Detection and Prevention of Fraud, Waste, and Abuse, and Applicable Federal and State Laws

WVHCS is committed to the detection and prevention of fraud, waste and abuse in federal and state health care programs and to complying with all applicable federal and state laws and regulations. To that end, WVHCS (1) operates under a Compliance Program, (2) promotes Compliance Program Standards of Conduct and Policies and Procedures and (3) maintains departmental policies and procedures that support compliance and good business practices. The WVHCS Compliance Program Standards of Conduct, Policies and Procedures and departmental policies and procedures are posted on the WVHCS Intranet.

Federal and State Laws Pertaining to Civil or Criminal Penalties for False Claims and Statements

The federal Civil False Claims Act, the Program Fraud Civil Remedies Act and Pennsylvania’s Medicaid Fraud and Abuse Control Law are important laws in the prevention and detection of fraud, waste and abuse in federal and state health care programs. These laws are detailed in Compliance Services Policy CS-190 (“False Claims Act Information”) and are summarized below.

Federal Civil False Claims Act (42 U.S.C. § 3729 et seq.)

The federal Civil False Claims Act (“FCA”) is a law aimed at preventing fraud against the federal government, including fraudulent billing and submission of claims to all federal health care programs (e.g., Medicare and Medicaid). In general, the FCA prohibits any person or entity from:

• Knowingly presenting, or causing to be presented, a false or fraudulent claim, record or statement to the government for payment or approval;
• Conspiring to defraud the government by getting a false or fraudulent claim allowed or paid;
• Using a false record or statement to avoid or decrease on obligation to pay the government; or
• Committing any other fraudulent acts detailed in the FCA.

The term “knowingly” means that the person has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information or acts in reckless disregard of the truth or falsity or the information. No proof of a specific intent to defraud the government is required.

The U.S. Attorney General may bring civil actions for violations of the FCA. A private person also may file a FCA suit in the name of the United States for false or fraudulent claims submitted by individuals or entities. Commonly known as “qui tam” actions, such lawsuits by a private person are commenced when a “relator” (also referred to as a “whistleblower”) files a civil complaint in federal court, under seal, and discloses material evidence to the U.S. Attorney General. Whistleblowers who file a qui tam action may receive a reward of 15-30 percent of the monies recovered for the government, plus attorneys’ fees and costs. (This amount may be reduced, however, if, for example, the court finds the whistleblower planned and initiated the violation.)

FCA Whistleblower Protections

Whistleblowers are afforded certain protections against retaliation for bringing an action under the FCA. An employee who is discharged, demoted, suspended, threatened, harassed or confronts discrimination in furtherance of such an action or as a consequence of whistleblowing activity is entitled to all relief necessary to make the employee whole. Such relief may include reinstatement, double back pay, and compensation for any special damages, including litigation costs and reasonable attorneys’ fees.

The Program Fraud Civil Remedies Act of 1986 (31 U.S.C. § 3801 et seq.)

The Program Fraud Civil Remedies Act (“PFCRA”) provides for administrative remedies against persons or entities that make, or cause to be made, a false claim or written statement to certain federal agencies, including the U.S. Department of Health and Human Services. The conduct prohibited by the PFCRA is similar to that prohibited by the FCA. The PFCRA makes it unlawful for any person or entity to make, present or submit or to cause to be made, presented, or submitted, a claim that the person or entity knows or has reason to know:

• Is false, fictitious, or fraudulent;
• Includes or is supported by any written statement which asserts a material fact which is false, fictitious, or fraudulent;
• Includes or is supported by any written statement that omits a material fact; is false, fictitious, or fraudulent as a result of such omission; and is a statement in which the person or entity making, presenting, or submitting such statement has a duty to include such material fact; or
• Is for payment for the provision of property or services which the person or entity has not provided as claimed.

Pennsylvania’s Medicaid Fraud and Abuse Control Law (62 P.S. § 1407)

Pennsylvania’s Medicaid Fraud and Abuse Control Law (“Medicaid Fraud Control Act”) provides a criminal remedy for the submission of false or fraudulent claims to Pennsylvania’s medical assistance (i.e., Medicaid) program. The Medicaid Fraud Control Act prohibits any person from, among other things:

• Knowingly or intentionally presenting for allowance or payment any false or fraudulent claim or cost report for furnishing services or merchandise under the Medicaid program;
• Knowingly presenting for allowance or payment any claim or cost report for medically unnecessary services or merchandise under the Medicaid program;
• Knowingly submitting false information, for the purpose of obtaining greater compensation than that to which he or she is legally entitled for furnishing services or merchandise under the Medicaid program; or
• Knowingly submitting false information for the purpose of obtaining or furnishing services or merchandise under the Medicaid program.

Pennsylvania Whistleblower Protections

The Pennsylvania Whistleblower Law (43 P.S. §§ 1421-1428) provides protection from discrimination and retaliation to any person who witnesses or has evidence of wrongdoing or waste while employed by a public body (e.g., state, county or city agency, department, division or council, etc.) and who makes a good faith report of the wrongdoing or waste, verbally or in writing, to one of the person’s superiors, to an agent of the employer or to an appropriate authority. No employer may discharge, threaten or otherwise discriminate or retaliate against an employee regarding the employee’s compensation, terms, conditions, location or privileges of employment because the employee, or a person acting on behalf of the employee, makes a good faith report or is about to report, verbally or in writing, to the employer or appropriate authority an instance of wrongdoing or waste.

WVHCS Whistleblower Protections

Consistent with the FCA and the Pennsylvania Whistleblower Law, WVHCS’s policy is to protect employees from any retaliation or retribution for reporting suspected violations of the law to law enforcement officials or to WVHCS management or for filing “whistleblower” lawsuits on behalf of the government. Specifically, Compliance Services Policy CS-170 (“Non-Retaliation/Non-Retribution”) prohibits retaliation in any manner or retribution against an employee who has made or intends to make a report of an activity, practice or arrangement that the employee believes violates or may violate a law (including the FCA), a regulation, or Compliance Program Standards of Conduct or Policies or Procedures.

Questions?

Questions regarding the FCA, the PFCRA, Pennsylvania’s Medicaid Fraud Control Act, related whistleblower protections or WVHCS’s commitment to preventing fraud, waste and abuse in federal and state health care programs, should be directed to WVHCS’s Chief Compliance Officer. Any employee who has knowledge or information of any potential false claims or other wrongdoing has a duty under the WVHCS Compliance Program to report such suspected misconduct to the Chief Compliance Officer, to the employee’s direct supervisor, or through WVHCS’s Compliance Line at (800) 822-2122. Information may be reported to the Chief Compliance Officer or through the Compliance Line anonymously. For additional information regarding the handling of Compliance Line calls, see Compliance Services Policy CS-120 (“Internal Handling of Compliance Line Calls”).