancillary state entities (ie. Department of Health). The President/ED and governing body are responsible for review of all Corporate Compliance issues and ensuring appropriate, scheduled fiscal payments are made. DISCIPLINARY ACTION The Corporate Compliance Plan, and subsequent responsibility of the agency employees, is held in high regard by the agency, the governing body and state/federal government. The agency has adopted disciplinary policies to encourage good faith participation in the plan, by all affected individuals, and to ensure timely and appropriate disciplinary action take place, if necessary. Every confirmed violation of Corporate Compliance Plan, including the Code of Conduct, may result in corrective action or discipline. Any employee or contractor who violates or knowingly fails to report any violation of the Plan including the Code of Conduct, any applicable law or regulation, agency policy, procedure or practice is subject to appropriate disciplinary action, up to and including termination and may also be subject to legal action where indicated. 1. Failure to report suspected issues: Any agency employee who has information regarding fraudulent activity, or possible fraudulent activity, whether this information be first hand or not, is to report the situation immediately to the Corporate Compliance Officer, utilizing the method outlined in this plan. Failure to report any such activity, or suspected activity, will subject the agency employee to disciplinary action, leading to and/or up to termination. 2. Refusal to participate in agency compliance investigations: Any agency employee who refuses to cooperate and/or participate in an agency compliance investigation, is subject to agency disciplinary action up to and/or including termination. This does not negate the employees right to report fraudulent activity without fear of reprisal. updated

8 3. Encouraging, directing, facilitation or permitting fraudulent behavior/activities: Any agency employee who is involved in encouraging, directing, facilitating or knowingly permitting fraudulent behavior/activity will be subject to agency disciplinary action, leading to and/or up to termination. 4. Participating in fraudulent behavior/actions: Any agency employee who participates in fraudulent behavior/actions, as confirmed by an investigation and/or employee admission, is subject to immediate termination. This is considered a Zero Tolerance Offense within the agency, and as is outlined in the agency s Employee Handbook. * Disciplinary action is outlined in further detail in the agency s Employee Handbook. WHISTLEBLOWER PROTECTION ElderChoice maintains a firm anti-retaliation, anti-intimidation and whistleblower protection policy for any employee, vendor, patient, associate or other related entity that exercise their responsibility to report a known or suspected compliance violation (refer to ElderChoice Employee Handbook). Actions and/or attitude that show evidence of harassment, discrimination or ill treatment towards an individual who has reported a violation will not be tolerated. Any employee who is found to be demonstrating such behavior or who exhibits behavior this retaliatory in nature could face disciplinary action up to and including termination. The agency will not tolerate retaliation or intimidation of any kind, taken by a manager or employee against and employee, participant, associate, vendor, volunteer or any other related entity who has followed ElderChoice policy to notify the agency s Compliance Officer of any matter that violates the Corporate Compliance Policy/program, participant rights, employees rights, HIPAA, or federal/state or other regulations and/or laws. Whistleblower Protection under Federal/State Federal False Claims Act (31 U.S.C 3730(h)) The FAC provides protection to qui tam relators who are 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 furtherance of an action under the FCA 10 USC 3730 (h). Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any physical damages sustained as a result of the discrimination including litigation costs and reasonable attorney s fees. NYS False Claim Act (State Finances Law 191) The false Claim Act also provides protection to qui tam relators who are 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 furtherance of an action under the Act. Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation cost and reasonable attorneys fees. New York Labor Law 740 An employer may not take any retaliatory action against an employee if the employee discloses information about the employer s policies, practices or activities to a regulatory, law enforcement or other similar agency or public official. Protected disclosures are those the assert that the employer is in violation of a law that creates a substantial and specific danger to the public health and safety or which constitutes health care fraud under Penal Law 177 (knowingly files, with intent to defraud, a claim for payment that intentionally has false information or omissions). The employee s disclosure is protected only if the employee first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation. If an employer takes a retaliatory action against the employee, the employee may sue in state court for reinstatement to the same, or an updated

9 equivalent position, any last back wage and benefits and attorneys fees. If the employer is a health provider and the court finds that the employer s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer. New York Labor Law 741 A health care employer may not taken any retaliatory action against an employee if the employee discloses certain information about the employer s policies, practices or activities to a regulatory, law enforcement or other similar agency or public official. Protected disclosures are those that assert that, in good faith, the employee believes constitute improper quality of patient care. The employee s disclosure is protected only if the employee first bought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation, unless the danger is imminent to the public or patient and the employee believes in good faith, that reporting to a supervisor would not result in corrective action. If an employer takes a retaliatory action against the employee, the employee may sue in state court for reinstatement to the same, or an equivalent position, any lost back wages and benefits and attorneys fees. If the employer is a health provider and the court finds that the employer s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer. SELF EVALUATION, INTERNAL AUDITS and PREVENTATIVE MEASURES The agency recognizes the need for continual self evaluations and established preventative measures in order to ensure that there are numerous methods in place to identify and remediate any fraudulent or potential fraudulent activity. The following are in place to assist with this: The agency will cooperate fully with any and all state and/or federal program audits. The NYS Department of Health currently conducts program reviews on a minimum of a three year cycle. The results of these audits will be utilized as a format to identify any fraudulent and/or possible fraudulent behavior. The agency s Quality Improvement Committee will meet on a quarterly basis to review high risk areas. These meetings will review random samples of agency patient binders and personnel records. The Governing Body will also meet quarterly to review approved service initiation/start dates, new enrollees and program discontinuances. The agency s Quality Improvement Committee will review, on a quarterly basis, all complaints or concerns that have been brought to the attention of the Corporate Compliance Officer, review the action taken and follow up/plan of corrective action (if applicable). On an annual basis, the agency will conduct a Patient Satisfactory Survey, with results compiled and submitted to the agency Executive Director, Governing Body and Quality Improvement Committee for review and action, as is deemed necessary. Any fraudulent and/or possibly fraudulent behavior and/or documentation will be noted and a summary of concerns forwarded to the Corporate Compliance Officer for review and investigation, as necessary. The agency s Complaint (Grievance) Policy will also be used as a mechanism for identifying any fraudulent and/or potential fraudulent activities. The Complaint Policy is reviewed with all agency employees upon hire, and annually thereafter, as well as with each patient supported by the agency, at intake and on a minimal of annual basis. Any fraudulent or potentially fraudulent behavior noted in a Complaint investigation will immediately be brought to the attention of the Corporate Compliance Officer for investigation and action, as deemed necessary. The agency will abide by all Department of Health program regulations as pertain to state Serious Reportable Incidents. These incidents will be submitted and investigated, per agency policy and state regulations, with monthly review of all open incidents by the agency Incident Review Committee. In addition, the agency will abide by all internal agency Recordable Event policies. These completed Recordable Event forms will be investigated, per agency policy, and reviewed by the agency Incident Review Committee, on a monthly basis. updated

10 Any fraudulent and/or possibly fraudulent behavior and/or documentation will be noted and a summary of concerns forwarded to the Corporate Compliance Officer for review and investigation, as necessary. The agency will, as part of the Human Resources hiring process for all agency employees, conduct three Medicaid exclusionary checks on the applicant. These exclusionary checks will be conducted through the following resources: Any applicant in which one or more of these resources notes the individual has a Medicaid exclusion will not be offered employment with the agency. In addition to completing the three Medicaid exclusionary checks for each applicant prior to hire, the agency s Support Services Department will conduct these three Medicaid exclusionary checks on each agency employee on a monthly basis. All Medicaid exclusionary checks will be saved in the agency s digital employee personnel file. The agency will maintain a Corporate Compliance Committee, which will meet on a regularly scheduled basis, but at a minimum of four times per year. The committee will be responsible for reviewing/updating the Corporate Compliance Plan, reviewing all Corporate Compliance investigations/complaints and reviewing/making recommendations for the overall quality assurance/improvement of the agency s compliance program. All agency Department Heads/Supervisors (ie. Service Coordination, Direct Care, Structured Day Program) are responsible for insuring that each patient served remains an active waiver patient and has the following: Notice of Decision (TBI Waiver and NHTD Waiver) with no lapse in service approval - including a complete Service Plan Patient Review Instrument/Screen and/or UASNY completed annually that meets all requirements Appropriate Medical/Doctor s Orders for Direct Care service hours/frequency completed each 6 months or when there is a change. Agency Department Heads/Supervisors will utilized the established agency Service Plan documentation form to ensure all necessary components of the Service Plan packet are present and complete. All agency Department Heads/Supervisors are responsible for insuring that each patient served under the auspice of a LTHHC contract, insurance, private pay and/or other ancillary funding payor has current authorization for services from the corresponding program/agency. This authorization includes the mandatory Medical/Doctor s Orders for Direct Care services, completed each 6 months or when there is a change. If, at any time, the Department Head/Supervisor becomes aware of any outdated or inaccurate approvals or participant eligibility requirements, all Medicaid billing for services will immediately cease and the Corporate Compliance Officer will be made aware of the situation. The Corporate Compliance Officer will initiate an investigation, while assisting the Department Head/Supervisor to rectify the situation. No services will be billed to Medicaid for time when there is not appropriate approvals or participant eligibly has lapsed. All agency service notes, as of June, , will be completed in a digital format using the agency s Electronic Health Record platform. Agency Department Heads/Supervisors are responsible for reviewing, on a weekly basis, service notes submitted by their departments/teams, for accuracy in date/time, frequency/duration, note content and completion. Any service notes found to be inadequate and/or missing will not be billed and the issues reviewed with the employee for correction. Appropriate disciplinary action may ensue, based on the specific issues. Agency Department Heads/Supervisors will, on a weekly basis, compared submitted service notes to the employee s time/attendance sheet for accuracy and cohesiveness. If any inconsistencies are found between the service note and the employee s time/attendance sheet, the service will not be billed and the issues reviewed with the employee for correction. Appropriate disciplinary action may ensue, based on the specific issues. updated

11 On a weekly basis, all agency Medicaid services for billing will be approved, by the Department Head/Supervisor, in the agency s Electronic Health Record system. Prior to submission to Electronic Health Record for billing to Medicaid, the will review for agency s Billing Coordinator will review participants whose Medicaid may be inactive, to ensure basic patient information is correct, ensure there is no overlap in patient services and that all notes have been reviewed by the supervisor. If discrepancies are found, the Billing Coordinator will immediately notify the Department Head/Supervisor and the Corporate Compliance Officer for corrective action. No services will be billed in which there is a discrepancy, until such as a time as the discrepancy can be corrected. Agency Department Heads/Supervisors will maintain a data base of all patients served, the number of hours approved (per week) and the number of PRN/Float hours available. These data bases will be updated, on a weekly basis, to ensure continued compliance with number of approved hours in relation to the service units completed. At a minimum once per year, a member of the Corporate Compliance Committee will conduct an internal review of the agency s Corporate Compliance Program, utilizing the Corporate Compliance Program Self-Evaluation/Audit tool. The results of this internal audit will be reviewed by the Corporate Compliance Committee for follow up, corrections and/or modifications to the program. Concerns in regards to fraudulent and/or possible fraudulent behavior/activities may be reported to the Corporate Compliance Officer by an agency employee, a previous employee, a patient, family member, community advocate and/or by an external audit and/or internal audit/mechanism. It is the agency s expectation that all contractors/grantees, who provide services/billing through ElderChoice, follow all necessary compliance guidelines, as outlined by ElderChoice as well as their own agency. Any reports to the Corporate Compliance Officer will in be reviewed and assigned an initial level of severity, as per the Corporate Compliance Complaint Investigation cover sheet. This form will be completed by the Corporate Compliance Officer, and become part of the final investigation, with results submitted to the agency Executive Director for review. These investigative reports will include, but are not limited to the compliance issue in question, the method the concern was brought to the attention of the Corporate Compliance Officer, steps taken to immediately correct the concern and recommendations for implementing procedures, policies and systems as necessary to reduce the potential for reoccurrences. If an overpayment is identified during the course of an investigation, weekly billing reconciliation and/or other internal audit mechanisms, the situation will be rectified immediately by either voiding erroneously billed services or, if self-disclosure is warranted, the agency will report the overpayment to OMIG, in writing, and return the overpayment to the state. It will be the responsibility of the agency Executive Director and agency governing body to explain in full and report any compliance issues to the Office for Medicaid Inspector General and/or Department of Health and refund overpayments, if necessary. FEDERAL LAWS: FEDERAL AND NYS STATUTES RELATING TO FILING FALSE CLAIMS Patient Protection and Affordable Care Act 6402 The Patient Protection and Affordable Care Act (PPACA), 6402, as pertinent to Medicare and Medicaid Program integrity provides, in part, that: (d) Reporting and returning of overpayments (1) in general if a person (which includes corporations and partnerships) has received an overpayment, the person shall (a) report and return the overpayment to the Secretary, the State an Intermediary, a carrier or a contractor, as appropriate, at the correct address and (b) notify the Secretary, state, intermediary carrier, or contractor to who m the overpayment was retuned in writing of the reason for the overpayment. Per PPACA 6402(d)(2), an overpayment must be reporting and returned within 60 days after the date on which the overpayment was identified or (b) the date on which any correspondent cost report is due. Providers may use void process through CSC (emedny claims system) for smaller or routine claims. A void is submitted to negate a previously paid claim based updated

12 upon a billing error or late reimbursement by a primary carrier. Overpayments of a smaller or routine claims which cannot be attributed to billing error or late reimbursement by a primary carrier should be reported to CSC in writing. These should include known mistakes in CSC of DOH billing and payment programs. False Claims Act (31 USC ) The False Claims Act ( FCA ) provides, in pertinent part, that: (a) Any person who (1) knowingly present, or causes to be presented, to an officer or employee of the US Government or a member of the Armed Forces of the US, a false or fraudulent claim for payment or approval (2) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government (3) conspires to defraud the Government by getting a false or fraudulent claim paid or approved by the Government.. or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or propriety to the Government, is liable to the US Government for a civil penalty of not less the n $5000 and more then $10, 000, plus 3 times the amount of damages which the Government sustain because of the act of that person (b) For purposes of this section, the terms knowing and knowingly mean that a person, with respect to information (1) has actual knowledge of the information: (2) acts in deliberate ignorance of the truth or falsity of the information or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required. While the False Claims Act imposes liability only when the claimant acts knowingly, it does not require that the person submitting the claim have actual knowledge that the claim is false. A person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information, also can be found liable under the Act 31U.S. C. 3729(b). In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government that he/she knows (or should know) is false. An example may be a physical who submits a bill to Medicare for medical services she knows she has not provide. The false Claims Act also imposes liability on an individuals who may knowingly submit a false record in order to obtain payment from the government. An example of this may include a government contractor who submits records that he knows (or should know) is false and that indicate compliance with certain contractual or regulatory requirements. The third area of liability includes those instances in which someone may obtain money from the federal government to which he may not be entitles, and that uses false statements or records in order to retain the money. An example of this so called reverse false claims may include a hospital who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare program. In addition it it s substantive providers, the FCA provides that private parties may bring an action on behalf of the US. 31 U.S.C (b). These private parties, known as qui tam relators, may share in a percentage of the proceeds from an FCA action or settlement. Section 3730 (d)(1) of the FCA provides, with some exceptions, that a qui tam relator, when the Government has interviewed in the lawsuit, shall receive at least 15% but not more then 25% of the proceeds of the FAC Action depending upon the extent to which the relator substantially contributed to the prosecution of the action. When the Government does not intervene, section 3730 (d)(2) provides that he relator shall receive an amount that the court decides is reasonable and shall not be less than 25% and not more than 30%. Administrative Remedies for False Claims (31 USC Chapter ) This statute allows for administrative recoveries by federal agencies. If a person submits a claim that the person knows is false or contains false information, or omits material information, then the agency receiving the claim may impose a penalty of up to $5,000 for each claim. The agency may also recover twice the amount of the claim. Unlike the False Claims Act, a violation of this law occurs when a false claim is submitted, not when it is paid. Also, unlike the False Claims Act, the determination of whether a claim sis false, and the imposition of the tines and penalties is made by the administrative agency, not by prosecution in the federal court system. updated

13 NEW Y ORK STATE New York s false claims law fall into two categories; civil and criminal laws. Some apply to recipient false calms in and some apply to provider false claims, and while most are specific to healthcare or Medicaid, some of the common law crimes apply to areas of interacting with the government. NYS CIVIL/ADMINISTRATIVE LAWS NY False Claims Act (State Finances Law ) The NY False Claims Act closely tract the federal False Claims Act. It imposes penalties and fines on individuals and entities that filed false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. The penalty for filing a false claim is $6,000- $12,000 per claim and the recoverable damages are between two and three times the value of the among falsely received. In addition, the false claims filer may have to pay the government s legal fees. The Act allow private individuals to file lawsuits in state court, joust as if they were state or local government parties. If the suit eventually concludes with payments back to the government, the person who started the case can recode 25%- 30% of the proceeds if the government did not participate in the suit of 15%-25% if the government did participate in the suit. Social Services Law 145-c False Statements It is a violation to knowingly obtain or attempt to obtain payment for items or services, furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment or other fraudulent scheme or device. The State or local Social Services district may remove three times the amount incorrectly paid. In addition, the Department of Health (DOH) may impose a civil penalty of up to $2,000 per violation. If repeat violations occur within 5 years, a penalty up to $7,500 per violation may be imposed if they involve more serious violation of Medicaid rules, bulling for services not rendered or providing excessive services. Social Services Law 145-c Sanctions If any person applies for or receives public assistance, including Medicaid, by intentionally making a false 0r misleading statement, or intending to do so, the parsons, the person s family s needs are not taken into account for 6 months if a first offense, 12 months is a second (or once if benefits received are over $3,9000) and live years for 4 or more offenses. NYS CRIMINAL LAW Social Services Law 145 Penalties Any person who submits false statements or deliberately conceals material information in order to receive public assistance, including Medicaid, is guilty of a misdemeanor. Social Services Law 366-b; Penalties for Fraudulent Practices (a) any person who obtains or attempts to obtain, for himself or others, medial assistance by mean of a false statement, concealment of material facts, impersonation or other fraudulent means is guilty of a Class A misdemeanor. (b) any person who, with intent to defraud, presents for payment and false or fraudulent claim for furnishing services, knowingly submits false information to obtain greater Medicaid compensation or knowingly submits false information in order to obtain authorization to provide items or services is guilty of a Class A misdemeanor. Penal Law Article 155; Larceny updated

14 The crime of larceny applies to a person who, with intent to deprive another of his property, obtains, takes or withholds the property by means of a trick, embezzlement, false pretense, false promise, including a scheme to defraud, or other similar behavior. It has been applied to Medicaid fraud cases. (a) Fourth degree grand larceny involves property valued over $1,000. It is a Class E felony. (b) Third degree grand larceny involves property valued of $3,000. It is a Class D felony. (c) Second degree grand larceny involves property valued of $50,000. It is a Class C felony. (d) First degree grand larceny involves property valued over $1,000,000. It is a Class B felony. Penal Law Article 175, False Written Statements Four crimes in this Article relate to filing false information or claims and have been applied in Medicaid fraud prosecutions: (a) , Falsifying business records involves entering false information, omitting material information or altering an enterprise s business records with the intent to defraud. It is a Class A misdemeanor. (b) , Falsifying business records in the first degree includes the elements of the offense and includes the intent to commit amount crime or conceal its commission. It is a Class E felony. (c) , Offering a false instrument for filing in the second degree involves presenting a written instrument (including a claim for payment) to a public office knowing that it contains false information. It is a Class A misdemeanor. (d) , Offering a false instrument for filing in the first degree includes the elements of the second degree offense and must include an intent to defraud the state or a political subdivision. It is a Class E felony. Penal Law Article 176, Insurance Fraud Applies to claims for insurance payments, including Medicaid or other health insurances and contains six crimes. (a) Insurance Fraud in the 5 th degree involves intentionally filing a false insurance claim knowing that it is false. It is a Class A misdemeanor. (b) Insurance Fraud in the 4 th degree involves filing a false insurance claim over $1,000. It is a Class E felony. (c) Insurance Fraud in the 3 th degree involves filing a false insurance claim over $3,000. It is a Class D felony. (d) Insurance Fraud in the 2 th degree involves filing a false insurance claim over $50,000. It is a Class C felony. (e) Insurance Fraud in the 1 st degree involves filing a false insurance claim over a $1,000,000. It is a Class B felony. (f) Aggravated insurance fraud is committing insurance fraud more than once. It is a Class D felony. Penal Law Article 177, Health Care Fraud Applies to claims for health insurance payment, including Medicaid, and contains five crimes: (a) Health care fraud in the 5 th degree if knowingly filing, with intent to defraud, a claims for payment that intentionally has false information or omissions. It is a Class A misdemeanor. (b) Health care fraud in the 4 th degree is filing a false claim and annually receiving over $3,000 in aggregate. It is a Class E felony. (c) Heath care fraud in the 3 rd degree is filing false claims and annually receiving over $10,000 in the aggregate. It is a Class D felony. (d) Health care fraud in the 2 nd degree is filing false claims and annually receiving over $50,000 in the aggregate. It is a Class C felony. (e) Health care fraud in the 1 st degree if filing false claims and annually receiving over $1,000,000 in the aggregate. It is a Class B felony. updated