Education Concerning

Anti-Fraud Compliance

Compliance Policy #915

It has long been the policy of Boulder Community Hospital ("BCH") to comply with all applicable federal and state laws and regulations, including those related to the submission of claims and other documentation to state and federal health care programs.  To further this policy, and to comply with Section 6032 of the Deficit Reduction Act of 2005, BCH shall ensure that all employees, including management, along with BCH's contractors or agents, are provided with information regarding the federal and state false claims statutes, BCH's own anti-fraud policies, and the role of such laws and policies in preventing and detecting fraud, waste and abuse in federal health care programs.

Responsibility:  Chief Executive Officer; Compliance Officer; Compliance Committee

PROCEDURE

BCH shall provide notice to all employees, including management, and any contractors or agents regarding the federal and state false claim statutes, BCH's own anti-fraud policies, and the role of such laws and policies in
preventing and detecting fraud, waste and abuse in federal health careprograms.  The form of the Notice is set forth in Attachment A to this Policy and may be amended by the Compliance Officer as necessary to reflect current laws.

Upon adoption of this policy, BCH shall publish a summary of this Policy and the Notice to all employees and shall inform employees how to access this Policy, the Notice and other BCH Compliance Policies on BCH's intranet site for employees.  The Notice shall also be included in the BCH orientation material and employee handbook, along with a specific discussion of BCH's policies and procedures for detecting and preventing fraud, waste and abuse.

BCH shall provide this Policy and the Notice to BCH's contractors and agents and shall require such contractors to notify their employees and to comply with applicable laws and BCH's Compliance Policies.  This Policy, the Notice and BCH's Compliance Policies shall be available on BCH's website.

References: Colo. Rev. Stat.    25.5-4-304-306; 31 U.S.C.    3801-3812; 31
U.S.C.    3729-3733;  Deficit Reduction Act of 2005, Sections 6031, 6032; BCH
Compliance Policies ##901- 914

Attachment A to Compliance Policy #915

BOULDER COMMUNITY HOSPITAL NOTICE CONCERNING ANTI-FRAUD COMPLIANCE

The information in this Notice describes the primary false claims laws that apply to Boulder Community Hospital ("BCH") and the BCH policies adopted to comply with such laws.

A.  Federal False Claims Act:  31 U.S.C.  §3729-3733

One of the primary purposes of the federal False Claims Act is to combat fraud and abuse in government health care programs.  The False Claims Act does this by making it possible for the government to bring civil actions to recover damages and penalties when healthcare providers submit false claims.  The False Claims Act permits qui tam suits as well, which are lawsuits brought by individuals against healthcare facilities that submit false claims.

False Claims Act ProhibitionsThe federal False Claims Act imposes liability on any person or entity who:

 1. Knowingly files a false or fraudulent claim for payments to Medicare, Medicaid or other federally funded health care program;

 2. Knowingly uses a false record or statement to obtain payment on a false or fraudulent claim from Medicare, Medicaid or other federally funded health care program; or

 3. Conspires to defraud Medicare, Medicaid or other federally funded health care program by attempting to have a false or fraudulent claim paid.

While the False Claims Act imposes liability only when an individual acts "knowingly," the Act does not require that the person submitting the claims have actual knowledge that the claim is false.  A person or entity who acts in
reckless disregard or in deliberate ignorance of the truth or falsity of the information can also be found liable under the Act.

Examples of violations of the False Claims Act include the following:

  A physician who submits a bill to Medicare or Medicaid for medical services he knows or should know were not provided;
  A health care provider who submits records to Medicare or Medicaid that the provider knows or should know are false and that indicate compliance with certain contractual or regulatory requirements that were not met; and
  A hospital that obtains interim payments from Medicare or Medicaidthroughout the year and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the government.

Penalties

A person or entity that violates the False Claims Act is liable for significant fines and penalties.  The fines include civil money penalties ranging from $5,500 to $11,000 per false claim, plus three times the damages sustained by the government because of the false claim and the government's costs of the civil action.

Qui Tam and Whistleblower Protection Provision

One of the unique aspects of the federal False Claims Act is the Aqui tam provision, commonly referred to as the A whistleblower provision.  This allows a private person with knowledge of a false claim to bring a civil action on behalf of the United States Government.  The purpose of bringing the qui tam suit is to recover the funds paid by the Government as a result of the false claims.  If the suit is ultimately successful, the whistleblower that
initially brought the suit may be awarded a percentage of the funds recovered. Sometimes the United States Government decides to join the qui tam suit.  The percentage the recovery awarded to the whistleblower is generally lower when the government intervenes.  Additionally, the court may reduce a whistleblower's share of the proceeds if the court finds that the whistleblower planned and initiated the violation.  A whistleblower who brings a clearly frivolous qui tam action can also be held liable for the defendant'sattorneys' fees and costs.

 

The federal False Claims Act includes protections for people who file qui tam lawsuits.  An employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against in his employment as a result of the employee's lawful acts in furtherance of a false claims action is entitled to all relief necessary to make the employee whole.  Such relief may include reinstatement, two times the amount of back pay, plus interest, and
compensation for any special damages, including attorneys' fees and the costs of the litigation.

 

B.  The Program Fraud Civil Remedies Act of 1986; 31 U.S.C.§3801-3812

The Program Fraud Civil Remedies Act of 1986 (the APFCRA) provides administrative remedies for knowingly submitting false claims and false statements to federal agencies.
The PFCRA imposes liability on a person or entity that files a claim that is false or is supported by a written statement that is false or omits a material fact.

A violation of the PFCRA results in a maximum civil penalty of $5,000 per each wrongfully filed claim, plus an assessment of up to twice the amount of each false or fraudulent claim that has been paid.  These remedies are separate from, and in addition to, any liability that may be imposed under the federal False Claims Act.


C.  Colorado Fraud and Abuse Law:  Colo. Rev. Stat. §25.5-4-304 - 306

The State of Colorado has adopted a Medicaid anti-fraud statute that is intended to prevent the submission of false and fraudulent claims to the Colorado Medicaid program.  The statute makes it unlawful for any person to
 intentionally or with reckless disregard present a false claim to Medicaid, make a false representation of a material fact in connection with a claim; present a cost document the person knows contains a false material statement; or make a claim for services payable by Medicaid with knowledge that the individual who furnished the services was not licensed to provide such services.

Violations of the Colorado anti-fraud statute are civil offenses and are punishable by monetary penalties of $1,000 per claim up to $50,000 or twice the amount paid by the Medicaid program.

D.  BCH Policies

BCH takes issues regarding false claims and fraud and abuse seriously.  BCH encourages all employees, management, and contractors or agents of BCH's affiliated hospitals to be aware of the laws regarding fraud and abuse and false claims, and to identify and resolve any issues immediately. BCH has adopted Compliance Policies (##900-915) regarding the detection and prevention of health care fraud and abuse.  The Compliance Policies are available to BCH employees on the BCH Meditech system for employees and arealso available on the BCH website (http://www.bch.org/).  These policies include the following:

    Code of Conduct (Compliance Policy #900)
    Response and Corrective Action (Compliance Policy #908)
    Monitoring and Auditing (Compliance Policy #910)

BCH has also adopted a specific policy regarding reporting suspected misconduct.  BCH Compliance Policy #907, entitled "Reporting Compliance Issues and Concerns" establishes a reporting system whereby employees and other agents can report suspected criminal conduct or other violations of law, regulations or BCH's compliance standards and policies by others within the organization without fear of retaliation.

Pursuant to Policy #907, all BCH employees and agents have a duty to report any suspected wrongdoing or violation of applicable laws, regulations or BCH's compliance standards or policies.  Suspected misconduct may be reported directly to the BCH compliance officer, to the employee's supervisor, or by any other means established by the BCH Compliance Officer or the Compliance Committee.  BCH will treat such reports as confidential to the greatest extent possible.  BCH prohibits any form of retaliation against any employee or agent
for filing a bona fide report under BCH's reporting policy.  Employees, contractors and agents of BCH are responsible for complying with the Compliance Policies adopted by BCH.  Contractors and agents are also
responsible for assuring that their employees and agents comply with applicable laws and BCH compliance policies.

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