BRIDGEPORT HEALTH CARE CENTER, INC.
POLICIES AND PROCEDURES
I. STANDARDS OF CONDUCT, POLICIES AND PROCEDURES TO PROMOTE COMPLIANCE
The Standards of Conduct set forth below reflect the Company’s expectations as to how its employees, contractors and consultants will conduct themselves when engaged in Company business.
1. Employees and contractors will use their best efforts to meet the requirements of their positions with the Company. Meeting the requirements of their position includes performing duties as set forth in the employee’s or contractor’s job description or contract.
2. Meeting the requirements of a position includes knowing and complying with applicable federal and state laws and professional standards of conduct which may apply to that position.
3. Employees, contractors and consultants are expected to exercise good judgment when conducting the affairs of the Company and performing their job responsibilities and duties. If there is uncertainty as to what is right in a given situation, the appropriate Company representative or supervisor should be consulted for assistance.
4. Management and supervisory personnel will (a) educate employees whom they manage and supervise on the applicable federal and state laws and professional standards of conduct, (b) monitor the performance of employees whom they manage and supervise to ensure compliance with these laws and standards, and (c) take appropriate remedial and, where warranted, disciplinary action in situations where employees fail to comply with applicable laws or professional standards.
5. The Company’s employee evaluation process, as well as evaluation of contractors and consultants, will include where appropriate, compliance with applicable federal and state laws, and professional standards as evaluation criteria. Also, evaluation of the performance of managerial and supervisory employees will include consideration of the extent to which they promote compliance with the employees they manage and supervise, and the extent to which those employees comply with applicable laws and professional standards.
Failure of an employee to comply with applicable laws and professional standards may have a detrimental effect on the employee’s evaluation, result in failure to receive a salary increase or other financial incentive, or result in demotion or other disciplinary action, up to and including termination of employment.
Failure of managerial or supervisory employees to detect noncompliance of subordinate employees with applicable federal or state laws, professional standards, or other noncompliance, where the manager or supervisor should have detected such noncompliance through the exercise of reasonable care, may subject the manager or supervisor to discipline.
Noncompliance with applicable law or professional standards by contractors or consultants may result in the termination of their engagement by the Company.
6. Employees are expected to attend Company sponsored inservice or other education programs regarding their job responsibilities and duties, including learning applicable laws and standards.
7. If an employee is provided with written instructions or directions as to the manner in which his/her employment responsibilities or duties must be performed, the employee is responsible for following those written instructions or directions. Such instructions or directions may include, but are not limited to, billing instructions furnished by governmental or private third-party payors.
8. All communications, either communications between employees, or communications between Company employees and persons outside the Company, will be truthful and accurate. The term “communications” includes, but is not limited to, all information provided in medical records, billing information provided to federal or state payors, private third party payors, residents or their families, information provided to governmental agencies in the course of performing inspections or audits, and other communications both internal and external. All employees are responsible for the truthfulness and accuracy of their communications.
B. Quality of Care
1. The Company is committed to providing high quality care for residents in substantial compliance with federal and state laws governing long-term care facility operations and care and services provided to residents.
2. The Quality Assurance Committee established for the facility pursuant to the requirements of 42 C.F.R. § 483.75(o) is the primary mechanism by which the Company monitors the quality of care provided to residents.
3. The Quality Assurance Committee and its activities comprise part of the Company’s Compliance Program.
4. The Board of Directors and shall establish a system of regular communication with the Quality Assurance Committee for this purpose.
C. Maintenance of Medical Records
The maintenance of complete and accurate medical records is important for many reasons. Medical records provide the means of communicating information regarding a Resident’s condition from one caregiver to another. Medical records also provide the basis on which the performance of the Company with respect to its patient care obligations is judged by regulatory agencies. The medical record is also, in many instances, the basis for billing for services and the proof that services for which bills were rendered were actually provided. The Company expects, as a minimum, the following with respect the maintenance of medical records.
1. All information included in the medical record must be true and accurate to the best of the knowledge of the person entering the information into the medical record.
2. All information included in the medical record must be recorded in legible, complete and up-to-date notes or entries, in a timely manner, i.e., promptly upon completion of the service or observation, and entered in accordance with the professional standards of the discipline of the person making the entry.
3. Where the entry involves providing a service to a resident, the entry must accurately and fully describe the service rendered. Failure to accurately and fully describe services rendered may not only provide incomplete information for purposes of rendering care, but may also fail to support bills rendered by the Company.
4. The entry should support the fact that the services rendered were medically necessary for the health of the recipient of the service. The medical records should support that the services were reasonable and necessary for the diagnosis or treatment of illness or injury of the resident involved. It is the expectation of the Company that physicians and other caregivers will order and render only services which are medically necessary.
D. Billing Practices
The Company’s policy is to submit timely and accurate bills for services which it renders. It is also the Company’s policy to render bills in accordance with the billing requirements of federal or state agencies, or private payors which pay for the Company’s services. In order to fulfill theses objectives, the Company has established the following as standards for billing. These standards are supplemented by the billing instructions provided by federal or state agencies, or private payors.
1. It is the Company’s policy that it will bill only for services actually rendered to residents. Billing for services not actually rendered, i.e., submitting a claim that represents that the Company provided a service, all or part of which was not performed, is illegal and is prohibited by the Company.
2. It is the Company’s practice to bill payors only for services for which the payor has said that it will pay. In the case of government agencies, this means that the services must be medically necessary, i.e. “reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of [a] body member.” See 42 U.S.C. §1395 y (a)(1)(A).
a. Where the certification or order of a physician or other provider is required in order to bill for a service, the physician or other provider should provide the necessary certification or order in the medical record.
3. Where billing requires that services be designated by a “code,” it is the Company’s policy to provide accurate coding of all services which it has provided to a patient. The practice sometimes referred to as “upcoding,” i.e. using a billing code that provides a higher payment rate than the billing code that actually reflects the service furnished to the patient, is prohibited. All employees responsible for assigning codes in billing matters must utilize the code which most accurately reflects the services provided.
4. It is the policy of the Company to avoid duplicate billing for the same services. Duplicate billing may occur when more than one claim for the same service is submitted or a bill is submitted to more than one primary payor at the same time. Employees should take appropriate steps to avoid duplicate billing.
a. It is also Company policy to return duplicative payments in an appropriate manner. For example, a bill may be paid twice by the same payor or primary and secondary insurers may both pay the same bill. When this occurs, the employee discovering the overpayment must inform his/her supervisor, or other person responsible for reimbursing the appropriate party.
5. Employees with billing responsibilities are required to fully familiarize themselves with the billing requirements of federal and state programs and of private payors. If an employee is unsure about the correctness of the billing practice, it is the Company’s expectation that the employee will seek assistance from a supervisor about the appropriate billing practice. Where there is doubt as to the meeting of a particular requirement, the billing manager or supervisor should request advice from the governmental agency or private payor to whom the bill will be submitted. The managers should document and retain a record of the request for information and any response.
6. It is the responsibility of billing managers and supervisors to provide employees with all necessary information to allow the employees to prepare and render accurate bills. It is the responsibility of billing managers and supervisors to stay up to date as to changes in payor billing policies or practices and to fully instruct employees in these changes.
7. The Company will not accept payment for any item or service paid for by Medicare, Medicaid, or any other government program or private insurance program, in excess of the amount allowed under such programs in accordance with applicable law.
a. For example, payors may require that services be “bundled” and billed at a prescribed rate. The practice sometimes referred to as “unbundling,” i.e., submitting bills piecemeal or in fragmented fashion to maximize reimbursement for tests or procedures which are required to be billed together at a reduced cost, is often prohibited by a payor. It is the responsibility of managers and supervisors to be familiar with the payor’s practice as to bundling and to ensure that bills are submitted as required by the payor.
E. Cost Reporting Practices
Accurate preparation of cost reports is the responsibility of both Company personnel and independent consultants who are engaged to prepare cost reports. The Company expects that both its employees and its independent consultants will endeavor to prepare and submit only accurate cost reports. It is the Company’s policy to obtain full compliance with applicable statutes, regulations and program requirements relating to governmental cost reports, as well as private payor plans. The following are general cost reporting principles and standards which the Company has adopted:
1. Costs Must be Related to Patient Care. Federal and state health care programs pay only for costs related to patient care. A brief definition of such costs is as follows:
[Costs related to patient care] include all necessary and proper costs which are appropriate and helpful in developing and maintaining the operation of patient care facilities and activities. Necessary and proper costs related to patient care are usually costs which are common and accepted occurrences in the field of the provider’s activity. They include personnel costs, administrative costs, costs of employee pension plans, normal standby costs, and others. Allowability of costs is subject to the regulation prescribing the treatment of specific items under the Medicare program.
It is expected that employees and consultants will include in cost reports filed with federal and state agencies only appropriate patient care related costs.
2. Consultants. Consultants retained by the Company to prepare cost reports are expected to be familiar with categories of allowable and unallowable costs under the applicable programs. It is expected that consultants will advise the Company appropriately if they believe that costs which are not allowable are being included in cost reports so that the Company may take appropriate action to remove such costs from cost reports. Consultants are also expected to advise the Company as to changes in the Medicare and Medicaid or other governmental programs which may affect cost reporting obligations.
3. Costs should not be claimed on cost reports unless they are based on appropriate and accurate documentation.
4. Allocation of costs through various costs centers should be accurately made and supported by appropriate documentation. Employees responsible for allocating costs to various cost centers should understand the basis upon which an allocation is made. It is expected that independent consultants will employ reasonable professional standards, accepted by governmental agencies, in providing direction as to allocation of costs.
5. Unallowable costs are not claimed for reimbursement. It is the responsibility of all employees with responsibility for paying bills, reimbursing employees for business expenses or preparing cost reports, and all independent consultants, to avoid including unallowable costs in cost reports. Managers and supervisors should implement appropriate procedures for so doing. This should include, but not be limited to, analyzing accounts containing both allowable and unallowable costs to determine the unallowable amount that should not be claimed for reimbursement.
6. Managers, supervisors and consults should review prior year audit adjustments and implement those adjustments in the preparation of cost reports, unless these adjustments are appealed thorough appropriate channels. In situations where such adjustments are appealed, and costs related to these items are to be included in cost reports, they must be clearly identified as protested amounts on the cost report.
7. On its costs reports the Company identifies all related parties on appropriate forms submitted with the cost report and reduces all related party charges to cost. Both the federal Medicare and state Medicaid programs require that costs applicable to services, facilities and supplies furnished to the provider by organizations related to the provider by common ownership or control be included in the allowable cost of the provider at the cost to the related organization. Also, such cost must not exceed the price of comparable services, facilities or supplies that could be purchased elsewhere.
F. Conflict of Interest and Outside Remuneration
1. Conflict of Interest. The Company expects that decisions made by Company employees regarding the purchase or lease of services, facilities or goods will be made with the best interest of the Company in mind. A conflict of interest may exist where an employee, or a member of the employee’s family, may benefit directly from any sale or lease of services, facilities or supplies to the Company. It is not possible to list every circumstance giving rise to a possible conflict of interest, but the following will serve as examples of the types of activities that might cause a conflict of interests:
a. Holding, directly or indirectly, a position or material financial interest in any outside entity which does business with the Company.
b. Competing, directly or indirectly, with the Company.
c. Rendering direction or managerial or consultative services to any outside entity that does business with or competes with the Company.
d. Engaging the services of a family member or company with which a family member of an employee is affiliated to provide goods or services.
Employees are expected to inform the Company of such situations.
2. Gifts, gratuities and entertainment. The issues to consider when purchasing or leasing services, facilities or supplies are the quality and cost to the Company or its patients. The personal interests of the Company employee arranging for the purchase or lease of services, facilities or supplies should not be a consideration. Therefore, acceptance of gifts, entertainment, money, or other favors from any outside individual or concern that does, or is seeking to do, business with, the Company, or competes with the Company, is prohibited. Employees are expected to politely decline the acceptance of any such gifts, entertainment, money or other favors.
3. Illegal remuneration. Employees are expected not to solicit, receive, offer or pay any remuneration, or anything of value, in connection with referral of residents to or from our facility or in connection with purchasing, leasing, or ordering any good, facility, service or item.
II. TRAINING AND EDUCATION
The Company believes that proper training and education of employees and consultants is important if the Company is to achieve its compliance goals. The Company’s training and education program consists of the following:
1. Initial training regarding D.R.A Compliance . All employees will receive training on the Compliance Program. The training will emphasize the Company’s commitment to compliance, the various policies and procedures included in the Compliance Program, Federal and State laws governing fraud and abuse and whistleblower protections.
Employees who do not provide direct care, billing or coding services and who are not in a supervisory/managerial position will receive more limited training and education on the Compliance Program.
All employees will receive, and sign that they have received a copy of the Code of Conduct.
The Company will also provide the Compliance Policies and Procedures to independent contractors and consultants who provide service to the Company on a regular basis.
2. The Company will provide more targeted training to employees whose actions affect the accuracy of claims submitted to governmental or private payors, such as employees involved in the coding, billing, cost reporting and marketing processes. This training may be done in-house or by having employees attend outside seminars or training sessions. Issues that will be covered in this training may include, but not be limited to, the following:
a. The prohibition against billing for items or services not provided.
b. Providing unnecessary medical services.
c. Proper coding.
d. The avoidance of duplicate billing.
e. Proper cost reporting practices, including general government and private payor reimbursement principles.
f. Bundling and unbundling issues.
g. Legal restraints concerning receipt of remuneration and referrals.
h. Documentation in medical records (for appropriate employees).
i. Other issues relevant to governmental programs.
3. Orientation of new employees. New employees will be oriented to applicable portions of the Compliance Program upon hire. Each new employee will receive, and sign that he or she has received, a copy of the Code of Conduct.
4. The Company will in-service employees annually on the compliance program including any changes in the Compliance Program. The Company believes that annual in-servicing on the Compliance Program for appropriate employees emphasizes the organization’s commitment to compliance with applicable laws.
5. Training may be provided by Staff Development or other managers or supervisors as appropriate. In addition, the Company may utilize outside consultants for training at the facility or send employees to training off site.
6. The Facility is responsible for maintaining complete records of training. In all cases the record should include attendance logs, the name of the instructor, a summary of the training program and a copy of any material distributed at the training session.
III. LINES OF COMMUNICATION
1. No Retaliation Policy. It is the policy of the Company to encourage communications between employees, contractors and consultants and Company officials responsible for overseeing the Compliance Program.
It is the policy of the Company that there will be no retaliation by the Company against any person, whether that person is an employee, contractor or consultant, or other person, who: (a) seeks information regarding compliance issues, suggests changes or improvements to the compliance process; or (b) provides information, in good faith, concerning possible or suspected violations of federal or state laws, inappropriate billing or cost reporting practices, or other improper conduct.
2. Obtaining Information. Employees at any level, are encouraged to seek information or clarification regarding Company policies or procedures, government or private payor programs, billing requirements, cost reporting requirements, or other issues which may affect the employee’s ability to comply with Company policy and procedure or federal or state law.
Similarly, consultants or contractors who may have questions or who are seeking information or clarification may seek such information from the Department Head of the department with which that consultant or contractor works or directly from the Compliance Officer. Information may be requested either orally or in writing. If requests for information are made in writing, they should be dated.
3. Reporting potentially inappropriate or illegal conduct — policy on confidentiality. The Company encourages employees, consultants or contractors to report conduct which they believe may violate federal or state law, proper billing or cost reporting practices, or is otherwise inappropriate. The Company will endeavor to keep the identity of the person making the report confidential. However, it is possible that if government authorities become involved in the matter, it will be necessary to reveal the identity of the person making the report. There are also other limited circumstances in which it may be necessary to breach confidentiality.
Reports may be made to the Company in the following ways:
a. A person wishing to make a report in writing, whether anonymous or otherwise, may do so by addressing a communication to the Facility Administrators:
Bridgeport Health Care Center
600 Bond St.
Bridgeport, Ct 06610
540 Bond Street
Bridgeport, Ct 06610
4. Responsibility of Managers and Supervisors.
Employees, consultants or contractors may bring questions and/or reports to managers or supervisors, not only to the Administrators. If a manager or supervisor should receive a request for information or clarification, the manager or supervisor should, if he or she is able to respond, provide such response in a prompt manner. If the response is given in writing, the response should be dated, and a copy should be maintained by the manager or supervisor. If it is appropriate to document an oral response in writing, the manager or supervisor should do so.
It is the responsibility of managers and supervisors, if they do not know the answer to a question, to obtain that answer and to provide it to the employee, consultant or contractor who made the inquiry. The manager or supervisor involved may find it necessary to contact the Administrator to obtain the information.
If a report of a suspected violation of federal or state law, billing or cost reporting practices, or other possible wrongdoing or inappropriate conduct is made to a manager or supervisor, the manager or supervisor should contact the Administrator who will assist in handling the matter.
IV. ENFORCEMENT OF STANDARDS
1. Disciplinary Action. The Company believes that its employees, consultants and contractors share the Company’s concern with compliance and will take all reasonable steps to comply with applicable federal and state laws, billing practices of governmental and private payors, cost reporting procedures, and professional standards of conduct.
Company personnel at any level who failed to comply with the Company’s standards of conduct, policies and procedures, or applicable federal and state laws, or who otherwise engage in wrongdoing, are subject to disciplinary action. Disciplinary action will be taken at the discretion of the Company in accordance with its personnel policies and may include, as appropriate, any one or more of the following:
a. Oral Warning;
b. Written warning;
c. Placing a person on probationary status;
d. Suspension with or without pay;
e. Termination of employment.
The Company, in its sole discretion, will determine which of the above methods of discipline is appropriate in each instance.
2. Avoiding Disciplinary Action. The Company would prefer to avoid the need for disciplinary action. The Company encourages employees to ask questions, seek information or clarification of Company policies and procedures, or applicable laws. The Company has a policy of no-retaliation when such inquiries are made. Consequently, employees should feel free to ask questions and seek information concerning any aspect of their employment responsibilities, especially the need to comply with this Compliance Program, federal or state laws, billing practices or cost reporting practices. When necessary, the Company will provide additional training or education to personnel.
3. Consultants and Contractors. Consultants or contractors who fail to comply with the Company’s standards of conduct, federal or state laws, billing or cost reporting practices or professional standards of conduct may have their contracts terminated.
4. New Employee Policy. With respect to all new employees who have authority to make decisions that may involve compliance with the law or oversight of the Company’s Compliance Program, the Company will contact references prior to hire. The Company will also require applicants to disclose any criminal conviction as defined by federal law or exclusion from the Medicare or Medicaid programs. The Company will also consult the Cumulative Sanction Report produced by the United States Department of Health and Human Services, Office of Inspector General to determine whether a person has been excluded from participation in the Medicare and Medicaid programs. The Cumulative Sanction Report is available on the Internet at: www.dhhs.gov/progorg/oig or www.hhs.gov.oig.
6. Convicted and Excluded Persons. The Company will not employ individuals who have disclosed criminal convictions related to health care or who are listed as debarred, excluded or otherwise ineligible for participation in federal or state health care programs. Prospective employees who have been officially reinstated into the Medicare and Medicaid programs by the OIG may be considered for employment upon proof of such reinstatement. In addition, the Company will not contract with companies that have recently been convicted of criminal offenses relating to health care, or have been listed by a federal agency as debarred, excluded, or otherwise been deemed ineligible for participation in federal or state health care programs. Debarred contractors are listed at http://epls.arnet.gov.
With respect to current employees and contractors, the Company may relieve current employees and contractors from responsibility for any involvement in any federal or state health care program if criminal charges or proposed debarment or exclusion proceedings are brought against a current employee or contractor. If the matter results in conviction, debarment or exclusion, the Company will terminate the employment or contractual arrangement with the individual or company.
V. CORRECTIVE ACTION INITIATIVES.
1. If the Company should receive a report or reasonable indication of suspected noncompliance, the Compliance Officer will initiate steps to investigate the conduct in question to determine whether there has been a material violation of applicable law or the requirements of the Compliance Program. If so, steps will be taken to correct the problem. This further investigation may be accomplished through outside legal counsel.
2. Where a determination is made that there has been an overpayment made to the Company, the Company will take prompt action to make restitution to the appropriate payor.
3. If the company determines that there has been a violation of criminal, civil or administrative law, the Company will promptly report the existence of such violation to the appropriate governmental authority within a reasonable period of time, but not more than sixty (60) days after determining that there is credible evidence of a violation.
4. In addition, there may be disciplinary action taken against persons responsible for the violation.
VI. Federal and State False Claims Laws and Whistleblower Protections
1. Federal False Claims Act
The Civil False Claims Act (31 U.S.C. §3729 et seq.) is a statute that imposes civil liability on any person who:
§ knowingly presents, or causes to be presented, a false or fraudulent claim, record or statement for payment or approval,
§ conspires to defraud the government by getting a false or fraudulent claim allowed or paid,
§ uses a false record or statement to avoid or decrease an obligation to pay the Government, and
§ other fraudulent acts enumerated in the statute.
The term “knowingly” as defined in the Civil False Claims Act (“FCA”) includes a person who has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.
The term “claim” includes any request or demand for money or property if the United States Government provides any portion of the money requested or demanded.
Potential civil liability under the FCA currently includes penalties of between five thousand five hundred and eleven thousand per claim, treble damages, and the costs of any civil action brought to recovery such penalties or damages.
The Attorney General of the United States is required to diligently investigate violations of the FCA, and may bring a civil action against a person. Before filing suit the Attorney General may issue an investigative demand requiring production of documents and written answers and oral testimony.
The FCA also provides for Actions by Private Persons (qui tam lawsuits) who can bring a civil action in the name of the government for a violation of the Act. Generally, the action may not be brought more than six years after the violation, but in no event more than ten. When the action is filed it remains under seal for at least sixty days. The United States Government may choose to intervene in the lawsuit and assume primary responsibility for prosecuting, dismissing or settling the action. If the Government chooses not to intervene, the private party who initiated the lawsuit has the right to conduct the action.
In the event the government proceeds with the lawsuit, the qui tam plaintiff may receive fifteen to twenty-five per cent of the proceeds of the action or settlement. If the qui tam plaintiff proceeds with the action without the government, the plaintiff may receive twenty-five to thirty per cent of the recovery. In either case, the plaintiff may also receive an amount for reasonable expenses plus reasonable attorneys’ fees and costs.
If the civil action is frivolous, clearly vexatious, or brought primarily for harassment, the plaintiff may have to pay the defendant its fees and costs. If the plaintiff planned or initiated the violation, the share of proceeds may be reduced and, if found guilty of a crime associated with the violation, no share will be awarded the plaintiff.
Whistleblower Protection. The Civil False Claims Act also provides for protection for employees from retaliation. An employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against in terms and conditions of employment because of lawful acts conducted in furtherance of an action under the FCA may bring an action in Federal District Court seeking reinstatement, two times the amount of back pay plus interest, and other enumerated costs, damages, and fees ..
2. Federal Program Fraud Civil Remedies Act of 1986
The Program Fraud Civil Remedies Act of 1986 (“Administrative Remedies for False Claims and Statements” at 38 U.S.C. §3801 et seq.) is a statute that establishes an administrative remedy against any person who presents or causes to be presented a claim or written statement that the person knows or has reason to know is false, fictitious, or fraudulent due to an assertion or omission to certain federal agencies (including the Department of Health and Human Services).
The term “knows or has reason to know” is defined in the Act as a person who has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.
The term “claim” includes any request or demand for property or money, e.g., grants, loans, insurance or benefits, when the United States Government provides or will reimburse any portion of the money.
The authority, i.e., federal department, may investigate and with the Attorney General’s approval commence proceedings if the claim is less than one hundred and fifty thousand dollars. A hearing must begin within six years from the submission of the claim. The Act allows for civil monetary sanctions to be imposed in administrative hearings, including penalties of five thousand five hundred dollars per claim and an assessment, in lieu of damages, of not more than twice the amount of the original claim.
3. Connecticut – False Claims Laws
In addition to the Federal laws described above, there are several state laws designed to prevent and detect fraud and abuse. Employees and contractors of the Facility are expected to act in accordance with these laws which are described in detail below. Violations of these laws carry the possibility of criminal or monetary penalties as well as exclusion from participation in the Medicaid program.
a. Vendor Fraud. Conn. Gen. Stat. § 53a-290. The facility, employees or contractors will be considered to have committed vendor fraud, when, with intent to defraud, the company or the individual:
Presents for payment any claim for goods or services that is false;
Accepts payment for goods or services in excess of the amount actually due or the amount allowed by law for those goods or services;
Attempts to provide services or sell goods to a resident knowing the resident does not need the goods or services;
Sells goods or services to a resident without prior authorization from the Department of Social Services when a prior authorization is required; or
Accepts from any person or source additional compensation in excess of the amount allowed under the law.
Such acts are considered fraudulent whether done by an employee or contractor on his or her own behalf or on behalf of another person or entity. Any person found guilty of vendor fraud may be subject to imprisonment, monetary penalties, exclusion from participation in the Medicaid program and/or revocation of any license held by that person.
b. Health Insurance Fraud. Conn. Gen. Stat. § 53-440 et seq. A person is guilty of health insurance fraud when, with the intent to defraud, he/she:
Makes any written or oral statement as part of (or in support of) an application for health insurance or claim for payment knowing the statement is false, incomplete, deceptive or misleading or omitting material information whether for himself, a family member or third party;
Assists, solicits or conspires with another to prepare or present any written or oral statement to any insurer or agent in connection with an application or claim for health care benefits knowing that the statement contains false, deceptive or misleading information. Misleading information includes falsely representing that goods or services were medically necessary or that they met professionally recognized standards.
The term “insurer” includes any private or governmental agency that provides medical benefits to Medicare or Medicaid recipients. Conn. Gen. Stat. § 53-441(c). Health insurance fraud is punishable by imprisonment and/or fines and may result in exclusion from participation in the Medicaid program and/or loss of license.
c. Larceny. Defrauding the Government. Conn. Gen. Stat. § 53a-119. A person is guilty of larceny against the government when he/she:
Authorizes, certifies, attests or files a claim for benefits or reimbursement from a local, state or federal agency knowing it is false; or
Knowingly accepts the benefits from a claim he knows is false.
Larceny is a crime punishable by imprisonment and/or fines.
4. Reporting/Whistleblower Protection Under Connecticut Law
The Facility encourages persons who believe that a violation of law or Facility policy has occurred to communicate their concerns to Facility management. Employees and contractors who become aware of any violation of these laws are required as part of their job responsibilities to bring such violations to the attention of Facility management.
It is the right of all persons under Connecticut law to be protected against retaliation for reporting violations of these laws. The Facility will not discriminate or retaliate in any manner against employees or contractors who disclose information about suspected violations. The following laws prohibit discrimination and/or retaliation:
a. Conn. Gen. Stat. §19a-498a. Discriminatory Practices Prohibited. No health care facility may discriminate or retaliate in any manner against an employee for submitting a complaint or initiating or cooperating in an investigation relating to the care, services or conditions in the facility.
b. Conn. Gen. Stat. §19a-532. Discrimination Against Complainants. No nursing home may discharge, discriminate or retaliate against any patient, employee or other person for filing a complaint, instituting a proceeding, testifying in a proceeding or exercising any rights.
c. Conn. Gen. Stat. §31-51m. Protection of Employee Who Discloses Employer’s Illegal Activities or Unethical Practices. Civil Action. No employer may discharge, discipline or otherwise penalize any employee because that person reports a violation or suspected violation of any state or federal law or regulation or because the employee is requested by a public body to participate in an investigation, hearing or inquiry.
d. Conn. Gen. Stat. §4-61dd. Whistleblowing. Large state contractors. No employee or officer of a large state contractor may take or threaten to take any personnel action against an employee in retaliation for disclosing information of any matter involving corruption or violation of state or federal laws or regulations.