SUBJECT False Claims Act, Qui Tam Protections and Health

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					                              CENTRAL MICHIGAN COMMUNITY HOSPITAL

SUBJECT:           False Claims Act, Qui Tam Protections and Health                               POLICY #: 115.128
                   Care Programs Education Policy
SCOPE:             CMCH, All Departments                                                                   Page 1 of 2
                   CMCH Radiation Oncology
                   CMCH – SHH Cardiology
                   Medical Staff
Issued By:         Corporate Compliance Officer                                                       Approved By:
Reviewed By:       Compliance Steering Committee                                      Compliance Steering Committee

ORIGINAL EFFECTIVE DATE: 03/02/07                                                    REVISED DATE: June 16, 2008

PURPOSE:
 1.0 To provide all associates (employees, medical staff, volunteers, contractors, and other agents) of Central
     Michigan Community Hospital (CMCH) with an awareness of the following:
     1.1 Definitions and examples of Medicare/Medicaid fraud, abuse and waste.
     1.2 Federal False Claims Act, whistleblower protection and penalties.
     1.3 State False Claims Act, whistleblower protection and penalties.
 2.0 Educate on the appropriate protocol for administrative remedies of Medicare/Medicaid fraud, abuse or
     waste.
 3.0 Educate on appropriate procedures for prevention of Medicare/Medicaid fraud, abuse or waste.
 4.0 Educate on CMCH Compliance Policies for violations of procedures with Medicare/Medicaid.

SUPERCEDES:             NA

REFERENCE:

1.0    Deficit Reduction Act of 2005 (42 U.S.C. 1396a(a)(68))
2.0    Central Michigan Community Hospital DRA Compliance Review (01/16/06), Smith Haughey Rice &
       Roegge

POLICY:

1.0    CMCH will have zero tolerance for anyone engaging in fraud, abuse or waste of Medicare/Medicaid
       benefits.
2.0    CMCH will provide associates, as required and appropriate, with information pertaining to the federal and
       state laws pertaining to federal and state False Claims Acts and Whistleblower protections.
3.0    CMCH will provide associates, as required and appropriate, with information pertaining to the polices for
       reporting possible issues of illegal or noncompliant activities and protection associated with the reporting
       such activities.
4.0    The following information will be provided either through distribution of this policy or as part of other
       materials used in other training efforts:
               Central Michigan Community Hospital is committed to complying with its regulatory obligations
               as they relate to detecting and reporting health care fraud and abuse. Healthcare compliance
               is a proactive practice designed to prevent fraudulent activities. In the interest of educating
               and familiarizing employees, medical staff, volunteers, contractors, and other agents of CMCH
               about health care compliance in this arena, pertinent Federal and Michigan laws and
               regulations are summarized below. In addition, this information is also detailed in the following
               Corporate Compliance’s policies: Reporting of Compliance Issues (policy #115.122),
               Investigating and Remedying Compliance Issues (policy #115.123) and Non-Retaliation for
               Reporting (policy #115.124)
               The Federal government has enacted the Federal False Claims Act, which is paralleled by the
               Michigan Medicaid False Claims Act. Both the Federal and Michigan versions of the Act cover
               fraud involving any state or federally funded contract or program.
                             CENTRAL MICHIGAN COMMUNITY HOSPITAL

Subject:         False Claims Act, Qui Tam Protections and Health                                 Policy #: 115.128
                 Care Programs Education Policy
                                                                                                      Page 2 of 2
Original Effective Date: 03/02/2007                                                   Revised Date: June 16, 2008

               The Federal False Claims Act allows private citizens to bring suits against companies or
               persons who have committed fraud with any federally funded contract or program.
               Medicare/Medicaid is now included under this Act. Those found guilty under this act are liable
               for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false
               claim.
               The Michigan Medicaid False Claim Act prohibits fraud, kickbacks, bribes, and conspiracies
               in connection to the Medicaid program. Under this Act, the Attorney General is authorized to
               investigate, directly or indirectly by appointment, any alleged violations of the Act. In addition,
               this Act provides specific guidelines for any person to bring a civil action against another
               person or health facility and/or its agency on behalf of the state for violations of this Act. A
               person that initiates a civil action and follows the guidelines will be protected under this Act
               from retaliation by the employer. Those found guilty under this Act could face imprisonment
               between 4-9 years and/or be subject to fines of $30,000 to $50,000.
               Each Act establishes liability for any person or entity that knowingly presents or causes to be
               presented a false or fraudulent claim to the United States government or the State of Michigan
               for payment. Both the Federal and Michigan versions of the False Claims Act do not require
               proof of a specific intent to defraud the Federal government or the State of Michigan. Instead,
               health care providers and facilities can be prosecuted for conduct that leads to the submission
               of fraudulent claims to the Federal government or the State of Michigan.
               To encourage individuals to come forward and report misconduct involving false claims, both
               the Federal government and the State of Michigan have enacted “qui tam” or whistleblower
               protections. The Federal False Claims Act allows any person with actual knowledge of
               allegedly false claims submitted to the government to file a lawsuit on behalf of the United
               States government. In addition, the Michigan Whistleblower Protection Act and the
               Michigan Health Facility Whistleblower Protection Act protect a person who makes a
               report of a violation. Under these acts, an individual employed or under contract with a health
               facility and seeking to take action under the Act, must give the facility sixty days written notice
               of any issues that may pose as an illegal or unsafe practice and the individual must not have a
               reasonable expectation that the facility has taken or will take timely action to the address the
               issue. Individuals reporting violations under either of these acts are assured that such reports
               will be treated confidential and employers are prohibited from taking adverse employment
               action (for example, discharge, threats or discrimination) against an individual because the
               individual, or someone on the individuals behalf, reports or is about to report a violation of a
               law, rule or regulation, when the report is made to a public body. It also protects an individual
               who is requested by a public body to participate in an investigation, hearing or inquiry, or a
               court action. An individual who suffers an adverse employment action under this Act may file a
               lawsuit in Circuit Court, seeking actual damages, including lost wages, benefits and other
               appropriate relief.
               In addition, Federal Agencies have authority under Program Fraud Civil Remedies Act to
               investigate allegations that a company or person has committed a fraud upon the Government.
               An employee with knowledge of a fraud against the United States Government can file a report
               with the appropriate agency to trigger such an investigation.




DISTRIBUTION:
All Departments
Active Medical Staff
Central Michigan Community Hospital Radiation Oncology
CMCH – SHH Cardiology
                              CENTRAL MICHIGAN COMMUNITY HOSPITAL

Subject:          Reporting of Compliance Issues                                                Policy No. 115.122
SCOPE:            CMCH, All Departments                                                                 Page 1 of 2
                  CMCH Radiation Oncology
                  CMCH – SHH Cardiology
Issued By:        Corporate Compliance Officer                                                     Approved By:
Reviewed By:      Compliance Steering Committee                                  Compliance Steering Committee

Original Effective Date: 08/05/2002                                                   Revised Date: June 16, 2008

PURPOSE:          It is Central Michigan Community Hospital’s (CMCH) conviction that positive employee relations and
morale can be best achieved and maintained in a working environment that promotes ongoing open communication
between all levels of the organization. This includes open and candid discussion of problems and concerns for the
following purposes:
     To encourage employees to express their problems, concerns and opinions on any compliance issue. Toward
     that end, it is the policy of CMCH to provide its employees a procedure to express problems, concerns and
     opinions without fear of retaliation or reprisal.
     To reiterate the commitment of CMCH to comply with the standards established Section 6032
     (Employee Education About False Claims Recovery) of the Deficit Reduction Act of 2005. The DRA
     requires that state Medicaid Plans be amended to require certain types of health care providers to
     establish written policies that address the whistleblower protections provided under both federal and
     state laws, and role of these laws in preventing and detecting fraud, waste and abuse. A summary of
     the whistleblower protections under the Federal False Claims Act and the Michigan Health Facility
     Whistleblower Protection Act is detailed in the Corporate Compliance policy: “False Claims Act, Qui
     Tam Protections and Health Care Programs Education Policy”, (policy # 115.128).
SUPERSEDES: NA
REFERENCES:
1.0  Central Michigan Community Hospital, Standards of Conduct
2.0  Central Michigan Community Hospital Compliance Responsibilities
3.0  Central Michigan Community Hospital Corporate Compliance Plan
4.0  Compliance Program Guidance For Hospitals, The Office of Inspector General
5.0  Deficit Reduction Act of 2005, Section 6032
6.0  Central Michigan Community Hospital DRA Compliance Review (01/16/06), Smith Haughey Rice &
     Roegge
POLICY:
1.0     Each Associate has an obligation, if they become aware of; to immediately report to the appropriate
        person(s) within CMCH any activity they believe to be inconsistent with any laws, rules and/or regulations
        of the United States, State of Michigan and every locality where CMCH does business.
2.0     The Compliance Department will establish and maintain methods for associates to report any activity they
        believe to be inconsistent with any laws, rules and/or regulations of the United States, State of Michigan
        and every locality where CMCH does business.
3.0     Associates may report any activity they believe to be inconsistent with any laws, rules and/or regulations of
        the United States, State of Michigan and every locality where CMCH does business by one of the following
        methods.
        3.1     Report through a Department Director, Manager, or Supervisor.
                3.1.1   All of the following are acceptable means of communication with the Department Director,
                        Manager or Supervisor:
                        • Discussion with the Department Director, Manager or Supervisor,
                        • Written form or memorandum,
                        • Email, or
                        • Voicemail.
        3.2     Associates may also report directly to the Corporate Compliance Officer
                3.2.1   All of the following are acceptable means of communication with the Corporate
                        Compliance Officer:
                                CENTRAL MICHIGAN COMMUNITY HOSPITAL

Subject:         Reporting of Compliance Issues                                               Policy No. 115.122
                                                                                                     Page 2 of 2
Original Effective Date: 08/05/2002                                                  Revised Date: June 24, 2008

                       •   Corporate Compliance Hotline, which is accessible 24 hours a day. The number for
                           this hotline is 772-6816,
                       •   Corporate Compliance Violation report form (attachment #1), which should be
                           available in each department, can be printed from CMCH’s Policy and Procedure
                           website, or may be printed from the Compliance Forms folder, located in the
                           Conf_RM folder, located on the Common on ‘Fs-cmch… drive.,
                       •   Email (to dcornell@cmch.org) ,
                       •   Voicemail (772-6806),
                       •   Meet personally with the Corporate Compliance Officer.
       3.3     The Corporate Compliance Hotline and Violation report form may be used anonymously.

4.0    Failure to report knowledge of wrong doing may result in disciplinary action against those who fail to report.

5.0    There will be no reprisals for good faith reporting of actual or possible non-compliant issues. Concerns
       about possible retaliation or harassment should be reported to the Corporate Compliance Officer.

6.0    Whenever possible, the identity of the employee making the report will be kept confidential.




ATTACHMENTS:
115.122.A1 Compliance Violation Report form




DISTRIBUTION:
All Departments
Active Medical Staff
Central Michigan Community Hospital Radiation Oncology
CMCH – SHH Cardiology
                                                 Compliance Violation Report
                This form is for reporting alleged violations of Federal, State, or other regulations and
                        laws which the Compliance Department has jurisdiction to investigate.
          Note:     This form is not for reporting grievances or general complaints. You must follow the normal process for such
                    complaints.

Please Complete all of the following information:
Today’s Date:                                                          Date or Dates of Violations:

Person or Dept. alleged to have committed the violation:

Please describe in detail what you believe is not in compliance with applicable Federal, State, or other regulations or
laws at our Hospital (please submit any supporting documentation you may have, or indicate where the documentation
can be found):




What is the Federal, State, or other regulations or laws that you believe has been violated:




                                                          (Please attach additional sheets if necessary)

Has this violation been reported to anyone previously, if yes, to whom and when?



                                                                OPTIONAL INFORMATION:
NAME:                                                                  POSITION:

Telephone Number:
Please note: Although this information is not required for an investigation to be conducted, the Compliance Department will be unable to report findings back to
you or obtain additional information if needed without this information. CMCH does not permit retaliatory action against employees who, in good faith,
report violations.



115.122 attachment #1 Compliance Violation Report form                                                                                         Page: 1 of 1
                               CENTRAL MICHIGAN COMMUNITY HOSPITAL

Subject:          Non-Retaliation for Reporting                                                 Policy No. 115.124
SCOPE:            CMCH, All Departments                                                                 Page 1 of 2
                  CMCH Radiation Oncology
                  CMCH – SHH Cardiology
                  Medical Staff
Issued By:        Corporate Compliance Officer                                                      Approved By:
Reviewed By:      Compliance Steering Committee                                     Compliance Steering Committee

Original Effective Date: 03/04/2003                                                    Revised Date: June 16, 2008

PURPOSE:          It is Central Michigan Community Hospital’s (CMCH) conviction that positive employee relations and
morale can be best achieved and maintained in a working environment that promotes ongoing open communication
between all levels of the organization. This includes open and candid discussion of problems and concerns for the
following purposes:
     To encourage employees to express their problems, concerns and opinions on any compliance issue. Toward
     that end, it is the policy of CMCH to provide its employees a procedure to express problems, concerns and
     opinions without fear of retaliation or reprisal.
     To protect employees from retaliation/retribution for reporting of information under the Compliance Program.
     To meet the requirement of the Office of the Inspector General’s “Compliance Program Guidance for Hospitals”
     and to establish a policy of non-retaliation/non-retribution for employees who report suspected violations of the
     law, regulations, organizational policies and procedures and the CMCH Standards of Conduct.
     To reiterate the commitment of CMCH to comply with the standards established Section 6032
     (Employee Education About False Claims Recovery) of the Deficit Reduction Act of 2005. The DRA
     requires that state Medicaid Plans be amended to require certain types of health care providers to
     establish written policies that address the whistleblower protections provided under both federal and
     state laws, and role of these laws in preventing and detecting fraud, waste and abuse. A summary of
     the whistleblower protections under the Federal False Claims Act and the Michigan Health Facility
     Whistleblower Protection Act is detailed in the Corporate Compliance policy: “False Claims Act, Qui
     Tam Protections and Health Care Programs Education Policy”, (policy # 115.128).

SUPERSEDES: None

REFERENCES:
1.   Compliance Program Guidance for Hospitals, The Office of the Inspector General
2.   Deficit Reduction Act of 2005, Section 6032
3.   Central Michigan Community Hospital DRA Compliance Review (01/16/06), Smith Haughey Rice &
     Roegge
POLICY:

1. All employees, including directors, managers and supervisors, are responsible for promptly reporting suspected
   wrongdoing, including a suspected violation of a law, regulation, policy, procedure and/or our Standards of
   Conduct.

2. Employees who, in good faith, report a possible violation of law, regulation, policy, procedure and/or our
   Standards of Conduct will not be subject to retaliation, retribution or harassment. No employee is permitted to
   engage in retaliation, retribution or any form of harassment against a colleague who reports compliance related
   concerns. Any employee who conducts or condones retaliation, retribution or harassment in any way will be
   subject to discipline, up to and including termination.

3. Employees cannot exempt themselves from the consequences of wrongdoing by reporting their own
   wrongdoing, although self-reporting may be taken into account in determining the appropriate course of action.

4. All employees, including directors, managers and supervisors, are responsible for promptly reporting suspected
   retaliation, retribution or harassment to the Corporate Compliance Officer.
                             CENTRAL MICHIGAN COMMUNITY HOSPITAL

Subject:         Non-Retaliation for Reporting                                         Policy No. 115.124
                                                                                               Page 2 of 2
Original Effective Date: 03/04/2003                                            Revised Date: June 16, 2008


DEFINITION:
   1.     Retaliation – Discipline, demotion, termination of employment or any other form of retribution or
          harassment because a colleague reported in good faith a suspected wrongdoing or other compliance
          concern.




DISTRIBUTION:
All Departments
Active Medical Staff
Central Michigan Community Hospital Radiation Oncology
CMCH – SHH Cardiology
                                 CENTRAL MICHIGAN COMMUNITY HOSPITAL

Subject:          Investigation and Remediation of Compliance Issues                            Policy No. 115.123
SCOPE:            CMCH, All Departments                                                                 Page 1 of 2
                  CMCH Radiation Oncology
                  CMCH – SHH Cardiology
Issued By:        Corporate Compliance Officer                                                      Approved By:
Reviewed By:      Compliance Steering Committee                                     Compliance Steering Committee

Original Effective Date: 08/05/2002                                                   Revised Date: June 24, 2008

PURPOSE:
1.0  To reiterate the commitment of CMCH to comply with the standards of conduct established by (1)
     The Federal False Claims Act; (2) The Michigan Medicaid False Claims Act; and (3) Other
     Michigan Medicaid plan amendments promulgated to comply with Section 6032 (Employee
     Education About False Claims Recovery) of the Deficit Reduction Act of 2005. The DRA requires
     that state Medicaid Plans be amended to require certain types of health care providers to establish
     written policies that address the following: (1) the Federal civil False Claims Act; (2) state laws
     pertaining to civil or criminal penalties for false claims and statements, and the role of these laws in
     preventing and detecting fraud, waste and abuse; (4) the administrative remedies found in the
     Program Fraud Civil Remedies Act; and (5) CMCH’s polices and procedures for detecting and
     preventing fraud, waste and abuse. A summary of the relevant federal and state laws is detailed in
     Corporate Compliance policy: “False Claims Act, Qui Tam Protections and Health Care Programs
     Education Policy”, (policy # 115.128).
2.0     To provide a protocol and mechanism for the investigation and remediation of all compliance issues.

SUPERSEDES: NA

REFERENCES:
1.0  Central Michigan Community Hospital, Standards of Conduct
2.0  Central Michigan Community Hospital Compliance Responsibilities
3.0  Central Michigan Community Hospital Corporate Compliance Plan
4.0  Compliance Program Guidance For Hospitals, The Office of Inspector General
5.0  Deficit Reduction Act of 2005, Section 6032
6.0  Central Michigan Community Hospital DRA Compliance Review (01/16/06), Smith Haughey Rice &
     Roegge

POLICY:
1.0     All issues believed to be inconsistent with any laws, rules and/or regulations of the United States, state of
        Michigan and any locality where CMCH does business will be investigated within five (5) working days of
        being discovered.
2.0     The Corporate Compliance Officer or appropriate representative will perform a preliminary evaluation and
        determine whether the alleged facts would establish an instance of non-compliance or could support
        further inquiry.
        2.1      The Compliance Officer will designate a member of the Compliance Steering Committee to
                 perform preliminary evaluation in the event of his absence.
3.0     The Corporate Compliance Officer or appropriate representative, acting alone or with external investigative
        support, will perform an investigation of all the facts and circumstances surrounding any issue determined
        to be an area of genuine concern.
4.0     The Corporate Compliance Officer, with the advice of legal counsel, when necessary, will provide a
        recommendation about whether the matter raises a genuine compliance concern.
5.0     The Corporate Compliance Officer will then determine whether the issue should be subject to further
        investigation, what level of management should be notified and formulate any other appropriate responses
        to the complainant.
6.0     The Corporate Compliance Officer will inform the Compliance Steering Committee, Administrative Council,
        President & CEO and/or the Chairman of the Board of Directors, as deemed appropriate for each reported
        issue.
                                CENTRAL MICHIGAN COMMUNITY HOSPITAL

Subject:         Investigation and Remediation of Compliance Issues                           Policy No. 115.123
                                                                                                      Page 2 of 2
Original Effective Date: 08/05/2002                                                   Revised Date: June 16, 2008

       6.1     A documentation log will be maintained for each issue and will be shared with the Compliance
               Steering Committee in a bi-monthly report as part of the Compliance Steering Committee meeting
               materials, unless deemed inappropriate due to the sensitivity of the issue. Any discussion had or
               directive reached during Compliance Steering Committee will be documented in the minutes and
               issue documentation log.
       6.2     For cases in which the information is not shared with the Compliance Steering Committee due to
               sensitivity of the issue, the Compliance Officer will maintain a documentation log for each issue,
               which will be shared and discussed with the CEO, Board of Directors, and/or other individuals as
               deemed appropriate.
7.0    After review, the Compliance Steering Committee, other appropriate individuals and/or legal counsel will
       recommend action(s) to be taken.
8.0    The affected Department Director, working with the Corporate Compliance Officer, will prepare process
       improvement plans for any instances of non-compliance that are identified.
       8.1     All process improvement plans will be developed with the guidance of Compliance Steering
               Committee, other appropriate individuals and legal counsel where appropriate.
       8.2     Process improvement plans will be designed to ensure not only that the specific issues are
               addressed, but also that similar problems do not exist in the future or in other areas or
               departments.
       8.3     Process improvement plans may require that policies be developed, that certain training and/or
               monitoring take place, that restrictions be imposed on billing, that repayment be made and/or that
               the matter be disclosed externally.
       8.4     Sanctions or discipline, in accordance with CMCH’s policies, may also be recommended. If it
               appears that certain individuals have a demonstrated history of engaging in practices that raise
               compliance concerns, process improvement plan should identify actions that will be taken to
               prevent such individuals from exercising substantial discretion with regard to those areas.
       8.5     The Corporate Compliance Officer will monitor the implementation of the process improvement
               plan and all other required activities to ensure correction of the identified issue.
       8.6     The process improvement plan and all actions taken will be recorded in the documentation log.
9.0    All reimbursement/funding obtained inappropriately will be refunded.
10.0   The Corporate Compliance Officer will maintain a record of all reported issues, significant or not.
11.0   The Corporate Compliance Officer will semi-annually prepare a report summarizing complaints received,
       as well as, any investigations and their dispositions for the Board of Directors and the CEO in the manner
       that preserves confidentiality and the relevant privileges.
12.0   Any instances of possible criminal conduct (fraud or abuse) will not be ignored and will be referred to legal
       counsel for determination of further action and self-reporting to the appropriate government agency,
       including the Office of Inspector General.
13.0   Upon the determination and assistance of legal counsel, self reporting to the appropriate government
       agency, including the Office of Inspector General, will be done in a timely fashion.




DISTRIBUTION:
All Departments
Active Medical Staff
Central Michigan Community Hospital Radiation Oncology
CMCH – SHH Cardiology