False Claims Act & Whistleblower Protection. False Claims Act. The False Claims Act (FCA) was established in 1863 by President, Abraham Lincoln, to curb contract fraud during the Civil War by incentivizing integrity through awards based on the size of the fraud brought to the US Government.
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False Claims Act The False Claims Act (FCA) was established in 1863 by President, Abraham Lincoln, to curb contract fraud during the Civil War by incentivizing integrity through awards based on the size of the fraud brought to the US Government. The False Claims Act (FCA) is a Federal law that establishes criminal and civil liability when any covered person or covered entity improperly receives reimbursement from or avoids payments (excluding tax fraud) to the Federal government.
False Claims Act How is the FCA applicable to GT? We receive federally funded dollars for providing our fiscal intermediary service.
False Claims Act Basic Points of the FCA • Not a Tip Line - FCA cases are evidence driven • Not Easy or Fast - Successful cases often require years of investigation, putting tremendous strain on whistleblowers and lawyers. Big cases can require big investments from private law firms. • Triple Damages – Person or entity committing fraud can be responsible for up to triple damages plus statutory penalties and exclusion being able to provide federally funded services. • Cheaters Pay Whistleblower Awards – The triple damages collected pay for the stolen government money, cost of investigations, lost interest, and whistleblower awards.
False Claims Act FCA Success 1987-2011
False Claims Act The False Claims Act has been so successful that it has been replicated: • In 29 states including MI, NC, WI, and FL • The Securities and Exchange Commission, Internal Revenue Service, and Commodities Future Trading Commission have all created a whistleblower program modeled on the FCA
Comprehension Check The False Claims Act is only applicable at the Federal level. True or False? FALSE Many states have implemented a False Claims Act.
Whistleblower Employee Protection Whistleblowers are private citizens who file suit on behalf of the State or Federal government to recover damages incurred by the government as a result of contractor fraud or other false claims. Whistleblowers may be entitled to a significant portion of the proceeds from a successfully prosecuted claim. Whistleblowers are protected from retaliation because of their participation in filing or testifying in a claim.
Comprehension Check The Whistleblower’s Act protects employees from retaliation in reporting. True or False? TRUE
False Claims Act – OUR RESPONSIBILITY At GT Independence, it is our policy to minimize the opportunities for fraud, waste, abuse, and neglect and report incidents as required by all applicable federal and state laws. All employees, including management, and any contractors or agents are educated in and should maintain familiarity with the types of fraud and any other action (or inaction) that results in fraud, waste or abuse of public resources. GT Independence will not retaliate against any employee, contractor, or agent who reports or testifies regarding fraud, abuse, or neglect.
Comprehension Check It is the policy of GT to minimize fraud, waste, abuse, and neglect. True or False? TRUE
False Claims Act – Our RESPONSIBILITY Examples of Fraud* • Billing for goods or services that were never provided • Submitting false service records in order to show better-than-average performance • Performing inappropriate or unnecessary medical procedures • Billing inflated charges instead of actual charges • Inflating bills by using a code that suggests a more expensive service was preformed • Charging more than once for the same service • Prescribing a medication or service in order to win kickbacks from hospitals, labs or pharmaceutical companies. *It is impossible to succinctly list all of the fraud schemes that have been prosecuted under the FCA. This list is non-exhaustive, but gives an idea of the scope of frauds that have been uncovered to date.
Comprehension Check It is okay to bill for goods and services that were never provided. True or False? FALSE This would be a fraudulent activity.
False Claims Act – OUR RESPONSIBILITY Types of Fraud We See at GT Independence • Forged signatures on time cards • Claiming hours not worked • Claiming hours under another worker’s name • Claiming hours while a participant is hospitalized • Impersonation of a participant or worker to obtain or change personal information, such as address or bank account
False Claims Act – OUR RESPONSIBILITY Look for Indicators of Potential Fraud • Time cards that appear to be copied or altered in anyway • Excessive hours being claimed for a pay period • No hours claimed over a 3 month period • High employee turnover • Indications participants or workers are over-controlling services such as only the participant calling about the employee’s paycheck/employee never makes contact • Purchasing excessive fuel that is not consistent with mileage logs • Inconsistent and/or suspicious information from caller such as the caller keeps changing the information provided or cannot verify their identity • Severe complaints or episodes of aggressive behavior • Any other behaviors that are not consistent with the program
False Claims Act – OUR RESPONSIBILITY Reporting Fraud – Incident Reporting • An Incident Report will be completed if you become aware of any actual or suspected fraud, waste, or abuse. • This form is available at P:\GFS File Server\Fiduciary Services\Common Forms & Letters- all states\Internal Forms\Incident Report for GT Independence
False Claims Act – OUR RESPONSIBILITY Reporting Fraud – Incident Reporting • When documenting an incident : • Use objective language, no assumptions or opinions • Fully complete the form with no missing information • Within 24 hours the report must be completed, faxed to the agency contact, as well as, a verbal notification made • Submit to your supervisor/team leader within 5 calendar days • You must gain follow-up or corrective action information from the agency contact.
False Claims Act – OUR RESPONSIBILITY Reporting Fraud – Corporate Compliance • The Compliance Officer will review all incident reports and determine if an internal investigation should be conducted. • The Quality Management Team will review collective incident reports to identify trends and overall improvements needed. • The Compliance Officer is the main contact for any outside (state, federal, or agency) investigation.
False Claims Act – OUR RESPONSIBILITY Reporting Fraud – Outside Reporting • Fraud can also be reported outside GT Independence through the Office of Inspector General, http://oig.hhs.gov/fraud/report-fraud/index.asp • And/Or by state via • Michigan Department of Community Health • Wisconsin Department of Justice • North Caroline Department of Health and Human Services • Florida Agency for Health Care Administration • Or any other appropriate agency
Comprehension Check Reporting fraud, abuse, or neglect is optional at GT Independence. True or False? FALSE We are required to report all incidents of fraud, waste, abuse, and neglect.
Questions More information on the FCA is available at: • http://www.taf.org/ • http://www.whistleblowerlaws.com/ • http://oig.hhs.gov/fraud/ You play an important role in upholding the public trust. If you suspect fraud or ethical violations that involve GT Independence, you are encouraged to contact the CEO and Compliance Officer. This training is meant to define and clarify fraudulent activities making it recognizable to the employees and staff of GT Independence. It should be understood that you may also notify any appropriate regulatory agency without fear of retaliation. Questions may be directed to your Supervisor, Team Leader, Human Resources Department., Compliance Officer, or CEO.
Acknowledgment Please complete the quiz and sign, acknowledging you understand the False Claims/Whistleblowers material presented in this training. Return the quiz to Human Resources. Thank you for participating in this training!