We are committed to protecting the Privacy of Your Health Information. To receive a copy of the Matheny Medical and Educational Center Notice of Privacy Practices, please contact:
It is the policy of the Matheny Medical and Educational Center to obey all federal and state laws, to implement and enforce procedures to detect and prevent fraud, waste and abuse regarding payments to Matheny from federal or state healthcare programs, and to provide protections for those who report actual or suspected wrongdoing.
Further, pursuant to the requirements of Section 6032 of the Deficit Reduction Act of 2005, employees will be provided information about the Federal False Claims Act and other laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws. Employees will also be provided with Matheny’s policies and procedures for detecting and preventing fraud, waste and abuse.
Set forth below are summaries of certain statutes that provide liability for false claims and statements. These summaries are not intended to identify all applicable laws but rather to outline some of the major statutory provisions as required by the Deficit Reduction Act of 2005.
If the government proceeds with the case, the person who filed the action will receive between 15 percent and 25 percent of any recovery, depending upon the contribution of that person to the prosecution of the case. If the government does not proceed with the case, the person who filed the action will be entitled to between 25 percent and 30 percent of any recovery, plus reasonable expenses and attorneys’ fees and costs.
Anyone initiating a qui tam case may not be discriminated or retaliated against in any manner by his or her employer. The employee is authorized under the FCA to initiate court proceedings to make himself or herself whole for any job related losses resulting from any such discrimination or retaliation.
The PFCRA creates administrative remedies for making false claims and false statements. These penalties are separate from and in addition to any liability that may be imposed under the FCA.
The PFCRA imposes liability on people or entities who file a claim that they know or have reason to know:
A violation of this section of the PFCRA is punishable by a civil penalty of up to $5,000 for each wrongfully filed claim, plus an assessment of up to twice the amount of any unlawful claim that has been paid.
In addition, persons or entities violate the PFCRA if they submit a written statement which they know or should know:
A violation of this section of the PFCRA carries a civil penalty of up to $5,000 for each such statement in addition to any other remedy allowed under other laws.
NEW JERSEY FALSE CLAIMS LAWS
Proposed New Jersey False Health Claims Act
At the time of the effective date of this policy, the state of New Jersey is considering legislation regarding false claims. This legislation would parallel federal law.
New Jersey Medical Assistance and Health Services Act ("NJMAHSA") (N.J.S.A. 30:4D-1 et seq.)
Under this Act,
● a person who willfully obtains benefits to which he or she is not entitled and any provider who willfully receives payments to which the provider is not entitled, and
● a person, entity or provider who:
knowingly and willfully makes or causes to be made a false statement or representation of a material fact in any cost study, claim form or document necessary to apply for or receive a benefit or payment under the Act, or
knowingly and willfully makes or causes to be made any false statement of a material fact for use in determining rights to such benefit or payment, or
conceals or fails to disclose the occurrence of an event that affects the initial or continued right to any such benefit or payment with an intent to fraudulently secure benefits or payments not authorized under the Act, or
knowingly and willfully converts benefits or payments to a use other than for which it was received
is guilty of a high misdemeanor and, upon conviction, will be liable for a penalty of up to $10,000 for the first and each subsequent offense or for imprisonment for up to three years or both.
Any person, entity or provider who solicits, offers or receives any kickback, rebate or bribe in connection with the furnishing of items or services for which payment may be made or whose cost may be reported in order to obtain benefits or payments under the Act or in connection with the receipt of any benefit or payment under the Act, will be liable for a penalty of up to $10,000 or for imprisonment up to three years or both.
Whoever knowingly and willfully makes, causes to be made or induces or seeks to induce the making of a false statement of material fact with respect to conditions or operations of a facility in order that the facility may qualify upon certification or recertification as a hospital or intermediate care facility, will be guilty of a high misdemeanor and will be liable for a penalty of up to $3,000 or for imprisonment up to one year or both.
Any person, entity or provider who violates any of the above provisions shall also be liable for civil penalties of (i) interest at the maximum legal rate on the excess benefits or payments, (ii) an amount up to three-fold the amount of the excess benefits, and (iii) the sum of $2,000 for each excessive claim for benefits or payment.
Any person, entity or provider who, without intent to violate the Act, obtains benefits or payments in excess of the entitled amount, may be liable for a civil penalty of the payment of interest on the excess benefits or payments at the maximum legal rate.
A provider or person participating in a benefit program or acting as agent, employee or independent contractor of a provider may be suspended, debarred or disqualified for good cause.
New Jersey Health Care Claims Fraud Act ("NJHCCFA") (N.J.S.A. 2C:21-4.2, 4.3; 2C:51-5)
The NJHCCFA provides the following:
With respect to "practitioners", defined as anyone licensed, registered or certified by any state agency to practice a profession or occupation in New Jersey or another jurisdiction:
1. It is a crime of the second degree to knowingly commit health care claims fraud in the course of providing professional services.
2. It is a crime of the third degree if that person recklessly commits health care fraud in the course of providing professional services. ("Recklessly" means consciously disregarding a substantial and unjustifiable risk that the fraud exists or will result from his or her conduct. The risk must be such that its disregard involves a gross deviation from the standard of conduct that a reasonable person would observe in the actor’s situation.)
In addition to all criminal penalties allowed by law, a person convicted under these provisions may be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained, and suspension or forfeiture of the professional license.
With respect to persons who are not "practitioners":
1. It is a crime of the third degree if that person knowingly commits health care fraud.
2. It is a crime of the second degree if that person knowingly commits five or more acts of health care fraud and the aggregate pecuniary benefit obtained or sought is at least $1,000.
3. It is a crime of the fourth degree if that person recklessly commits health care fraud.
In addition to all criminal penalties allowed by law, a person convicted under these provisions may be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained.
ANTI-RETALIATION "WHISTLEBLOWER" PROTECTIONS
Individuals within an organization who observe activities or behavior that may violate the law in some manner and who report their observations either to management or to governmental agencies are provided protections under certain laws.
For example, protections are afforded to people who file qui tam lawsuits under the Federal False Claims Act, which is discussed above. The Federal False Claims Act states that any employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment because of lawful actions taken in furtherance of a qui tam action is entitled to recover damages. He or she is entitled to "all relief necessary to make the employee whole," including reinstatement with the same seniority status, twice the amount of back pay (plus interest), and compensation for any other damages the employee suffered as a result of the discrimination. The employee also can be awarded litigation costs and reasonable attorneys’ fees.
In addition, the New Jersey Conscientious Employee Protection Act prohibits an employer from retaliating against an employee because the employee (i) discloses or threatens to disclose an activity that the employee reasonably believes is in violation of law, or is fraudulent or criminal, or (for employees who are certified or licensed health care professionals) constitutes improper quality of patient care, (ii) provides information to a public body conducting an investigation, hearing or inquiry into any violation of law, or (for employees who are certified or licensed health care professionals) into the quality of patient care, or (iii) objects to or refuses to participate in an activity that the employee reasonably believes to be a violation of law, is fraudulent or criminal, is incompatible with a clear mandate of public policy, or (for employees who are certified or licensed health care professionals) constitutes improper quality of patient care. Available remedies may include an injunction restraining a continuing violation, reinstatement of the employee including full fringe benefits and seniority rights, compensation for lost wages, benefits and other remuneration, punitive damages, a civil fine, and payment by the employer of reasonable costs and attorney’s fees.
ROLE OF FALSE CLAIMS LAWS
The laws described in this policy create a comprehensive scheme for controlling waste, fraud and abuse in federal and state healthcare programs by giving appropriate governmental agencies the authority to seek out, investigate and prosecute violations. Enforcement activities are pursued in three available forums – criminal, civil and administrative. This provides a broad spectrum of remedies to battle this problem.
Anti-retaliation protections for individuals who make good faith reports of waste, fraud and abuse encourage reporting and provide broader opportunities to prosecute violators. Statutory provisions, such as the anti-retaliation provisions of the Federal False Claims Act, create reasonable incentives for this purpose. Employment protections create a level of security employees need to assist with the prosecution of these cases.
MATHENY’S MECHANISMS FOR DETECTING AND PREVENTING FRAUD
Matheny Medical and Educational Center maintains a Corporate Compliance Program detailed in Policies #140-7.1 and 140-7.2. The program is overseen by a Corporate Compliance Officer. The Corporate Compliance Program includes:
provisions for educating staff, at the time of hire and periodically thereafter, about ethical issues in the business of healthcare;
mechanisms for the reporting of possible breaches of ethics, including a toll-free compliance hotline;
means for providing guidance to staff who have questions about compliance-related issues; and
investigation of allegations of regulatory non-compliance.
Procedure:
Matheny staff, and contractors or other agents who act on behalf of Matheny in furnishing, authorizing or monitoring Medicaid services, or who perform billing and coding functions, will be informed about the False Claims Act, related federal or state laws, and Matheny’s mechanisms for detecting and preventing fraud and abuse through:
inclusion of such information in Matheny’s Employee Manual (initially as an addendum to the Employee Manual until such time as a revised Manual is issued);
inclusion of such information in new employee orientation;
other means of staff education as deemed appropriate; and
provision of such information to contractors and agents who act on behalf of Matheny in furnishing, authorizing or monitoring Medicaid services, or who perform billing and coding functions.
