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Priority Health requires all parties that work with us to comply with all laws and regulations. This policy ensures that providers, contractors and vendors are aware of applicable federal and state laws designed to prevent and detect fraud, waste and abuse. In addition, this policy provides information about whistleblower protections.
Annual training on fraud, waste and abuse required by CMSThe Centers for Medicare and Medicaid Services require all health care providers offering services to Medicare plan members to complete an annual training session on how to recognize and prevent fraud, waste and abuse. Priority Health has created a presentation that, when you click through it, completes your obligation for this training.View the annual Fraud, Waste & Abuse training presentation (171KB PDF) Priority Health Policy: Federal and State Laws Related to Fraud, Waste and AbusePolicy number: 36/0006/R0Federal and State False Claims Acts As required by the federal and state False Claims Acts, all providers, contractors and vendors are prohibited from knowingly presenting (or causing to be presented) to the federal or state government a false or fraudulent claim for payment or approval. The acts define "knowingly" to mean a person that has actual knowledge of the false claim, 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. All individuals are prohibited from knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved by the federal or state government or its agents. The False Claims Acts are enforced against any individual/entity that knowingly submits (or causes another individual/entity to submit) a false claim for payment to the federal or state government. Violation of the False Claims Acts can result in civil penalties from $5,000 to $11,000 per claim. Priority Health monitors the compliance of our contractors and subcontractors to the False Claims Acts. The federal and state False Claims Acts permit individuals with knowledge of fraud against the federal or state government to file a lawsuit on behalf of the government against the individual/entity that committed the fraud. If the lawsuit is successful, the individual is entitled to a portion of the government's recovery. The False Claims Acts provide a "whistleblower" protection. Whistleblower The False Claims Acts include specific provisions to protect whistleblowers from retaliation by their employers. Any private party who initiates or assists with the federal False Claims Act case against his/her employer is protected from discharge, demotion, suspension, threats, harassment and discrimination in the terms and condition of his or her employment if the employer's actions are taken in response to the employees efforts on the case. A private party who does suffer retaliation for his or her assistance with a case against his/her employer is entitled to reinstatement, two times the amount of back pay, interest and compensation for special damages including attorney's fees. Anti-Kickback Statute As required by the Anti-Kickback Statute, individuals are prohibited from knowingly or willfully offering, paying, soliciting or receiving remuneration (the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind) in order to induce and reward business payable (or reimbursable) under the Medicare or other federal health care programs. A criminal sanction may place those in violation of the law in jail for up to 5 years, assess a $25,000 fine and impose mandatory exclusion from the participation in any government funded health care programs. On the civil side, the monetary penalty of $50,000 per violation and treble damages that equal three times the dollar amount the government is defrauded may apply. There are three objectives behind the federal anti-kickback law. 1) To prevent over-utilization of health care programsThe Program Fraud Civil Remedies Act The Program Fraud Civil Remedies Act of 1986 provides for administrative remedies against any person who makes, or causes to be made, a false claim or written statement to certain federal agencies, including the Department of Health and Human Services. The Program Fraud Civil Remedies Act addresses lower dollar fraud and generally applies to claims of $150,000 or less. Stark Law The Stark law pertains to physician referrals under both Medicare and Medicaid and states that a physician cannot refer patients to an entity for the purpose of furnishing certain designated health services if the physician or an immediate family member has a financial relationship with that entity. The entity cannot bill for improperly referred services unless an exception or safe harbor applies. It is essential to realize that the Stark law has no state-of-mind requirement. The intention and motives of the parties involved are irrelevant. If statutory requirements are met, there is a violation, unless an exception or safe harbor applies. The Stark law is targeted against over-utilization and improper patient steering, and is intended to increase market competition. Sanctions and fines are civil and criminal penalties do not apply. Under the civil penalty, the entity that did the billing must refund the payments for improperly referred services. There is also a civil monetary penalty of up to $15,000 for any person who presents or causes a claim for improperly referred designated health services as long as they know that the claim is improper. Reporting Any potential case of fraud, waste or abuse related to Priority Health programs, including Priority Medicare and Priority Medicaid, may be reported to the following:
OrPriority Health Fraud and Abuse Program Suspected cases of fraud related to Priority Medicaid may also be reported directly to the State of Michigan Medicaid department at:You may also fax the information to: 616 975-8893
Supporting documentation:Compliance verification:
Reference documentation:
Last modified
03/16/10
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