Deficit Reduction Act

The 2005 Deficit Reduction Act (DRA) established a new Medicaid Integrity Program that is very similar to the Medicare Integrity Program.  The 2005 DRA funded this new Fraud and Abuse detection program with an increased level of funding up to $75 billion by 2009.  This level of funding indicates the rising intensity of Medicaid scrutiny.  When an organization comes under the scrutiny of the Medicaid Integrity Program, one of the items that will be reviewed is whether the organization did an adequate job of communicating the details of the False Claims Act (FCA) and the whistleblower protections throughout the organization and to agents and contractors.  The attached document outlines the False Claims Act and HealthPlus’ role in assuring its compliance.

If you have any questions regarding the DRA or FCA, please contact HealthPlus’ Compliance & Privacy/Security Official, Theresa M. Schurman, Esq., at (810) 720-8199 or at tschurma@healthplus.org.  

False Claims Act

As a recipient of federal health care program funds, including Medicare and Medicaid, HealthPlus is required by law to include in its policies and provide to all employees, members, agents, and contractors, detailed information regarding the federal False Claims Act and applicable state civil and criminal laws intended to prevent and detect fraud, waste, and abuse in federal health care programs.

What is the False Claims Act?
The False Claims Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim to any federal health care program, which includes any plan or program that provides health benefits (whether directly, through insurance, or otherwise) which is funded directly, in whole or in part, by the United States Government or any State health care program.  “Knowingly” includes having actual knowledge that a claim is false or acting with “reckless disregard” as to whether a claim is false.  Examples of potential false claims include knowingly billing Medicare for services that were not provided, submitting inaccurate or misleading claims for actual services provided, or making false statements to obtain payment for services.

The False Claims Act contains provisions that allow individuals with original information concerning fraud involving government health care programs to file a lawsuit on behalf of the government and, if the lawsuit is successful, to receive a portion of recoveries received by the government.

State Laws

In most states, it is a crime to obtain something (e.g., such as a Medicaid payment or benefit) based on false information.  In addition to the federal law, Michigan has adopted similar laws allowing individuals to file a lawsuit in state court for false claims that were filed with the state for payment, such as the Medicaid program.

Penalties for Violating the False Claims Act

There are significant penalties for violating the federal False Claims Act.  Financial penalties to an organization that submits a false claim can total as much as three times the amount of the claim plus fines of $5,500-$11,000 per claim.  In addition to fines and penalties, the courts can impose criminal penalties against individuals and organizations for willful violations of the False Claims Act.  The false claims laws adopted in Michigan also carry significant fines and penalties of $5,000-$10,000 per claim.

Protections Under the False Claims Act

The federal False Claims Act protects anyone who files a lawsuit under the Act from being fired, demoted, threatened, or harassed by their employer as a result of filing a False Claims Act lawsuit.  Similar protections are also provided to individuals under the False Claims Act laws adopted in Michigan.

Our Commitment to Integrity

HealthPlus is committed to fully complying with all laws and regulations that apply to our health care organizations.  We have established a Corporate Compliance Program as evidence of our commitment to operating with the highest degree of integrity.

The Corporate Compliance Program includes the Standards of Conduct, policies and procedures, training and education, auditing and monitoring, and mechanisms for individuals to raise issues and concerns without fear of retaliation.  Information regarding HealthPlus Compliance Program may be accessed through the HealthPlus Internet website within the Compliance Program section.  Employees may also view this information on the HealthPlus Intranet web page. 

Whether you are an employee, member, vendor, provider, or another business partner of HealthPlus, you are reminded to:

• Act with honesty and integrity in all of your business activities.
• Follow all laws and regulations that apply to your work activities, including requirements of Medicare, Medicaid, and other federal health care programs.
• Contact one of the following resources available within HealthPlus if you have knowledge of or concern regarding a potential false claim:
• HealthPlus Compliance & Privacy/Security Official:
• Theresa M. Schurman, Esq.
  Compliance & Privacy/Security Official
  2050 S. Linden Road
  Flint, Michigan  48532
  (810) 720-8199
  tschurma@healthplus.com 

• HealthPlus Hotline:  1-800-345-9956 (message may be left anonymously)
• HealthPlus Employee Reporting E-Mail Address:  “ComplianceReporting”

HealthPlus policies strictly prohibit retaliation in any form against an individual reporting an issue or concern in good faith.  Retaliation is subject to discipline up to and including dismissal from employment or termination of the business relationship with HealthPlus.

Please contact the Compliance Official through the information listed above if you have any questions. 

Additional Fraud and Abuse Regulations

• Health Care Fraud, 18 U.S.C. 1347
• False Statements Relating to Health Care Matters, 18 U.S.C. 1035
• Medicare-Medicaid Anti-Fraud and Abuse Amendments 42 U.S.C. 1320a-7b(a)
• Theft or Embezzlement in Connection with Health Care, 18 U.S.C. 669
• Obstruction of Criminal Investigation of Health Care Offenses, 18 U.S.C. 1518
• Federal Anti-Kickback Statue, 42 U.S.C. 1320a-7b(b)
• Civil Monetary Penalties, 42 U.S.C. 1320a-7a
• OIG Exclusion Authority, 42 U.S.C. 1320a-7

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When we refer to HealthPlus, we, or our, we mean HealthPlus of Michigan, Inc. and its affiliated entities, HealthPlus Partners, Inc., HealthPlus Options, Inc., and HealthPlus Insurance Company. 

Updated 6/17/2008