Fraud, Waste and Abuse Compliance Program
Atlantic Dialysis Management Services, LLC and its network of contracted affiliates (hereafter “ADMS”) is committed to preventing and detecting any fraud, waste, or abuse in the organization related to CMS and state health care programs, and to the importance of submitting accurate claims and reports to Federal and State governments. In furtherance of these goals, and in compliance with the CMS guidance found in Chapter 9 of the Prescription Drug Benefit Manual Part D program to Control Fraud, Waste and Abuse, 42 C.F.R. §423.504(b)(4)(vi)(H), Deficit Reduction Act of 2005 (“DRA”) and 10 NYCRR § 98-1.21, this program is meant to reinforce to all personnel and First-Tier, Downstream and Related Entities the ADMS policies and procedures regarding fraud, waste and abuse, and about the role of certain Federal and State laws in preventing and detecting fraud, waste and abuse in health care programs.
ADMS is committed to conducting our business with integrity and in compliance with applicable laws and regulations. The ADMS Fraud, Waste and Abuse Compliance Program is designed to identify and eliminate fraud, abuse, streamline inefficiencies; ensure that we are adhering to all applicable state and federal requirements; and reinforce our commitment to zero-tolerance with respect to fraud, waste and abuse.
A. To maintain a vigorous Fraud, Waste, and Abuse compliance program which strives to educate its work force on fraud, waste and abuse laws, including the importance of submitting accurate claims and reports to the Federal and State governments.
B. Demonstrate to First-Tier, Downstream and Related Entities our commitment to responsible corporate conduct.
C. Maintain an environment that encourages employees and First-Tier, Downstream and Related Entities to report without fear of retaliation.
E. Indentify initiatives to continuously monitor and audit potential risk areas of fraud, waste and abuse.
F. Ensure appropriate investigation, resolution and disciplinary and corrective action of possible misconduct by the organization and its First-Tier, Downstream and Related Entities, reducing or eliminating benefit costs due to fraud, waste and abuse, ensuring proper value of benefits, including correct pricing, quantity, quality; Utilizing real-time systems that ensure accurate eligibility, benefits, services, refills, and pricing and that identify potential adverse drug interactions and quality of care issues; Reducing or eliminating fraudulent or abusive claims paid for with federal dollars; Preventing illegal activities; Identifying members with drug addiction problems and other overutilization issues; Identifying and recommending providers for exclusion, including those who have defrauded or abused the system; Referring potential cases of illegal drug activity, including drug diversion, to the National Benefit Integrity Medicare Drug Integrity Contract (NBI MEDIC) and/or law enforcement and conducting case development and support activities for NBI MEDIC and law enforcement investigations.
Fraud is an intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and that the individual.
Waste is the inappropriate utilization and/or inefficient use of resources. 42 CFR §§417.1,
Abuse occurs when an individual or entity unintentionally provides information to Medicare which results in higher payments than the individual or entity is entitled to receive. 42 CFR §§ 417.1, 422.2, 423.100, 423.112, 423.120, 423.272, 423.30, 423.4,
423.501, 423.464, 423.859
ADMS maintains a strict policy of zero tolerance toward fraud, waste and abuse and other inappropriate activities. Individuals who engage in any inappropriate activity alone or in collaboration with another employee, member, or First-Tier, Downstream and Related Entities are subject to immediate disciplinary action up to and including termination.
The ADMS Enterprise Compliance Officer
The ADMS Enterprise Compliance Officer shall officially oversee the activities and management of the ADMS fraud waste and abuse prevention policies are carried out. When necessary, the ADMS Enterprise Compliance Officer may designate individuals to assist with his/her fraud, waste, and abuse related responsibilities.
The ADMS Enterprise Compliance Officer shall be in charge of coordinating communication and activities between its contracted affiliates, ADMS staff operational areas and First-Tier, Downstream and Related Entities Additionally, the ADMS Enterprise Compliance Officer shall oversee and coordinate reviews with respect to fraud, waste and abuse activities of each of ADMS departments. The ADMS Enterprise Compliance Officer shall develop a standard form for employees, First-Tier, Downstream and Related Entities, and members to use to report suspected fraud, waste, and abuse and complainant procedures.
The ADMS Enterprise Compliance Officer or his/her designee shall review all verbal and written complaints of suspected fraud, waste, and abuse for particular actions of concern including, but not limited to the following examples:
Examples of Provider/Facility Fraud:
• Billing for services not provided
• Billing that appears to be a deliberate application for duplicate payments for the same services or unbundling, (i.e. billing for separate portions, rather than for the whole procedure)
• Misrepresentations of dates, description of services or identities of members or providers
• Billing for non-covered services as a covered service (e.g. cosmetic surgery, etc.)
• Altering medical records
• Intentional incorrect reporting of diagnoses or procedures to maximize payment (up-coding and unbundling)
• Use of unlicensed staff
• Drug diversion, for example prescribing more expensive rather than indicated medication
• Accepting or giving kickbacks for member referrals
• Inappropriate enrollment
• Prescribing additional and unnecessary treatments (over-utilization)
• Waiving member co-pays
• Balance billing members for services
• Falsifying credentials
• Conducting improper dis-enrollment practices
• Attracting healthy patients or refusing sicker patients
• Persuading sicker patients to dis-enroll
• Falsifying medical exemptions
• Use of telemarketing/selling as marketing tools, and other impermissible marketing or sales activities
• Falsifying encounter data
• Excluding distinct groups of beneficiaries [e.g. patients with chronic conditions]
• Engaging in under-utilization
• Regularly denying treatment requests and specialist referrals without regard to proper medical evaluation
• Concealing ownership in a related company.
Examples of Member Fraud:
• Providing false information when applying for the programs or services
• Forging or selling prescription drugs
• Using transportation benefit for non-medical related business
• “Loaning” or using another’s insurance card
Reporting Inappropriate Activity to the ADMS Enterprise Compliance Officer
As an organization, ADMS investigates any suspicions of fraud, waste, or abuse swiftly and thoroughly through its internal compliance programs and processes. As such, ADMS strongly encourages each employee to first report any concerns or suspicions of fraud, waste or abuse to his or her respective without fear of retaliation to the manager and/or the ADMS Enterprise Compliance Officer in writing or via telephone. The ADMS compliance line telephone number is 718-483-7403. Written reports may be mailed to: ADMS; Attention: ADMS Enterprise Compliance Officer, 23-14 College Point Boulevard, College Point, New York 11356. All reports shall remain confidential.
Information regarding reporting of inappropriate activity shall be provided to all ADMS employees and all First-Tier, Downstream and Related Entities of the organization. Employees reporting any concerns or suspicions to ADMS will retain all “whistleblower” protections under the law. Nonetheless, an employee also has the ability to bring his or her concerns to the appropriate government agency including CMS and the Medic under relevant Federal and State laws, as described below.
ADMS requires First-Tier, Downstream and Related Entities to bring any alleged inappropriate activity which involves ADMS to our attention. First-Tier, Downstream and Related Entities may confidentially report a potential violation of our compliance policies or any applicable regulation.
With respect to the reporting of any suspected incidents of fraud, waste, and abuse, ADMS personnel shall follow the following guidelines.
A. Anyone receiving a report of fraud, waste, and abuse must immediately inform the ADMS Enterprise Compliance Officer or designee before any employee action is taken. No supervisor or manager should directly confront the employee with the allegation of fraud, waste, and abuse or otherwise discuss the issue with anyone suspected of engaging in fraudulent or abusive practices.
B. The ADMS Enterprise Compliance Officer or designee is responsible for determining when incidents should be reported to an appropriate law enforcement agency. The ADMS Enterprise Compliance Officer or designee is responsible for ensuring the design and development of methods for identifying fraud, waste, and abuse and responding appropriately and immediately to all detected program violations, following the Self Reporting Policy guidance, incidents of fraud, waste, and abuse are identified, systematic changes and corrective action initiatives will be put into place as appropriate to prevent further offenses.
C. Complaints, allegations, and concerns reported through the hotline and/or received directly by the ADMS Compliance Office concerning fraud, waste, and abuse will be handled under direction and coordination of the ADMS Enterprise Compliance Officer or designee.
D. In the case where the allegation is a criminal violation of law, the ADMS Enterprise Compliance Officer or designee will confer with legal counsel for determination as to whether there is sufficient evidence to require referral to a duly authorized law enforcement agency.
Communication and Cooperation with Outside Organizations
The ADMS Enterprise Compliance Officer shall also be in charge of overseeing all communication between ADMS, a contracted affiliate and any other officer or employee of ADMS, and in coordinating all communication with the New York State Department of Financial Services, CMS and the MEDIC and other law enforcement agencies. The ADMS Enterprise Compliance Officer shall ensure that the CMS, the MEDIC and New York State Department of Health (“Health Department”) and/or the New York State Medicaid Fraud Control Unit ("MFCU") may conduct private interviews of ADMS personnel, First-Tier, Downstream and Related Entities and their personnel, witnesses, and enrollees. ADMS personnel and First-Tier, Downstream and Related Entities and their personnel shall cooperate fully in making all personnel available in person for interviews, consultation, grand jury proceedings, pre-trial conference, hearing''s own expense; and The ADMS Enterprise Compliance Officer shall ensure that ADMS will provide to CMS, the MEDIC, and the Health Department its authorized representatives, and/or MFCU, originals and/or copies of all records and information requested, in the form requested, and allow access to ADMS premises. All copies of records will be provided free of charge.
DETECTION AND PREVENTION PROCEDURES
ADMS will establish and maintain methods for detecting and preventing incidents of fraud, waste, and abuse, including but not limited to: a claims quality assurance program that monitors the accuracy of adjudicated claims, focused audits, data mining, investigations of complaints, allegations and concerns reported by staff members, First-Tier, Downstream and Related Entities or external parties, and a process that identifies employees, contractors, First-Tier, Downstream and Related Entities and providers that are debarred or excluded from participating in federal or state programs. Results of audits will be brought to and discussed at the affiliated Governing Body meetings.
ADMS will take appropriate disciplinary and enforcement action (i.e., corrective action plans, financial penalties, demotion, suspension, employment, contract termination) against employees, providers, contractors, consultants, and agents found to have committed fraud, waste, and abuse violations. Published materials outlining such disciplinary measures shall be circulated among all ADMS employees and available from the ADMS Enterprise Compliance Officer at all times. In order to ensure awareness and compliance of appropriate of ADMS fraud, waste, and abuse policies, ADMS shall develop and implement an awareness program including a manual for use by all ADMS personnel outlining the structure of and key individuals in its fraud, waste, and abuse prevention program, methods through which employees can help detect and prevent, correct and resolve fraud, waste, and abuse, visual aids and reminders regarding the importance of the fraud, waste, and abuse prevention program to be posted in employee workspaces, and web tutorials outlining the key points of a fraud, waste, and abuse prevention program.
All reports are treated as confidential and will be investigated as appropriate, including applicable referral to law enforcement and regulatory bodies. Employees are advised to include as much detail as possible to ensure the ability to investigate each issue. All reports will remain confidential and reports may be made anonymously. No individual who reports violations or suspected fraud, waste, and abuse shall be subjected to retaliation of any kind.
Anti - Kickback Statute
The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a-7b
Provides for criminal penalties for certain acts impacting Medicare and state health care (e.g., Medicaid) reimbursable services. Enforcement actions have resulted in principals being liable for the acts of their agents. Of primary concern is the section of the statute which prohibits the offer or receipt of certain remuneration in return for referrals for or recommending purchase of supplies and services reimbursable under government health care programs. Section 1320a-7b(b) provides: (1) whoever knowingly and willfully solicits or receives any remuneration (including any kickback, bribe or rebate (directly or indirectly, overtly or covertly, in cash or in kind - (A) in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under [Medicare] or a State health care program, or (B) in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under [Medicare] or a State health care program, shall be guilty of a felony and upon conviction thereof, shall be fined not more than $25,000 or imprisoned for not more than five years, or both.
The Federal False Claims Act; 31 U.S.C. §§ 3729-3733
The False Claims Act is a federal law that provides that whoever knowingly submits to the federal government a false claim for payment, or creates a false record in support of a claim for payment, or knowingly retains the proceeds of a false claim for payment submitted to the government shall be liable for a civil penalty in the amount of $5,500 to $11,000 per individual claim, and three times the actual damages sustained by the government. The Federal False Claims Act contains qui tam, or ‘whistleblower” provisions that allow citizens with evidence of fraud against government contracts and programs to sue, on behalf of the government, in order to recover the funds. In compensation for the risk and effort of filing a qui tam case, the citizen whistleblower or “relator” may be awarded a portion of the funds recovered, typically between 15 and 25 percent.
Whistleblower Protections under the False Claims Act
Persons bringing claims, also known as “relators” or “whistleblowers”, are granted protection under the law. Any whistleblower who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against by his or her employer for reporting a violation will be entitled to reinstatement with seniority, double back pay, interest, special damages, and attorney’s fees and costs.
The Program Fraud Civil Remedies Act (“PFCRA”); 31 U.S.C. §§ 3801-3812
The conduct prohibited by the PFCRA is similar to that prohibited by the False Claims Act. This Federal law makes it illegal for a person or entity to make, present, or submit a claim for property, services or money to a federal agency, such as the US Department of Health and Human Services, when the person knows or has reason to know that the claim is false or fraudulent. This includes claims that are false or fraudulent because of an omission of a material fact. The PFCRA provides for civil penalties up to $5,000 for each false claim paid by the government, and in certain circumstances, as assessment of
twice the amount of each claim.
NY State Insurance Law Section 409 and Regulation 95, §86.6
Every insurer writing private or commercial automobile insurance, workers’ compensation insurance, or individual, group or blanket accident and health insurance policies issued or issued for delivery in this state, which writes three thousand or more of such policies in any given year, or in the case of policies issued on a group basis, provides insurance coverage for three thousand or more individuals in any given year, shall develop and file with the superintendent a plan for the detection, investigation and prevention of fraudulent insurance activities in this state and those fraudulent insurance activities affecting policies issued or issued for delivery in this state. Notwithstanding the foregoing, insurers writing only reinsurance contracts shall not be required to comply with the provisions of this section.
NY False Claims Act (State Finance Law, §§187-194)
New York State makes it unlawful to knowingly make a false statement or representation to attempt to obtain or obtain Medicaid payments for services or supplies furnished under the New York State Medical Assistance Program. This Act imposes penalties and fines on entities and individuals who file false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. Penalties for filing a false claim range from $6,000-$12,000 per claim. Recoverable damages are between two to three times the amount falsely received. The filer of false claims may also have to pay the government’s legal fees.
Under this Act, private individuals may file lawsuits in state court, just as if they were state or local government parties. If it is found that payments must be made back to the government, the individual who first brought the suit can recover 25-30% of the proceeds if the government did not participate in the suit, and 15-20% if the government did participate in this suit.
Social Services Law §145-b —False Statements
Under this law, it is a violation to knowingly obtain or attempt to obtain payment for items or services furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment, or other fraudulent scheme. The State or local Social Services district may recover three times the amount incorrectly paid, and the Department of Health may impose a civil penalty of up to $2,000 per violation. If repeat violations occur within a five year period, penalties of up to $7,500 per
violation may be imposed.
New York Criminal Penalties
New York also imposes the threat of criminal prosecution against any person who, with intent to defraud, presents for payment any false or fraudulent claim for furnishing services or merchandise, knowingly submits false information for the purpose of obtaining greater compensation than otherwise permitted, or knowingly submits false information for the purposes of obtaining authorization for furnishing services or merchandise under the New York State Medical Assistance Program (Medicaid).
It is also a crime under New York Law to “commit healthcare fraud.” Such a crime occurs when a person or entity, with intent to defraud a private or public health plan, knowingly or willfully provides materially false information or omits information for the purpose of receiving payment for health care services, or items that the person is not otherwise entitled to receive.
Insurance Fraud – Penal Law Article 176
Insurance Fraud involves intentionally filing a health insurance claim knowing that it is false. There are various degrees of penalty depending on the dollar amount involved.
Health Care Fraud – Penal Law Article 177
Health care fraud is knowingly filing, within intent to defraud a claim for payment that intentionally has false information or omissions. The penalties relate to the dollar amount involved.
Stark Law§1877 of the Social Security Act. Additionally, the regulations are at [42C.F.R. §411.350 through §411.389].
Stark law, actually three separate provisions, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill. Congress included a provision in the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) which barred self-referrals for clinical laboratory services under the Medicare program, effective January 1, 1992. This provision is known as "Stark I". The law included a series of exceptions to the ban in order to accommodate legitimate business arrangements. A number of observers recommended extending the ban to other services and programs. The Omnibus Budget Reconciliation Act of 1993 (OBRA 1993) expanded the restriction to a range of additional health services and applied it to both Medicare and Medicaid; this legislation, known as "Stark II," also contained clarifications and modifications to the exceptions in the original law. Minor technical corrections to these provisions were included in the Social Security Amendments of 1994.
Social Services Law §145—Penalties
Any person, who submits false statements or deliberately conceals material information in order to receive public assistance, including Medicaid, is guilty of a misdemeanor.
Social Services Law §366-b - Penalties for Fraudulent Practices
Any person who, with intent to defraud, presents for payment a false or fraudulent claim for furnishing services, knowingly submits information in order to obtain greater Medicaid compensation, or knowingly submits false information to obtain authorization to provide items or services is guilty of a Class A misdemeanor.
Penal Law Article 155 - Larceny
A person, who, with intent to deprive another of his property, obtains, takes or withholds the property by means of trick, embezzlement, false pretense, false promise, or similar behavior, has committed the crime of larceny. This has been applied to Medicaid fraud cases. In addition to the laws already mentioned, penal laws regarding false written statements, insurance fraud, and health care fraud have been applied in Medicaid fraud prosecution.
If you have any questions regarding these laws, please contact the ADMS Compliance Department at (718) 483-7414