False Claims Recovery Policy
Merrick, Inc., will comply with the Deficit Reduction Act of 2005 and the purpose of this policy is to detect and prevent the waste, fraud, and abuse of Medicaid payments.
This policy applies to the Board of Trustees, and all employees, contractors, agents, and volunteers connected to Merrick, Inc.
3.00 POLICY STATEMENT:
It is a federal crime to provide materially false information on service billings for Medicaid or services provided under a federally approved waiver plan as authorized under Minnesota Statues, sections 256B.0913, 256B.0915, 256B.092, and 256B.49. It is our policy to provide information to all Trustees, employees, contractors, and agents about the federal and state false claims acts, remedies available under these provisions and how employees and others can use them, and about whistleblower protections available to anyone who claims a violation of the federal or state false claims acts.
The company has established procedures to detect and prevent waste, fraud, and abuse of Medicaid payments using the following terms:
4.11 Abuse is defined as – incidents or practices of providers that are inconsistent with sound medical practice and may result in unnecessary costs, improper payment, or the payment for services that either fail to meet professionally recognized standards of care or are medically unnecessary.
4.12 Claim is defined as – any request or demand for property or money, e.g., grants, loans, insurance or benefits, when the United States Government provides or will reimburse any portion of the money. Examples of a false claim might include: (i) making false statements regarding a claim for payment (ii) falsifying information in the medical record; (iii) double-billing for items or services; and/or (iv) billing for services or items not performed or never furnished.
4.13 Trustee, Employee, Contractor or Agent are defined as – (i) “Trustee” any volunteer serving on the Board, standing committee, or another governance role with the company; (ii) “Employee” any person hired by the company in any capacity; and (iii) “Contractor” or “Agent” anyone who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of Medicaid health care items or services, performs billing or coding functions, or is involved in monitoring of health care provided by the entity. It excludes individuals, businesses, or organizations that perform functions not associated with the provision of Medicaid health care items or services, such as copy and shredding services, ground maintenance, or hospital cafeteria or gift shop services.
4.14 False Claims Act (FCA) is defined as – statute (31 U.S.C. §3729 et seq.) that imposes civil liability on any person who: (i) knowingly presents, or causes to be presented, to an officer or employee of the United State Government or a member of the Armed Forces of the United States, a false or fraudulent claim for payment or approval; or (ii) 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; (iii) conspires to defraud the government by getting a false or fraudulent claim paid or approved by the Government; or (iv) has possession, custody, or control of property or money used, or to be used, by the Government and knowingly delivers, or causes to be delivered, less than all of that money or property; (v) is authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and, intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the receipt is true; (vi) knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the Government, or member of the Armed Forces, who lawfully may not sell or pledge property; or (vii) knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the government, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the Government. The Attorney General of the United States is required to diligently investigate violations of the FCA, and may bring a civil action against a person including penalties of between five thousand and ten thousand per claim, treble damages, and the costs of any civil action brought to recovery such penalties or damages.
4.15 Fraud is defined as – the intentional deception or misrepresentation that an individual knows to be false (or does not believe to be true) and makes, knowing that the deception could result in an unauthorized benefit to themselves or another person.
4.16 Knowingly is defined as – a person who 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 of the information. No proof of specific intent to defraud is required.
4.17 Qui Tam Action is defined as – actions by a private person who can bring a civil action in the name of the government for a violation of the FCA. Generally, the action may not be brought more than six years after the violation, but in no event more than ten. When the action is filed it remains under seal for at least sixty days. The United States Government may choose to intervene in the lawsuit and assume primary responsibility for prosecuting, dismissing, or settling the action. If the Government chooses not to intervene, the private party who initiated the lawsuit has the right to conduct the action. In the event the government proceeds with the lawsuit, the qui tam plaintiff may receive fifteen to twenty-five per cent of the proceeds of the action or settlement. If the qui tam plaintiff proceeds with the action without the government, the plaintiff may receive twenty-five to thirty per cent of the recovery. In either case, the plaintiff may also receive an amount for reasonable expenses plus reasonable attorneys’ fees and costs. If the civil action is frivolous, clearly vexatious, or brought primarily for harassment, the plaintiff may have to pay the defendant its fees and costs. If the plaintiff planned or initiated the violation, the share of proceeds may be reduced and, if found guilty of a crime associated with the violation, no share will be awarded the plaintiff.
4.18 Waste is defined as – the underutilization of any service, item, or material made available when it is reimbursed by the United States Government.
4.19 Whistleblower is defined as – a Trustee, employee, contractor, or agent (hereinafter “reporter”) connected to Merrick, Inc., that reports suspected waste, fraud, and abuse of Medicaid payments to the proper authority. The FCA provides for protection for reporters from retaliation. An employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against in terms and conditions of employment because of lawful acts conducted in furtherance of an action under the FCA may bring an action in Federal District Court seeking reinstatement, two times the amount of back pay plus interest, and other enumerated costs, damages, and fees.
4.20 A reporter is encouraged to contact the Executive Director of Merrick, Inc., or the President of the Board if the reporter is uncomfortable contacting the Executive Director, if they suspect waste, fraud, or abuse of Medicaid funds or have questions regarding the company’s conduct in this regard. However, a reporter is not required to first report a possible FCA violation to the Executive Director or President of the Board. A report may be made directly to the Department of Justice or the Minnesota Attorney General’s Office at the offices listed below. Still, in many instances Merrick, Inc., believes that the use of its internal reporting process is a better option because it allows us to quickly address potential issues. While we encourage reporters to consider first reporting suspected FCA violations to the Executive Director or President of the Board, the choice is up to the reporter.
Office of Inspector General
Department of Health & Human Services
P.O. Box 23489
Washington, DC 20026
Office of MN Attorney General
1400 Bremer Tower
455 Minnesota Street
St Paul, MN 55101
4.30 MN Statute 181.932 prohibits an employer from discharging, disciplining, threatening, otherwise discriminating against, or penalizing an employee regarding the employee’s compensation, terms, conditions, location, or privileges of employment because: (ii) the employee, or a person acting on behalf of an employee, in good faith, reports a violation or suspected violation of any federal or state law or rule adopted pursuant to law to an employer or to any governmental body or law enforcement official; (ii) the employee is requested by a public body or office to participate in an investigation, hearing, inquiry; (iii) the employee refuses an employer’s order to perform an action that the employee has an objective basis in fact to believe violates any state or federal law or rule or regulation adopted pursuant to law, and the employee informs the employer that the order is being refused for that reason; or (iv) the employee, in good faith, reports a situation in which the quality of health care services provided by a health care facility, organization, or health care provider violates a standard established by federal or state law or a professionally recognized national clinical or ethical standard and potentially places the public at risk of harm.
4.40 A notice explaining the purpose of the FCA, reporting information, and whistleblower protections will be posted at all times in the employee breakroom, explained in new employee orientation training, and summarized in the employee handbook which is available at all times either electronically or in hardcopy.
4.50 Any employee that retaliates against someone that has reported a FCA violation in good faith is subject to disciplinary action up to, and including, termination.
If a seizure occurs while the client is under the care of Merrick, Inc., employees are to follow the protocol outlined below and call 911 if any of the following are observed (unless the client has an individualized protocol to be followed):
- The client has never had a seizure before.
- Difficulty in breathing following a seizure or the client does not regain consciousness following a seizure.
- The client has a second seizure immediately following the first.
- The client has a seizure lasting more than five minutes.
- The client is experiencing a high fever.
- The client is experiencing heat exhaustion.
- The client is pregnant.
- The client has diabetes.
- The client has heart disease.
- The client sustained an injury prior to the seizure or during the seizure.
- The seizure occurred in water.
The Program Support Manager is responsible for: (i) completing a seizure form for the client’s file; (ii) contacting the client’s representative or home to notify them of the seizure activity; and (iii) instructing the caregiver to notify the client’s physician/medical provider.