Fraud and Abuse Policy

Mass Care Link Fraud, Abuse, and Waste Policy

It is the policy of Mass Care Link, Incorporated (hereinafter: MCL) to comply fully with all rules, regulations, and laws pertaining to the delivery of and billing for health care services including payor program and participation requirements of Medicaid, other federal payors, and third parties.

All affected parties, as defined below, shall be aware of and comply with the following fraud and abuse policies and procedures required by state and federal guidelines. Failure to comply with this policy and applicable fraud and abuse laws can lead to disciplinary action, up to and including termination or possible legal action.

All MCL employees and contractors as defined below shall be known as “affected parties.” Affected parties shall review and comply with this policy and procedure.

(A) Affected parties shall include any contractor, subcontractor, agent, or other person which or who, on behalf of MCL, furnishes or otherwise authorizes the furnishing of medical health care items or services, performs billing or coding functions, or is involved in the monitoring of health care provided by MCL.
(B) MCL shall notify affected parties of this policy.
(C) MCL is committed to compliance with applicable laws and regulations, including those laws and regulations designed to detect and deter fraud, waste, and abuse.
(D) MCL is committed to correcting conduct that results in fraud, waste, or abuse.
(E) MCL has a process to review reports of violations or suspected violations of applicable law and/or MCL policies.
(F) MCL shall not retaliate (i.e., discharge, demote, suspend, threaten, harass, or discriminate) against any affected party for reporting in good faith a violation or suspected violation of applicable law and/or MCL policies. In addition, MCL shall not retaliate against an affected party because of lawful acts done by the affected party in furtherance of a False Claims Act action, including investigation for, initiation of, testimony for, or assistance in filing a False Claims Act action. However, any person who deliberately makes a false accusation with the purpose of harming or retaliating against another affected party, person or entity will be subject to discipline.
(G) MCL is committed to the submission of accurate claims for payment and provides training regarding the claim submission process.
(H) MCL shall periodically review its policies and procedures, including those policies regarding billing, to prevent and detect fraud, waste, and abuse and to comply with applicable laws and regulations.
(I) Affected parties shall not engage in fraud, waste, or abuse.
(J) Affected parties shall not present or cause to be presented claims which are false, fictitious or fraudulent.
(K) Affected parties shall not make, use, or cause to be made or used a false record or statement to get a false or fraudulent claim paid.
(L) Affected parties shall comply with the MCL policies and procedures which apply to them, including those policies regarding documentation, medical records, medical necessity, billing, coding, waiver of coinsurance and deductibles, overpayments, licensure, compliance with state and federal laws and regulations, and government audits, reviews, and investigations.
(M) Affected parties who perform billing or coding services on behalf of MCL shall have the skills, quality assurance processes, systems, and procedures that are necessary for submitting accurate claims.
(N) If an affected party engages in conduct which is considered fraud, waste, or abuse, violating MCL policy or otherwise violates applicable state or federal laws and regulations, such affected party may be subject to adverse consequences, including disciplinary action, termination, investigation, audit and/or prosecution.
(O) Affected parties shall know about applicable fraud and abuse laws, the role of such laws in preventing and detecting fraud, waste, and abuse, protections applicable to whistleblowers and MCL’s policies and procedures regarding detecting and preventing fraud, waste, and abuse. Specifically, affected parties shall become familiar with the following:

1. The federal definitions of fraud and abuse.

‘Fraud’ means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to their self or some other person. It includes any act that constitutes fraud under applicable federal or state law.

‘Abuse’ means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to federal payor programs, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes practices that result in unnecessary cost to federal payor programs. 42 C.F.R. § 455.2.

2. The purpose of the fraud and abuse laws.

The purpose of the fraud and abuse laws is to ensure the safety of beneficiaries and the integrity of health care programs. The laws target conduct resulting in over-utilization, increased program costs, corruption of medical decision- making and unfair competition. They work to prevent and detect fraud, waste, and abuse by encouraging whistleblowers, punishing violators, and deterring potential violators through criminal and civil penalties, which may include imprisonment, exclusion, debarment, suspension, civil monetary penalties, and corporate integrity agreements.

3. The applicable fraud and abuse laws

The applicable fraud and abuse laws, include, but are not limited to, the laws mentioned below. The summaries of the laws below are not intended to alter the rights or obligations of the parties affected by the laws.

Federal False Claims Act

The federal False Claims Act (“FCA”) makes it illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. “Knowing,” according to the FCA, means the person has actual knowledge, 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. The FCA also applies to any false record or statement made or used to get a false or fraudulent claim paid, as well as the failure to pay an obligation or overpayment to the government. Violations of this statute include, but are not limited to:

Submitting claims for services that were never provided;
Submitting claims for services that are not medically necessary;
Submitting claims for services that may be medically necessary but are not covered;
Using a code for a higher level of reimbursement than the code for the services actually provided;
Billing separately for services that should be billed as a single global service;
Billing for services provided by an excluded or unlicensed provider;
Providing false information on cost reports;
Billing for services where there is an illegal relationship, such as a kickback relationship between a provider submitting a claim and the provider’s referral source; or
Retaining known overpayments for more than sixty (60) days after the
- a. Violators of the FCA are subject to damages, civil penalties, and exclusion. Civil penalties are assessed per false claim and up to three (3) times the amount of damages. Damages may be lowered to not less than (2) times the amount of damages if certain requirements are met.
  
  The FCA allows for a private whistleblower, otherwise known as a relator, to file a qui tam suit on behalf of the government. If the case is successful, the court may award the whistleblower a percentage of any recovery. The employer of a whistleblower may not retaliate against the whistleblower for filing a legitimate qui tam or for being involved with a lawful FCA case. This means an employer may not discharge, demote, suspend, threaten, harass or discriminate against the whistleblower because of his/her whistleblower actions. If a court finds that an employer retaliated, the court will grant the employee the relief it believes is necessary to make the employee whole. However, if the government does not proceed with the case and the court finds that the relator’s claim was frivolous, vexatious, or brought primarily for purposes of harassment, the court may order the relator to pay the defendant’s reasonable attorneys’ fees and expenses.
- b. Federal Anti-Kickback Statute. The federal Anti-Kickback Statute prohibits anyone from providing or offering to provide any remuneration (i.e., generally anything of value) in cash or in kind, directly or indirectly, in return for the referral of a patient whose treatment (item or service) is paid for in whole or in part by a federal health care program, including Medicare or Medicaid. The Anti-Kickback Statute also bans the payment or receipt of remuneration in return for purchasing, leasing, ordering, or recommending the purchase, lease, or order of any goods, facilities, services or items covered by a federal health care program.
  
  Examples of conduct and activities that may violate the Anti-Kickback Statute include, but are not limited to:
  - i Offering or receiving gifts, loans, rebates, services or anything of value between USA Health and physicians or other providers of designated Health Services (DHS), in exchange for patient referrals.
  - ii. Offering gifts, loans, rebates, services, or anything of value to a patient who utilizes or may utilize USA Health services;
  - iii. Discounts or payments offered by suppliers and vendors intended to induce business referrals from USA Health; or
  - iv. Rental of space and equipment to sources of patient referrals below fair market value, or at a rate based on the volume or value of referrals.
  - v. Violations of the Anti-Kickback Statute may result in criminal sanctions including imprisonment for up to five (5) years and a fine or both. In addition to criminal sanctions, violators may be excluded from participation in federal health care programs, civilly fined per violation, and assessed a monetary penalty of up to three (3) times the total amount of remuneration offered, paid, solicited or received. An Anti-Kickback Statute violation may also subject the violator to penalties under the False Claims Act.
- c. Federal Stark Self-Referral Law. Under the federal Stark Self Referral Law (“Stark Law”), if a physician or any member of the physician’s immediate family has a financial relationship with an entity, the physician may not make a referral to the entity for the furnishing of certain defined health care services (called “designated health services”), which are paid for in whole or in part by Medicare or Medicaid, and the entity may not present or cause to be presented a claim or bill to Medicare or Medicaid for the designated health service, unless an exception is met. Designated health services covered by the Stark Law include the following: clinical laboratory services; physical therapy, occupational therapy, and outpatient speech-language pathology services; radiology or certain other imaging services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral or enteral nutrients, equipment and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. Any relationship in which remuneration flows between the parties is considered a financial relationship.
  
  Violations of the Stark Law may result in civil penalties, including denial of payment for the designated health services, and refund of amounts collected from improperly submitted claims. A civil monetary penalty is assessed for each service a person knows or should know was provided in violation of the Stark Law, or each arrangement or scheme which the physician knows or should know has a principal purpose of assuring referrals. Damages may be assessed up to three (3) times the amount of the monetary penalty, and exclusion from federal health care programs. Violation of the Stark Law may also result in penalties under the False Claims Act.

Affected parties may direct questions regarding this policy or applicable fraud and abuse laws to:
USA Ethics and Compliance Hotline
1-844-666-3599

Affected parties shall report violations or suspected violations of this or any MCL policy
or of any applicable laws or regulations to:
USA Ethics and Compliance Hotline
1-844-666-3599

And / Or Alternatively, affected parties can report suspected fraud and abuse activities directly to
the Federal Department of Justice at:
Federal Department of Justice
(202) 514-2000

If the suspected fraud or abuse involves Medicaid claims, reports can be made directly
to the Massachusetts Medicaid Agency Fraud Hotline at: 617-727-6771

Health & Human Services Office of the Inspector General
1-800-223-8164

It is each affected party’s responsibility to comply with the applicable MCL policies, compliance plans, rules, regulations, and laws.