Transcript False Claims Act & Whistleblower Protection

False Claims Act &
Whistleblower Protection
False Claims Act
The False Claims Act (FCA) was established in 1863 by
President, Abraham Lincoln, to curb contract fraud
during the Civil War by incentivizing integrity through
awards based on the size of the fraud brought to the
US Government.
The False Claims Act (FCA) is a Federal law that
establishes criminal and civil liability when any
covered person or covered entity improperly receives
reimbursement from or avoids payments (excluding
tax fraud) to the Federal government.
False Claims Act
How is the FCA applicable to GT?
We receive federally funded dollars for providing our fiscal
intermediary service.
GT pays a participant's employee
for their work performed.
GT bills the participant's
referring agency for costs plus
our fee.
The referring agency pays our
bill from federally funded dollars
allocated for the participant .
False Claims Act
Basic Points of the FCA
• Not a Tip Line - FCA cases are evidence driven
• Not Easy or Fast - Successful cases often require years of
investigation, putting tremendous strain on whistleblowers and
lawyers. Big cases can require big investments from private law
firms.
• Triple Damages – Person or entity committing fraud can be
responsible for up to triple damages plus statutory penalties and
exclusion being able to provide federally funded services.
• Cheaters Pay Whistleblower Awards – The triple damages collected
pay for the stolen government money, cost of investigations, lost
interest, and whistleblower awards.
False Claims Act
FCA Success 1987-2011
False Claims Act
The False Claims Act has been so successful
that it has been replicated:
• In 29 states including MI, NC, WI, and FL
• The Securities and Exchange Commission, Internal
Revenue Service, and Commodities Future Trading
Commission have all created a whistleblower
program modeled on the FCA
Comprehension Check
The False Claims Act is only applicable at the Federal
level.
True or False?
FALSE
Many states have implemented a False Claims
Act.
Whistleblower Employee
Protection
Whistleblowers are private citizens who file suit on behalf
of the State or Federal government to recover damages
incurred by the government as a result of contractor fraud
or other false claims.
Whistleblowers may be entitled to a significant portion of
the proceeds from a successfully prosecuted claim.
Whistleblowers are protected from retaliation because of
their participation in filing or testifying in a claim.
Comprehension Check
The Whistleblower’s Act protects employees from
retaliation in reporting.
TRUE
True or False?
False Claims Act – OUR
RESPONSIBILITY
At GT Independence, it is our policy to minimize the
opportunities for fraud, waste, abuse, and neglect and report
incidents as required by all applicable federal and state laws.
All employees, including management, and any contractors or
agents are educated in and should maintain familiarity with the
types of fraud and any other action (or inaction) that results in
fraud, waste or abuse of public resources.
GT Independence will not retaliate against any employee,
contractor, or agent who reports or testifies regarding fraud,
abuse, or neglect.
Comprehension Check
It is the policy of GT to minimize fraud, waste, abuse,
and neglect.
True or False?
TRUE
False Claims Act – Our
RESPONSIBILITY
Examples of Fraud*
• Billing for goods or services that were never provided
• Submitting false service records in order to show better-than-average
performance
• Performing inappropriate or unnecessary medical procedures
• Billing inflated charges instead of actual charges
• Inflating bills by using a code that suggests a more expensive service was
preformed
• Charging more than once for the same service
• Prescribing a medication or service in order to win kickbacks from
hospitals, labs or pharmaceutical companies.
*It is impossible to succinctly list all of the fraud schemes that have been prosecuted
under the FCA. This list is non-exhaustive, but gives an idea of the scope of frauds that
have been uncovered to date.
Comprehension Check
It is okay to bill for goods and services that were
never provided.
True or False?
FALSE
This would be a fraudulent activity.
False Claims Act – OUR
RESPONSIBILITY
Types of Fraud We See at GT Independence
• Forged signatures on time cards
• Claiming hours not worked
• Claiming hours under another worker’s name
• Claiming hours while a participant is hospitalized
• Impersonation of a participant or worker to obtain
or change personal information, such as address or
bank account
False Claims Act – OUR
RESPONSIBILITY
Look for Indicators of Potential Fraud
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Time cards that appear to be copied or altered in anyway
Excessive hours being claimed for a pay period
No hours claimed over a 3 month period
High employee turnover
Indications participants or workers are over-controlling services such as
only the participant calling about the employee’s paycheck/employee
never makes contact
• Purchasing excessive fuel that is not consistent with mileage logs
• Inconsistent and/or suspicious information from caller such as the caller
keeps changing the information provided or cannot verify their identity
• Severe complaints or episodes of aggressive behavior
• Any other behaviors that are not consistent with the program
False Claims Act – OUR
RESPONSIBILITY
Reporting Fraud – Incident Reporting
• An Incident Report will be completed if
you become aware of any actual or
suspected fraud, waste, or abuse.
• This form is available at P:\GFS File
Server\Fiduciary Services\Common
Forms & Letters- all states\Internal
Forms\Incident Report for GT
Independence
False Claims Act – OUR
RESPONSIBILITY
Reporting Fraud – Incident Reporting
When documenting an incident :
 Use objective language, no assumptions or opinions
 Fully complete the form with no missing information
 Within 24 hours the report must be completed, faxed to the
agency contact, as well as, a verbal notification made
 Submit to your supervisor/team leader within 5 calendar days
 You must gain follow-up or corrective action information from
the agency contact.
False Claims Act – OUR
RESPONSIBILITY
Reporting Fraud – Corporate Compliance
• The Compliance Officer will review all incident reports and
determine if an internal investigation should be conducted.
• The Quality Management Team will review collective incident
reports to identify trends and overall improvements needed.
• The Compliance Officer is the main contact for any outside (state,
federal, or agency) investigation.
False Claims Act – OUR
RESPONSIBILITY
Reporting Fraud – Outside Reporting
• Fraud can also be reported outside GT Independence through the
Office of Inspector General, http://oig.hhs.gov/fraud/reportfraud/index.asp
• And/Or by state via
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Michigan Department of Community Health
Wisconsin Department of Justice
North Caroline Department of Health and Human Services
Florida Agency for Health Care Administration
• Or any other appropriate agency
Comprehension Check
Reporting fraud, abuse, or neglect is optional at
GT Independence.
True or False?
FALSE
We are required to report all incidents of
fraud, waste, abuse, and neglect.
Questions
More information on the FCA is available at:
• http://www.taf.org/
• http://www.whistleblowerlaws.com/
• http://oig.hhs.gov/fraud/
You play an important role in upholding the public trust. If you suspect
fraud or ethical violations that involve GT Independence, you are
encouraged to contact the CEO and Compliance Officer.
This training is meant to define and clarify fraudulent activities making it
recognizable to the employees and staff of GT Independence.
It should be understood that you may also notify any appropriate
regulatory agency without fear of retaliation.
Questions may be directed to your Supervisor, Team Leader, Human
Resources Department., Compliance Officer, or CEO.
Acknowledgment
Please complete the quiz and sign,
acknowledging you understand the False
Claims/Whistleblowers material presented in
this training.
Return the quiz to Human Resources.
Thank you for participating in this training!