Federal and State False Claims Statutes
Policy Number: OGC-7.01
Responsible Officer: General Counsel
Effective Date: December 11, 2006
Revisions: January 22, 2007
It is the policy of Drexel Med to provide detailed information to its employees – and those of its contractors and agents – about the role of the federal False Claims Act, the federal Program Fraud Civil Remedies Act, and applicable state false claims laws in preventing fraud, waste, and abuse in federal health care programs, including the Medicaid program.
The purpose of this policy is to comply with certain requirements set forth in the federal Deficit Reduction Act of 2005 (the “DRA”), and sections 6031 and 6032 of the DRA in particular, with regard to educating employees about federal and state false claims laws.
All Drexel Med programs and operations, including all Drexel Med employees and all Drexel Med's contractors and agents and their employees.
False claims laws seek to prevent fraud, waste, and abuse in government health care programs in two significant ways. First, they permit the government to bring civil lawsuits to recover damages and penalties against health care providers that submit false claims. Second, these laws often permit private persons, including current or former employees of such providers, to bring so-called “whistleblower” actions against the providers on the government's behalf.
There are both federal and state false claims laws.
• Federal False Claims Laws
The federal False Claims Act (“FCA”) makes any person or entity that knowingly submits a false or fraudulent claim for payment of United States government funds liable for significant penalties and fines. These sanctions include a penalty of up to three times the government's damages, civil penalties ranging from $5,500 to $11,000 per false claim, and the costs of the civil action against the entity that submitted the false claims. This law applies generally to federally-funded programs, including to health care programs such as Medicaid and Medicare.
The federal FCA also includes a “whistleblower,” or “qui tam,” provision. Under that provision, a private person with knowledge of a false claim may bring a civil action on behalf of the United States government to recover funds it has paid as a result of that false claim. The government will investigate the whistleblower's allegations and may or may not choose to join in the lawsuit. If the government chooses to participate, it assumes responsibility for all of the expenses associated with the lawsuit. If the lawsuit is ultimately successful, the court may award the whistleblower who initially brought the suit a percentage of the funds recovered. That percentage is lower when the government joins in the action. Regardless of whether the government participates, the court may reduce the whistleblower's share of the proceeds if it finds that the whistleblower planned and initiated the false claim violation. If the whistleblower is convicted of criminal conduct related to his or her role in the preparation or submission of the false claim, finally, the whistleblower will be dismissed from the civil action without receiving any portion of the proceeds.
The federal FCA also contains a provision that protects a whistleblower from retaliation by his or her employer. That provision applies to any employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against because of the employee's lawful conduct in furtherance of a false claim action. In such a case, the employee may bring an action in the appropriate federal district court and, if he or she prevails, is entitled to reinstatement with the same seniority status, two times the amount of back pay, interest on the back pay, and compensation for any special damages as a result of the retaliation, such as litigation costs and reasonable attorney's fees.
Like the federal FCA, the federal Program Fraud Civil Remedies Act (“PFCRA”) provides for administrative remedies against those who knowingly submitting false claims and statements. Under the PFCRA, a false claim or statement includes submitting a claim or making a written statement that is for services that were not provided, that assert a material fact that is false, or that omits a material fact. A violation of the statute may result in a maximum civil penalty of $5,500 per claim, plus an assessment of up to twice the amount of each false or fraudulent claim.
• State False Claims Law
Pennsylvania statutes make it a crime for providers to knowingly make false statements or present for allowance or payment a false or fraudulent claim or cost report for Medicaid items or services. Violations of these statutes are punishable by imprisonment and significant monetary penalties. State law also prohibits employers from retaliating against employees who make a good faith report of instances of wrongdoing or waste.
States periodically consider new legislation of this type, and the DRA includes specific incentives for states to pass their own FCAs. Accordingly, Drexel Med will update this policy as appropriate to identify any relevant new statute that the Pennsylvania General Assembly enacts.
Drexel Med takes compliance with the federal and state false claims laws seriously. Any employee who becomes aware of a violation or potential violation of such laws, or any fraudulent or potentially fraudulent conduct for that matter, is expected to report the same immediately. Employees, including Drexel Med management, contractors, and agents, should review, understand, and follow Drexel Med Policy OGC – 7 Reporting Allegations, found on the Human Resources policy page which sets forth general procedures for reporting and investigating suspected fraud. Employees may direct questions regarding the policy to their immediate supervisors or to Drexel Med's Chief Compliance Officer.
Drexel Med encourages employees initially to report compliance concerns to their immediate supervisors, when appropriate. In the alternative, reports may be made to Drexel Med's Compliance Hotline (at 866-936-1010 or on the web at www.drexelmed.edu click Faculty and Staff Resources and then click Compliance Hotline) or directly to the Chief Compliance Officer at 215-255-7819.
Any information that employees provide to their supervisors, or any member of the administration or the Chief Compliance Officer, will be kept in confidence to the extent feasible and legal. In the event of a government investigation or lawsuit, or if the need otherwise arises for Drexel Med to disclose the information, such information may be disclosed at the direction of legal counsel.
Drexel Med will not take adverse action against an employee for reasonably requesting assistance form, or reporting potential violations of law or Drexel Med policy to, a supervisor, the Compliance Hotline, or the Chief Compliance Officer. By reporting his or her own misconduct, however, an employee will not insulate himself or herself from potential disciplinary action for such a violation. Employees should report concerns about possible retaliation or harassment to the Chief Compliance Officer.
Drexel Med will not tolerate abuse of the reporting process. Any employee who makes an intentionally false statement, or makes a report of alleged misconduct in bad faith, shall be subject to appropriate disciplinary action.
31 U.S.C. §§ 3729-3733
31 U.S.C. §§ 3801-3812
62 P.S. §§ 1407, 1408
43 P.S. §§ 1421-1428