公司合規性

虛假索賠/聯邦赤字減少法案通知PDF

False Claims / Federal Deficit Reduction Act Notice

幫助停止醫療保健欺詐,浪費和虐待:

向Firelands公司合規官員報告

Firelands Regional Medical Center (Firelands) is committed and takes pride in complying with federal and state laws and regulations that govern the delivery of health care to its patients and the prevention of fraud, waste and abuse. Firelands relies on all of its employees, contractors, and agents to support this effort. This notice contains important compliance information for our employees, contractors and agents regarding the Federal False Claims Act, administrative remedies for false claims and statements, various section of the Ohio Revised Code promulgated to address false claims and Medicaid fraud; and whistleblower protections under state and federal law. Attachment A to this Policy provides an overview of the applicable federal and state laws.

虛假索賠法案是什麼?

聯邦虛假申報法》(FCA)禁止任何person from knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval of government funds. Under the Federal False Claims Act, any person who knowingly submits a false or fraudulent claim to a Medicare, Medicaid or other federal healthcare program is liable to the Federal Government for three times the amount of the Federal Government’s damages plus penalties of $5,000 to $11,000 per false or fraudulent claim.

什麼是錯誤索賠的例子?

根據聯邦錯誤索賠法,聯邦政府起訴,犯罪或民間,提交或致力於提交的個人或實體,當事人索賠是假的。在醫療保健行業中,這包括醫療保險,醫療補助和其他聯邦醫療保健計劃。可以創建錯誤索賠的示例包括但不限於:

  • 同一服務的兩次賬單;
  • 未呈現服務的計費;
  • 規定不必要的藥物
  • 有意使用關於索賠的不正確的代碼,以獲得更高的報銷速度;
  • 用於醫學上不必要的服務或偽造醫療必需品的賬單;
  • 單獨為應按單獨收取的服務或計費;
  • 創造虛假的醫療記錄或治療計劃以增加付款;
  • 未能報告和退款過度付款或信貸餘額;
  • Physician billing without personal involvement for services rendered by medical students, interns, residents or fellows in teaching hospitals; and
  • 向醫療保健提供者提供和​​/或接受非法誘因,以獲得服務的推薦。

我如何報告的是什麼以及如何報告?

If you suspect instances of fraud, submission of false medical billing claims or other non-compliance with federal, state, local laws, or regulations, you should report it. If you suspect any activity that violates any state or federal law or regulation (e.g. corruption, malfeasance, bribery, theft or misuse of property, fraud, coercion, or conversation); or wastes money, or involves gross misconduct, gross incompetence, or gross inefficiency you should report it.

You can report fraud, waste or abuse to Firelands by:

  • 在1-888-556-4984致電Firelands的熱線
  • 在1-419-557-5510致電公司合規官
  • 發送電子郵件至:compliance@firelands.com.
  • 發送傳真至419-557-6977
  • 向弗蘭爾斯地區醫療中心寫一封信或備忘錄,注意公司合規官,金宝博188bet.com1111 Hayes Ave.,Sandusky OH 44870
  • 在報告欺詐,浪費或濫用時,請提供盡可能多的細節的公司合規官,包括涉及涉嫌欺詐,浪費或濫用的個人或公司的姓名,地址和電話號碼。你可能會匿名;但是,如果您不提供您的姓名和聯係信息,公司合規官員將無法與您聯係以獲取更多信息。您的報告將在法律允許的程度上保密。

舉報人保護:

舉報人(或者在法律中提到他/她)必須是指控的原始來源,因此舉報人不能使用已發表的欺詐指控或已經引起Medicare中心注意的信息醫療補助服務(CMS)或其他政府機構。虛假索賠法案舉辦舉報人被聯邦和州法律保護,以任何形式的報複,因為他們的哨聲吹。如果您認為,您已根據舉報人報複,您可以通過聯係FireLains的合規官員來尋求補救措施。

附件A.

Federal False Claims Act. 31 USC section 3729

虛假索賠法是一項聯邦法規,涵蓋涉及任何聯邦資助合同或計劃,包括Medicare和Medicaid。該法對任何故意呈現或導致對美國政府發出的虛假或欺詐性索賠的任何人來說,這一行為對美國政府提供了虛假或欺詐性索賠的責任,使得欺詐政府或故意製造或使用虛假記錄來隱瞞退款款項的義務。

術語“故意”被定義為意味著一個人:

  • Has actual knowledge of falsity of information in the claim;
  • Acts in deliberate ignorance of the truth or falsity of the information in a claim; or
  • 魯莽地忽視了索賠中信息的真實性或虛假行為。

The act does not require proof of a specific intent to defraud the U.S. government. Health care providers can be prosecuted for a variety of conduct that leads to submission of a false claim such as falsifying records, double-billing for items or services, or submitting bills for services never performed. Persons and organizations violating the False Claims Act can be subject to civil monetary penalties ranging from $5,000 to $11,000 for each false claim submitted. If a provider is convicted of a False Claims Act violation, the Office of the Inspector General may seek to exclude the provider or supplier from participation in federal health care programs.

Section 3730 in the False Claims Act is a qui tam provision allowing any person with actual knowledge of allegedly false claims being made to the government to file a lawsuit on behalf of the U.S. government, to participate in any resulting settlement, and to make such claim without fear of retribution from the employer.

虛假索賠和陳述的行政補救措施,31 USC第38章/計劃欺詐民事補救措施1986年(PFCRA)

PFCRA授權衛生和人力服務部(“HHS”)等聯邦機構調查和評估向原子能機構提交虛假索賠或陳述的處罰。PFCRA禁止的行為類似於虛假索賠法禁止的行為。一個人可能會根據PFCRA責任,以製定,提交或提交,提交或提交,提交或提交人員所知或有理由知道的索賠或聲明:

  • Is false, fictitious, or fraudulent;
  • 包括或由任何書麵陳述支持,這些聲明宣稱是虛假,虛構或欺詐性的重要事實;
  • 包括或由任何書麵陳述提供支持:
    • 省略物質事實;
    • Is false, fictitious, or fraudulent as a result of such omission; and
    • 是一個陳述,其中製作,提出或提交此類聲明有責任包括此類物質事實;要麼
    • 是用於提供財產或服務的付款,該人未被申索未提供。

The government agency may assess twice the amount of its damages and a civil penalty of up to $5,500 for each false or fictitious claim. The United States Attorney General has exclusive authority to enforce such assessments and penalties in federal court.

赤字減少法案(DRA)2005年,第6032條

The DRA establishes section 1902(a)(68) of the Social Security Act and relates to “Employee education about false claims recovery.” Ohio has promulgated a series of sections of the Ohio Revised Code in response to the DRA. These sections are outlined below.

ORC§5111.101 - 欺詐,浪費和濫用預防和檢測

要求在5,000,000或更長時間的日曆年內收到醫療補助金額,作為一個收到醫療補助付款的條件,做以下所有內容:

  • Provide each employee, contractor, and agent detailed, written information about the role of all of the following in preventing and detecting fraud, waste, and abuse in federal health care programs:
    • 聯邦錯誤索賠法,31 USC 3729-3733
    • Federal administrative remedies for false claims and statements, 31 USC 3801-3812
    • ORC 2913.40, 2913.401, and 2921.13 and any other state laws pertaining to civil or criminal penalties for false claims and statements

ORC§5111.03 - 醫療補助提供者的罪行

醫療提供者犯罪法規禁止醫療補助提供者“通過欺騙”來獲取或接收或試圖獲得或收到提供者無權獲得的付款或偽造與醫療補助有關的任何報告或文件的付款。

  • “欺騙”包括表演with reckless disregard or deliberate ignorance of the truth or falsity of information or withholding information.
  • Penalties for violation of the Medicaid Provider Offenses Statute include interest on excess payments, three times the amount of excess payments, civil penalties of $5,000 to $10,000 per claim, recovery of the costs of enforcement and termination of the Medicaid provider agreement
  • 俄亥俄州律師將在州法院執行本規約的規定
    • 在上述法律下的舉報人保護。

ORC§2913.40 - 醫療補助欺詐

醫療補助欺詐行為對其他事項征收刑事處罰:

  • Knowingly making or cause to be made a false or misleading statement or representation for use in obtaining Medicaid reimbursement.
  • 做以下任何一種,以涉嫌欺詐或故意促進欺詐:
    • 除了由醫療補助和任何授權的扣除或共同支付的報銷金額之外,還有收費,征求,接受或接受任何金額;
    • Soliciting, offering or receiving any remuneration other than authorized deductibles and co-payments in cash or in kind, including kickbacks or rebates, in connection with the furnishing of goods or services for which payment may be made under the Medicaid program.
  • 故意改變,摧毀,隱瞞或刪除支持醫療補助聲明或成本報告所需的任何記錄
  • 醫療補助資格欺詐行為對故意做出虛假或誤導性陳述的人來說,隱瞞財產的興趣,或者未能披露財產的轉讓,以確定獲得醫療補助福利的可靠性的罪行,或者未能披露財產的轉讓。

ORC§2913.401 - 醫療補助資格欺詐

醫療補助資格欺詐行為對故意做出虛假或誤導性陳述的人來說,隱瞞財產的興趣,或者未能披露財產的轉讓,以確定獲得醫療補助福利的可靠性的罪行,或者未能披露財產的轉讓。

ORC§2921.13 - 偽造

Ohio criminal law prohibits persons from knowingly making false statements or swearing or affirming the truth of a false statement for the purpose of securing payment of benefits administered by a governmental agency or paid out of a public treasury, for the purpose of securing a provider agreement with the government or in connection with any report that is required or authorized by law, such as the Medicaid cost report.

orc§4113.52 - 雇員雇用雇主違反法律的權利

為報告違反國家或聯邦法律的非國家雇員提供舉報人保護,即雇主有權糾正,員工合理地認為是刑事犯罪或可能對公共衛生造成迫在眉睫的身體傷害或危害的危險風險。政府可以頒發員工返還薪酬,利息,恢複,律政費和法庭費用。

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