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Federal & State False Claims Act/Whistleblower Protections Policy

It is the policy of Johns Hopkins HealthCare LLC (“JHHC”) to actively engage in efforts to prevent, detect, and mitigate losses related to fraud and abuse. The Johns Hopkins Health System Corporation (JHHSC) and JHHC take health care fraud and abuse very seriously. JHHC is committed to following all applicable laws and regulations, in particular those that address health care fraud, waste and abuse and the proper billing of all government-funded health care programs. This includes the Federal False Claims Act , the Maryland False Claims Act (Claims Against State Health Plans and State Health Programs enacted in April 2010) , and all applicable State laws and/or related enforcement policies.  It is expected that when an individual becomes aware of active or suspected fraud and abuse, they will immediately report it to the appropriate entity.

Scope

This policy applies to JHHC, as well as Employer Health Programs (“EHP”), Priority Partner MCO (“PPMCO”), and the Johns Hopkins Uniformed Services Family Health Plan (“USFHP”).  It addresses reporting of fraud and abuse committed by or against JHHC, EHP, PPMCO, and/or USFHP providers, enrollees, beneficiaries, members, employees, contractors and vendors.

Definitions

For the purpose of this policy, the following definitions apply: 

  • Fraud - the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or to some other person.
  • Abuse – the practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. 

Set forth below is information about the federal and state false claims acts, remedies available under these acts and how individuals can use them, and whistleblower protections available to anyone who claims a violation of the federal or state false claims acts. We also will advise our employees of the steps JHHC has in place to detect health care fraud and abuse.

Federal False Claims Act

Federal statute which allows for civil and/or criminal action to be brought against a health care provider who:
1. Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval to any federal healthcare program; 
2. Knowingly makes, uses or causes to be made or used a false record or statement to get a false or fraudulent claim paid; or
3. Conspires to defraud the government by getting a false of fraudulent claim allowed or paid.

Examples of a false claim are:
1. Billing for procedures not performed
2. Violation of another law, for example a claim was submitted appropriately but the service was the result of an illegal relationship between a physician and the Hospital (physician received kick-backs for referrals)
3. Falsifying information in the medical record
4. Billing of medically unnecessary services
5. Billing for non-covered services
6. Billing for incorrect level of service

Maryland False Claims Act (codified at Health General §2-601-611)

A person may not knowingly:
1. Present or cause to be presented a false or fraudulent claim for payment or approval;
2. Make, use, or cause to be made or used a false record or statement material to a false or fraudulent claim;
3. Conspire to commit a violation under this subtitle;
4. Have possession, custody, or control of money or other property or on behalf of the State under a State health plan or State health program and knowingly deliver or cause to be delivered to the State less than all of that money or other property;
5. Be authorized to make or deliver a receipt or other document certifying receipt of money or other property used or to be used by the State under a State health plan or program and intending to defraud the state or the Department make or deliver a receipt or document knowing that the information contained in the receipt or document is not true; 
6. Buy or receive as a pledge of an obligation or debt publicly owned property from an officer, employee, or agent of a State health plan or a State health program who lawfully may not sell or pledge the property;
7. Make, use, or cause to be made or used, a false record or statement material to an obligation to pay or transmit money or other property to the State;
8. Conceal or knowingly and improperly avoid or decrease an obligation to pay or transmit money or other property to the State;
9. Make any other false or fraudulent claims against a State health plan or program; or
10. A person who is found to have violated the aforementioned subsection is subject to Civil Monetary Penalties.

Under Maryland’s False Claim Act, a person is prohibited from, among other things, knowingly presenting or causing to be presented a false or fraudulent healthcare claim for payment. Unlike the federal law, the Maryland’s False Claims Act specifically provides that a mistake or a negligent action that causes a false or fraudulent claim to be presented for payment is not in violation thereof. Also unlike the Federal False Claims Act, under the Maryland False Claims Act, qui tam actions must be supported by the intervention of the Office of the Maryland Attorney General in order to proceed.

Remedies

A federal false claims action may be brought by the U.S Department of Justice Civil Division, the United States Attorney.  An individual may bring what is called a qui tam action. This means the individual files an action on behalf of the government. In certain circumstances, the person who files the lawsuit (known as a relator), may be entitled to share in a percentage of the recovery on behalf of the federal 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 says 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 10 years after the date on which the violation was committed.  The submission of false claims may also give rise to criminal liability.

Federal Whistleblower Protections

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

Maryland False Health Claims Act Protections

The Maryland False Claims Act has whistleblower protections which prohibit retaliation against the reporter. You may report directly to the United States Department of Justice or to the Maryland Attorney General. You are not required to report a possible false claims act violation to JHHC first.  JHHC will not retaliate against you if you inform anyone of a possible false claims act violation.

Responsibility

What you should do if you think your organization may have made a false claim:

All JHHC providers, enrollees, beneficiaries, members, employees, contractors and vendors are required to report concerns about actual, potential, or perceived fraud and abuse or other misconduct to the Johns Hopkins HealthCare Corporate Compliance Department. You may reach the Department using one of the methods listed immediately below.

  • Mail:   Johns Hopkins HealthCare Corporate Compliance Department
    6704 Curtis Court
    Glen Burnie, MD 21060,
  • Telephone: (410-424-4996),
  • Fax: (410-762-1527), and
  • Email: Compliance@jhhc.com

 JHHC encourages timely disclosure of such concerns and expressly prohibits any adverse actions directed against any person for making a good faith report of such concerns. No one at JHHC may retaliate against you if you inform the Health Plan or the federal government of a possible false claims act violation. All JHHC workforce members, providers, contractors, subcontractors, and vendors have a right to oppose or refuse to engage in acts that they believe, in good faith, are unethical, improper, or unlawful, provided that the manner of opposition is reasonable and the questionable act is immediately reported to the JHHC Corporate Compliance Department using one of the contact methods listed in the previous paragraph.

Training

We will train all new members of our workforce regarding federal and state False Claims Acts and also provide periodic updates for existing members of our workforce. All members of our workforce are required to participate in training.  All providers, contractors and vendors are required to accept educational information offered by a JHHSC institution or JHHC or to participate in scheduled training.

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