Current through all regulations passed and filed through September 16, 2024
(A)
Policy
statement
The university of Toledo ("UToledo") is
committed to ensuring compliance with laws and regulations that address the
false claims act that includes medicare fraud, waste, and
abuse.
(B)
Purpose of policy
This policy defines false claims act
including fraud, waste, and abuse and the sanctions for violation of the
federal and state regulations.
(C)
Scope
All UToledo campuses including vendors
and contractors that perform services for the university of Toledo medical
center and its clinics. In addition, any academic department that performs
services for the covered entity. The academic departments are but not limited
to: physical therapy, speech therapy, and occupational therapy and psychology
departments.
(D)
Definitions
(1)
"Abuse" is payment for items or services when there is
no legal entitlement to that payment and the individual or entity has not
knowingly and/or intentionally misrepresented the facts to obtain
payment.
(2)
"False claims act ("FCA") establishes liability for any
person who knowingly presents or causes to be present a false or fraudulent
claim to the federal government for payment.
(3)
"Fraud" is
generally defined as knowingly and willfully executing or attempting to execute
or artifice to defraud any healthcare benefit program or to obtain (by means of
false or fraudulent pretenses, representation or promises) any of the money or
property owned by, or under the custody or control of, any healthcare benefit
program. (18 U.S.C. 1347).
(4)
"Waste" is overutilization of services or other
practices that, directly or indirectly, result in unnecessary costs to the
healthcare system, including the medicare and medicaid programs. It is not
generally considered to be caused by criminally negligent actions but by misuse
of resources.
(E)
Whistleblower protection
The whistleblower protection act
provides employees that come forward and report in good faith misconduct
involving false claims (fraud, waste, and abuse) protection from workplace
retaliation. See rule
3364-15-04
of the Administrative Code (non-retaliation policy).
(F)
Fraud, waste and
abuse
(1)
Examples of fraud:
(a)
Billing for
services not provided.
(b)
Giving false information about credentials such as a
college degree.
(c)
Billing for more services than were
performed.
(d)
Billing and receiving duplicate payments, not returning
the funds.
(e)
Billing non-covered services as a covered
code.
(f)
Prescription drug switching.
(2)
Examples of
waste:
(a)
Waste can include spending on services that lack evidence of
producing better health outcomes compared to less expensive
alternatives;
(b)
Inefficiencies in the provision of health care goods
and services; and
(c)
Costs incurred while treating avoidable medical
injuries, such as preventable infections in hospitals.
(3)
Examples of abuse
Abuse is defined as practices that are
inconsistent with accepted sound fiscal, business, or medical practices, and
result in:
(a)
An unnecessary cost or in reimbursement for services
that are not medically necessary or
(b)
That fail to meet
professionally recognized standards for health care,
(c)
Such as:
(i)
Misusing codes on
a claim;
(ii)
Charging excessively for services or supplies;
and
(iii)
Billing for services that were not medically
necessary.
(4)
Penalties and
fines
Violations of the FCA that includes
fraud, waste and abuse may result in any or all of the following
(a)
Civil monetary
penalties: payment of interest at the maximum rate on the amount of the
payments, a fine between five thousand five hundred dollars and eleven thousand
dollars for each false filing, and any other reasonable expenses determined by
the court.
(b)
Fines: In addition to five thousand five hundred
dollars to eleven thousand dollars for each act, an assessment of damages three
times the amount of the overpayment may be prescribed.
(c)
Criminal
penalties: If convicted, the individual could face jail time and be ordered to
pay fines and restitution. Additionally, a licensure could come under review
and be suspended or permanently revoked.
(d)
Medicare/medicaid
exclusion: A conviction under the FCA could lead to exclusion from medicare,
medicaid and all other federal health care programs. If excluded, then no
payment will be made by any federal health care program for any items or
services furnished, ordered or prescribed by an excluded individual or
entity.
(e)
Health care providers and suppliers (person and
organizations) who violate the FCA are subject to an investigation by the
office of inspector general ("OIG"), who may seek to exclude the provider or
supplier from participation in federal health care programs.
(G)
Reporting
(1)
Workforce members should report suspected violations of
the false claims act that includes fraud, waste and abuse. Reports should
follow our UToledo policies, rule
3364-15-03
of the Administrative Code (compliance incident reporting) and rule
3364-15-05
of the Administrative Code (protected disclosures and anonymous reporting
line).
(2)
Employees that report violations of the FCA and UToledo
does not investigate or does not remediate verified violations may report to
the federal government as a whistleblower.
(3)
UToledo will not
retaliate against any workforce member who reports in good faith suspected
violation of the FCA, workforce members who reports is protected from
retaliation. See rule
3364-15-04
of the Administrative Code (non-retaliation).
(H)
Non-retaliation
In accordance with the FCA, any
employee who reports suspected misconduct is protected from retaliation. See
rule
3364-15-04
of the Administrative Code (non-retaliation).
Replaces: 3364-15-02
