Mt. Washington Pediatric Hospital

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Corporate Compliance

Information about Federal and State False Claims Legislation 1

Mt. Washington Pediatric Hospital (the "Hospital"), is required by federal law to provide information to all of its employees, contractors and, agents regarding the federal false claims act, administrative remedies for false claims and statements, the state false claims act and whistleblower protections under these laws. The federal and state false claims acts play an important role in detecting fraud, waste and abuse in federal health care programs.

Federal False Claims Act

What the law does:

It allows a civil action to be brought against a health care provider that:

Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval from the federal government;
Knowingly makes, uses or causes to be made or used a false record or statement material to a false or fraudulent claim;
Conspires to defraud the government by getting a false or fraudulent claim allowed or paid; or
Knowingly conceals, avoids or decreases an obligation to pay amounts to the federal government.

Examples of a false claim:

Billing for procedures not performed
Violating another law, for example submitting an appropriate claim, but the service was resulted from an inappropriate arrangement between a physician and a hospital (e.g., physician received a kickback for referring patients to the hospital)
Falsifying information in the medical record
Billing than once for the same service
Retaining improper overpayments received from a federally funded program

Remedies:

A federal false claims action may be brought by the U.S Department of Justice
An individual may bring a "qui tam" action. This means the individual files an action on behalf of the government.
Violation of the federal False Claims Act is punishable by a civil penalty of between $5,500 and $11,000 per false claim, plus three times the amount of damages incurred by the government.
A statute of limitations indicates how much time may pass before an action may no longer be brought for violation of the law. Under the False Claims Act, the statute of limitations is six years after the date of violation or three years after the date when material facts are known or should have been known by the government, but no later than ten years after the date on which the violation was committed.

Federal Whistleblower Protections

Federal law prohibits an employer from retaliating against an employee, contractor or agent in the terms or conditions of employment because the employee, contractor or agent initiated or otherwise assisted in a false claims action. The employee, contractor or agent is entitled to all relief necessary to make the employee, contractor or agent whole.

Maryland False Claims Provisions

Maryland, like many other states, has enacted a statute similar to the federal False Claims Act that provides for criminal and civil remedies for the submission of false and fraudulent claims to the Medicaid program. Under Maryland’s Medicaid fraud statute, it is a crime for a person to knowingly and willfully:

Defraud or attempt to defraud the Medicaid program in connection with the delivery of or payment for a health care service or
Obtain or attempt to obtain by means of a false representation anything of value in connection with the delivery of or payment for a health care service through the Medicaid program

Examples of false representations include:

Knowingly and willfully concealing, falsifying or omitting a material fact
Knowingly and willfully making a material false or fraudulent statement
Knowingly and willfully using a document that contains a statement of material fact that the user knows to be false or fraudulent

Maryland Whistleblower Protections

Maryland law prohibits retaliatory action by an employer against an employee who in good faith reports:

Any potential violation of state or federal law by an employer as a health care provider; or

Any situation where an employer provides care in a manner that violates state or federal standards or laws or recognized clinical or ethical standards.

Monitoring Mt. Washington Pediatric Hospital’s Policies & Procedures for Detecting Fraud & Abuse

The Hospital has established internal systems and controls to monitor its coding and billing practices on an ongoing basis to ensure compliance with the False Claims Act and similar state laws.

In addition, an external independent auditor performs an annual audit of the Hospital’s patient financial services operations. The auditors test the accuracy of the Hospital’s reporting and checks to make sure the appropriate checks and balances are adhered to in each phase of the department's operations.

What you should do if you think the Hospital may have made a false claim?

If you as an employee or a contractor/agent see something that looks like one of the examples of a false claim provided above, the Hospital encourages you to:

Report the information to a supervisor for further investigation
If you are not comfortable reporting the information in this manner or do not see action in response to an earlier report, please contact the Hospital’s Compliance Office at 1-877-300-DUTY (3889) or logon to www.reportit.net to submit an electronic report to the Hospital’s Compliance Office

You are not required to report a possible false claims act violation to the Hospital first. You may report directly to the federal Department of Justice.

If you have any questions about this information, please call the Hospital’s Compliance Department at 410 328-3848.

You can find additional information about the False Claims Act at:

United States Department of Justice: http://www.usdoj.gov
Department of Health & Human Services: http://www.hhs.gov
Office of Inspector General: http://oig.hhs.gov
Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov

1 This information is being provided in compliance with the federal Deficit Reduction Act of 2005.

Mt. Washington Pediatric Hospital: Advancing the care of children. A jointly owned corporate affiliate of The University of Maryland Medical System and The Johns Hopkins Health System.