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					5037 Employee Education About False Claims Recovery                                5037

         The purpose of this policy is to educate employees, contractors, and agents on

the requirements of the Deficit Reduction Act (DRA) of 2005 which contains

provisions to combat fraud and abuse in government health care programs. Under the

Deficit Reduction Act, the District is required to provide employees, contractors and

agents with information regarding federal and state false claims laws, administrative

remedies under those laws, whistle-blower protections to employees who report

incidents of false claims, and the District’s programs for detecting and preventing

fraud, waste and abuse in Medicaid programs.



Federal False Claims Act

         The False Claims Act prohibits any person from knowingly presenting or

causing to be presented, a false or fraudulent claim to the United States government

for payment. The False Claims Act imposes civil liability on any person who:

        Knowingly presents a false or fraudulent claim for payment or approval.

        Knowingly makes or uses a false record or statement to get a false or

         fraudulent claim paid or approved.

        Conspires with another to get a false or fraudulent claim paid or allowed.

        Knowingly makes or uses a false record or statement to conceal, avoid, or

         decrease an obligation to pay or transmit money or property.

        Commits other fraudulent acts enumerated in the statute.




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5037 Employee Education About False Claims Recovery                                5037- 2

Remedies - Federal

         The federal False Claims Act includes a “qui tam,” or whistleblower

provision to report misconduct involving false claims. The qui tam provision allows

any private person (Qui Tam Relater) with actual knowledge of allegedly false

claims to file a lawsuit on behalf of the United States government.

         The federal government has the opportunity to intervene in the lawsuit and

assume primary responsibility for prosecuting, dismissing or settling the action. If

the federal government decides to intervene, the private person (Qui Tam Relater)

who initiated the action may be eligible for a portion of the proceeds of the action or

settlement of the claim. If the federal government does not proceed with the action,

the Qui Tam Relater may continue with the lawsuit or settle the claim and he or she

may receive a portion of the proceeds of the action or settlement. The Qui Tam

Relater may also receive an amount for reasonable expenses, including reasonable

attorney fees and costs incurred in connection with bringing the lawsuit.

         Violations of the federal false claims act can result in penalties of not less

than $5,500.00 and not more than $11,000.00 per claim, plus three times the amount

of damages that the government sustains.



Medicaid False Claim Act

         The State of Michigan has a companion law known as the Medicaid False

Claims Act. This act imposes prison terms of up to four (4) years and fines up to

$50,000 for:




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5037 Employee Education About False Claims Recovery                                           5037- 3

        Knowingly making a false statement or false representation of a material fact

         in any application for Medicaid benefits or for use in determining rights to a

         Medicaid benefit;

        Soliciting, offering or receiving kickbacks or bribes for referrals to another

         for Medicaid-funded services (fine up to $30,000);

        Entering an agreement with another to defraud Medicaid through a False

         Claim; or

        Making or presenting to the State of Michigan a False Claim for payment.



Remedies - State

         Any person (Qui Tam Relater) may bring a civil action on behalf of the State

of Michigan to recover losses that the State suffered from a person violating the

Michigan Medicaid False Claims Act, and the Michigan Attorney General is to be

notified and has an opportunity to appear and intervene in the action brought on

behalf of the State of Michigan. If the Michigan Attorney General intervenes, in

addition to the person (Qui Tam Relater) receiving his or her expenses, costs and

reasonable attorney fees, the person may also receive a portion of the monetary

proceeds resulting from the action or any settlement.                        If the Michigan Attorn ey

General does not intervene, the Qui Tam Relater will receive a portion of the

monetary proceeds.




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5037 Employee Education About False Claims Recovery                                5037 – 4

Whistleblower Protection Laws

         In addition to the District’s Retaliation and Whistle-Blowing policy, both the

federal and state laws protect individuals who investigate or report possible False

Claims made by their employer against discharge or discrimination in employment

because of such investigation. Employees who are discriminated again st based on

whistleblower activities may sue in court for damages. Under either the federal or

state law, any employer who violates the whistleblower protection law is liable to the

employee for (1) reinstatement of the employee’s position without loss of seniority,

(2) two times the amount of lost back pay, (3) interest and compensation for any

special damages, and such other relief necessary to make the employee whole.



Detection of Potential Fraud or Abuse

         The District combats Medicaid fraud, waste and abuse by investigating

complaints, raising awareness of anti-fraud initiatives, and assuring compliance with

state and federal laws.           A quality assurance program is also used to detect and

prevent potential fraud, waste or abuse that includes the following:

                 Proactive review of claims and other types of data

                 Recommending and implementing claims processing safeguards

                 Conducting employee education on fraud and abuse prevention,

                  recognition and reporting

                 Encourage and promote the reporting of fraud or abuse by employees

                  and contractors




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5037 Employee Education About False Claims Recovery                                5037 – 5

Notice

          The Superintendent shall provide information to all employees, contractors

and agents about federal and state false claim laws and the district’s quality

assurance program to detect and prevent fraud, waste and abuse. The information

from this policy shall be included in the employee handbook and distributed to all

contractors and agents as required by the Deficit Reduction Act of 2005.



          The Superintendent shall establish the necessary rules to implement this

policy.


CROSS REF:                  Policy 5040 – Retaliation and Whistle-Blowing
                            Policy 5210 – Employee Complaints

LEGAL REF:                  31 U.S.C. §3729 et seq., “False Claims Act”
                            M.C.L. 400.601 et seq., “Medicaid False Claim Act”




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5037 Employee Education About False Claims Recovery                                5037 - R

         The District shall adhere to both state and federal laws governing fraud and

abuse of claims payments from state and federal programs



Federal False Claims Act

         The False Claims Act prohibits any person from knowingly presenting or

causing to be presented, a false or fraudulent claim for payment or approval of

government funds.



         Definitions

         “Knowingly” is defined to mean that a person (1) has actual knowledge of

false information on the claim, (2) acts in deliberate ignorance of the truth or falsity

of the information, (3) acts in reckless disregard of the truth or falsity of the

information.

         “Claim” is defined to include any request or demand for money or property if

the United States Government provides any portion of the money requested or

demanded.

         “Contractor or agent” includes any contractor, subcontractor, agent, or other

person which or who, on behalf the entity, furnishes, or otherwise authorizes the

furnishing of, Medicaid health care items or services, or performs billing or coding

functions.

         The federal false claims act does not require proof of a specific intent to

defraud the government. A wide variety of conduct may lead to the submission of




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fraudulent claims to the government including knowingly making false statements,

falsifying records, double-billing for items or services, or submitting bills for

services or items never furnished.



Medicaid False Claim Act

         The Medicaid False Claim Act, in part, prohibits fraud in the obtaining of

benefits or payments in connection with Medicaid and civil actions to recover money

received by reason of fraudulent conduct.

         Definitions

         “Claim” means any attempt to cause the department of social services to pay

out sums of money under the social welfare act, Act No. 280 of the Public Acts 1939,

being sections 400.1 to 400.121 of the Michigan Compiled Laws.

         “False” means wholly or partially untrue or deceptive.

         “Knowing” and “knowingly” means that a person is in possession of facts

under which he or she is aware or should be aware of the nature of his or her conduct

and that his or her conduct is substantially certain to cause the payment of a

Medicaid benefit. Knowing or knowing does not include conduct which is an error

or mistake unless the person’s course of conduct indicates a systematic or persistent

tendency to cause inaccuracies to be present.



Whistle-Blower Protection

         If any employee has knowledge or information that fraud or abuse activity as




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5037 Employee Education About False Claims Recovery                                5037 – R – 2

prohibited by federal or state law may have taken place, the employee must notify

the Program Investigation Section of MDCH or the Department of Attorney General

as follows:

                               Michigan Department of Community Health
                                     Program Investigation Section
                                   Capitol Commons Center Building
                                       400 South Pine, 6 th Floor
                                           Lansing, MI 48909
                                            1.866.428.0005

                                                           or

                                    Department of Attorney General
                                      Health Care Fraud Division
                                            P.O. Box 30218
                                          Lansing, MI 48909
                           24-hour Hotline 1-800-24-ABUSE/1-800-242-2873
                                      Email: hcf@michigan.gov


Retaliation

         The District is committed to protecting employees from any form of reprisal,

retaliation or discrimination if they, in good faith, report suspected illegal activity.

An employee who believes he or she has suffered reprisal, retaliation or

discrimination shall immediately report the incident(s) to the Director of Human

Resources, Superintendent, or Board of Education as set forth in Policy 5040 -

Retaliation and Whistle-Blowing.

         The Board of Education considers retaliation to be a major offense that will

result in disciplinary action against the offender including termination of

employment.




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