False Claims Policy

It is CoxHealth’s policy to conduct all of its business and other practices in compliance with all applicable laws and regulations. 

In furtherance of this policy, it is CoxHealth’s objective to use its best efforts to prevent and detect possible fraud, waste and abuse in its operations. CoxHealth also encourages its employees, volunteers, physicians, and vendors to report any incidents that they, in good faith, believe could lead to fraud, waste and abuse against federal and state health care programs, such as Medicare and Medicaid. 

The purpose of this policy is to help the members of CoxHealth understand the tools the Hospital, federal and state agencies and individuals can use to fight such fraud, waste and abuse including the federal and state false claims laws and the right of the members of CoxHealth to report violations of such laws. 

The Federal False Claims Act

The Federal False Claims Act (FCA), in general, prohibits a health care provider from knowingly presenting or causing to be presented a false or fraudulent claim, or knowingly making or causing to be made a false record or statement, to the federal government for payment. The term “knowingly” is defined to mean the person has actual knowledge that the information is false, or acts in deliberate ignorance or reckless disregard of the truth or acknowledges that the information is inaccurate. Conduct that could lead to the submission of a false or fraudulent claim might include falsifying records, double-billing for items or services or submitting bills for services never performed or items never furnished. Anyone who violates the FCA could be subject to fines between $5,000 and $11,500.00 for each false claim, plus three times the actual damages sustained by the federal government. 

Qui Tam “Whistle-blower” Provisions

“Whistleblowers” are generally employees who observe activities or behavior that may violate the law in some manner. These individuals report their observations either to management or to governmental agencies. To encourage these individuals to come forward and report possible misconduct involving false claims, the FCA includes a “qui tam” or whistleblower provision which essentially allows a person with actual first-hand knowledge of false claims activity to bring an action in federal court. The lawsuit is initiated by filing a copy of the complaint and all available relevant evidence with the federal government. The lawsuit will remain sealed (meaning it will be kept confidential) for at least 60 days so the federal government can investigate the complaint and decide how to proceed. The government may then decide to pursue the matter in its own name or decline to proceed, at which time the person bringing the action has the right to continue with the lawsuit on their own. If the lawsuit is successful, the person bringing the action may receive between 15-30% of any proceeds, plus reasonable expenses, costs and attorney’s fees, depending upon the contributions the individual made to the success of the case. Any false claims case must be brought up for action within six years from the date that the false claim was filed. 

No Retaliation

The FCA provides protection for whistleblowers. Anyone initiating a qui tam case may not be discriminated or retaliated against in any manner by their employer for filing the lawsuit. Under the FCA, an employee may initiate court proceedings to make themselves whole for any job related losses resulting from any such discrimination or retaliation. Program Fraud Civil Remedies Act The Program Fraud Civil Remedies Act (PFCRA) is another federal law which addresses false claims. It is similar to the FCA, but imposes different penalties. In general, it subjects anyone who violates the PFCRA to administrative penalties if they submit an improper statement or file a false claim with the federal government: a) which they know, or should know, is false; b) which omits a material fact and is, therefore, false or fraudulent because of the omission; or c) for payment of services not rendered. Anyone who violates the PFCRA could be subject to penalties of up to $5,000 plus two times the amount of the claim if the claim has been paid. Although an individual can report any incidents to the government that they believe could be a violation of the PFCRA, the individual is not allowed to bring a qui tam lawsuit similar to what is allowed under the FCA. 

Missouri False Claims Statute

Missouri’s False Claims Statute deals with claims submitted to the Missouri HealthNet. In general, the statute makes it a criminal offense for a health care provider to: (a) knowingly present any false claim for payment of goods and services that may be paid for by Medicaid; b) knowingly make a false statement for use in determining payment, or the rate of payment, of goods and services that may be paid for by Missouri HealthNet; and c) knowingly submits any claim for payment of services that were medically unnecessary. The Attorney General brings all criminal or civil actions under the statute. Because a violation can be criminal in nature, the Attorney General must prove that the health care provider intended to violate the statute. Violations of the statute constitute a felony punishable by fines, imprisonment, or both. 

Qui Tam “Whistle-blower” Provisions

The Missouri False Claims statute has a “whistleblower provision” similar to that of the Federal False Claims statute.“Whistleblowers” are generally employees who observe activities or behavior that may violate the law in some manner. These individuals may report their observations either to management or to the Missouri State Attorney General’s Office. To encourage these individuals to come forward and report possible misconduct involving false claims, the Missouri False Claims Statute includes a “qui tam” or whistleblower provision which essentially allows a person with actual first-hand knowledge of false claims activity to bring an action in state or federal court. 

Penalties

Anyone who violates the Missouri False Claims statute could be subject to fines between $5,000 and $10,000 for each false claim, plus three times the actual damages sustained by the State of Missouri. The first offense will be a Class C felony, the second offense is a Class B felony. Anyone who is convicted of a violation shall be referred to the Office of Inspector General (OIG). Any person who willfully prevents, obstructs, misleads, or delays an investigation would be found guilty of a Class D felony. Any individual found guilty would have to refund monies received in payment for the services and reimburse the Missouri HealthNet Program the reasonable costs attributed to the investigation and prosecution. 

No Retaliation

The Missouri False Claims statute provides protection for whistleblowers. Anyone initiating a qui tam case may not be discriminated or retaliated against in the terms or conditions of their employment because of their initiation, assistance or participation in a court action. Under the Missouri False Claims statute an employee may initiate court proceedings to make themselves whole for any job related losses resulting from any such discrimination or retaliation. Whistleblowers are not protected if their complaint is found to be frivolous or clearly vexatious (intent to bring harm without merit or facts). This action can carry a Class A misdemeanor. 

CoxHealth’s Policies and Procedures for Detecting and Preventing Fraud

The Corporate Compliance Program for CoxHealth is defined in detail in the Standard’s Manual. The CoxHealth Code of Conduct in the Standard’s Manual is considered a part of the Corporate Compliance Program at CoxHealth. This policy details the conduct CoxHealth expects of all CoxHealth employees. The specified conduct, if followed, will ensure that the Integrity of CoxHealth is protected. The purpose of the Compliance Program is to ensure that we maintain a reputation of honesty, integrity, and respect towards others. It is important that the members of CoxHealth have these values in their interactions with those we serve. To ensure that reputation remains strong, we must abide by the federal and state laws, regulations, and guidelines that govern the provision of health care. A part of assuring that our reputation remains strong and that we are recognized as a respectful, compassionate place to work and receive health care services; is to ensure that we are abiding by the federal and state laws and regulations; and CoxHealth policies that govern our working environment ( e.g. the Fair Labor Standards Act, and prohibitions against Discrimination and Harassment). 

The Corporate Compliance Program at CoxHealth is managed by the Corporate Integrity Department with the assistance of every employee and Department within CoxHealth. It is the role of the Corporate Integrity Department to ensure that processes are in place to encourage communication regarding concerns about their interactions with CoxHealth, to investigate those concerns, and to take appropriate action based on that investigation. The Department has established processes whereby we will detect possible fraud, waste of valuable resources, and abuse of the system for personal or corporate gain. 

One of the key processes is the operation of the Compliance Hotline – 417-269-5297or toll free 1-888-340-5297. Other processes include the various Compliance Committees who are charged with meeting regularly to discuss areas of concern. Members of these committees function as spokespersons for others at CoxHealth regarding areas of concern or activities that might be considered to be high-risk areas. High-risk areas are those that are defined as having a possibility that errors could occur, regulations are difficult to understand, or there is a high volume of specific transactions that are highly regulated by the government.