QSAC Whistle Blower Policy
QSAC is committed to observing the highest standards of business and personal ethics. As employees and representatives of the Agency, we must practice honesty and integrity in fulfilling our responsibilities and complying with all applicable laws and regulations.
It is the responsibility of employees and volunteers to report violations or suspected violations of fraud, theft, embezzlement, bribery, kickbacks misuse of QSAC assets or suspected regulatory, compliance or ethics related issues concerns or violations. Theft includes taking money or property of the agency including food, theft from consumers or staff. Fraud could include filing false disability, workers comp or insurance claims.
Staff members who file a valid complaint or a complaint which leads to the correction of an ethical or legal problem will be eligible for compensation of up to $300, depending upon the situation.
No employee who in good faith reports a violation shall suffer in any way. An employee who retaliates against someone who has reported a violation in good faith is subject to discipline up to and including termination of employment. This Whistleblower Policy is intended to encourage and enable employees and others to raise serious concerns within our Agency.
Questions, concerns, suggestions or complaints regarding the ethical and legal standards noted above should be addressed directly to the QSAC Executive Director at 212 244 5560 x 2020 or QSAC Executive Director, 253 W 35th St, 16th flr, NY NY 10001 or thru the Executive Director Hotline @ (718) 728-8476, extension 1040. If the complaint involves the Executive Director, the report should be addressed to the President of the Board of Directors. Reports or complaints can be submitted anonymously but, in such event, no compensation can be granted.
Anyone filing a complaint concerning a violation or suspected violation of the ethical and legal standards noted above must act in good faith and have reasonable grounds for believing the information disclosed may indicate a violation of such standards. Any allegations that prove to have been made maliciously or knowingly to be false will be viewed as a serious disciplinary offense.
Any discipline of a bargaining union member under this policy is subject to the grievance procedure of the collective bargaining agreement.
CORPORATE COMPLIANCE POLICY AS IT RELATES TO THE FEDERAL DEFICIT REDUCTION ACT OF 2005 AND THE NEW YORK STATE SOCIAL SERVICES LAW SECTION 363-D
Policy: It is the policy of QSAC that all employees, including management, and contractors and agents representing QSAC are educated and trained in matters of compliance and the applicable laws as it relates to the Federal Deficit Reduction Act of 2005 and the New York State Social Services Law Section 363-d, and the roles of these laws in preventing and detecting fraud, waste and abuse in federal health care programs.
QSAC Policy also requires that there is periodic auditing, monitoring and oversight of compliance as it relates to the Federal Deficit Reduction Act of 2005 and the New York State Social Services Law Section 363-d.
QSAC strives to create an atmosphere that encourages and enables the reporting of non-compliance without fear of retribution.
Responsibility for compliance will not be delegated to persons with a propensity to act in a non-compliant manner, and this policy ensures that mechanisms exist to investigate, discipline and correct non-compliance.
Purpose: The purpose of this policy is to comply with the requirements of the Deficit Reduction Act of 2005 and the New York State Social Services Law Section 363-d as it relates to federal and state False Claims laws.
Definition: For the purposes of the False Claims Act laws, a “claim” includes, but is not limited to, any request or demand for money or property that is submitted to the U.S. Government or to a contractor, grantee, or other recipient, if any portion of the request is to be funded or reimbursed by the government.
APPLICABLE FEDERAL LAWS
Federal False Claims Act, 31 U.S.C. §§ 3729 - 3733: The federal False Claims Act ("FCA") helps the federal government combat fraud and recover damages resulting from fraud in a federally funded program, purchases, or contracts. The act establishes significant liability for any person or entity that knowingly presents or causes to be presented, a false or fraudulent claim to the U.S. Government for payment.
The term “knowingly” is defined to mean that a person, with respect to information:
• Has actual knowledge of falsity of information in the claim
• Acts in deliberate ignorance of the truth or falsity of the information in a claim, or
• Acts in reckless disregard of the truth or falsity of the information in a claim.
• The act does not require proof of a specific intent to defraud the U.S. government for the act.
Actions that violate the FCA include, among other things:
1) knowingly submitting a false claim for payment,
2) knowingly making or using a false record or statement to obtain payment for a false claim,
3) conspiring to make a false claim or get one paid or
4) knowingly making or using a false record to avoid payments owed to the U.S. Government.
The United States Attorney General may bring civil actions for violations of the FCA. As with most civil actions, the government must establish its case by presenting a preponderance of the evidence rather than by meeting the higher burden of proof that applies in criminal cases. Proof of intent is not a requirement to determine whether an act is a violation of the FCA.
Private or Qui Tam Actions/Whistleblower Provisions: An individual (or qui tam plaintiff) can file a civil suit for himself and for the government for violations of the FCA. Individuals who report fraud may be awarded a percentage by the courts depending upon a number of circumstances, including, whether the government prosecutes the case, the factual bases, and/or the whistleblower’s involvement in the act.
Under federal law, an employee who has been discharged, demoted, suspended, threatened, harassed, or in any way discriminated or retaliated against by his employer because of involvement in a FCA disclosure is entitled to reinstatement of status, back pay and compensation for any special damages sustained because of the discrimination or retaliation.
APPLICABLE NEW YORK STATE LAWS
New York’s false claims laws fall into two categories: civil and administrative; and criminal laws. Some apply to recipient false claims and some apply to provider false claims, and while most are specific to healthcare or Medicaid, some of the “common law” crimes apply to areas of interaction with the government.
Civil and Administrative Laws:
NY False Claims Act (State Finance Law, §§187-194): The NY False Claims Act closely tracts the federal False Claims Act. It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. The penalty for filing a false claim is $6,000 -$12,000 per claim and the recoverable damages are between two and three times the value of the amount falsely received. In addition, the false claim filer may have to pay the government’s legal fees. The Act allows private individuals to file lawsuits in state court, just as if they were state or local government parties. If the suit eventually concludes with payments back to the government, the person who started the case can recover 25-30% of the proceeds if the government did not participate in the suit of 15-25% if the government did participate in the suit.
Social Services Law §145-b False Statements: It is a violation to knowingly obtain or attempt to obtain payment for items or services furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment or other fraudulent scheme or device. The State or the local Social Services district may recover three times the amount incorrectly paid. In addition, the Department of Health may impose a civil penalty of up to $2,000 per violation. If repeat violations occur within 5 years, a penalty up to $7,500 per violation may be imposed if they involve more serious violations of Medicaid rules, billing for services not rendered or providing excessive services.
Social Services Law §145-c Sanctions: If any person applies for or receives public assistance, including Medicaid, by intentionally making a false or misleading statement, or intending to do so, the person’s, the person’s family’s needs are not taken into account for 6 months if a first offense, 12 months if a second (or once if benefits received are over $3,900) and live years for 4 or more offenses.
Criminal Laws:
Social Services Law §145 Penalties: Any person who submits false statements or deliberately conceals material information in order to receive public assistance, including Medicaid, is guilty of a misdemeanor).
Social Services Law § 366-b, Penalties for Fraudulent Practices: a. Any person who obtains or attempts to obtain, for himself or others, medical assistance by means of a false statement, concealment of material facts, impersonation or other fraudulent means is guilty of a Class A misdemeanor).
b. Any person who, with intent to defraud, presents for payment and false or fraudulent claim for furnishing services, knowingly submits false information to obtain greater Medicaid compensation or knowingly submits false information in order to obtain authorization to provide items or services is guilty of a Class A misdemeanor).
Penal Law Article 155, Larceny; The crime of larceny applies to a person who, with intent to deprive another of his property, obtains, takes or withholds the property by means of trick, embezzlement, false pretense, false promise, including a scheme to defraud, or other similar behavior. It has been applied to Medicaid fraud cases.
a. Fourth degree grand larceny involves property valued over $1,000 (Class E felony).
b. Third degree grand larceny involves property valued over $3,000 (Class D felony).
c. Second degree grand larceny involves property valued over $50,000 (Class C felony).
d. First degree grand larceny involves property valued over $1 million (Class B felony).
Penal Law Article 175, False Written Statements: Four crimes in this Article relate to filing false information or claims and have been applied in Medicaid fraud prosecutions:
a. §175.05, Falsifying business records involves entering false information, omitting material information or altering an enterprise’s business records with the intent to defraud (Class A misdemeanor).
b. § 175.10, Falsifying business records in the first degree includes the elements of the §175.05 offense and includes the intent to commit another crime or conceal its commission (Class E felony).
c. §175.30, Offering a false instrument for filing in the second degree involves presenting a written instrument (including a claim for payment) to a public office knowing that it contains false information (Class A misdemeanor).
d. §175.35, Offering a false instrument for filing in the first degree includes the elements of the second degree offense and must include an intent to defraud the state or a political subdivision (Class E felony).
Penal Law Article 176, Insurance Fraud: Applies to claims for insurance payment, including Medicaid or other health insurance and contains six crimes.
a. Insurance Fraud in the 5th degree involves intentionally filing a health insurance claim knowing that it is false. (Class A misdemeanor).
b. Insurance fraud in the 4th degree is filing a false insurance claim for over $1,000 (Class E felony).
c. Insurance fraud in the 3rd degree is filing a false insurance claim for over $3,000 (Class D felony).
d. Insurance fraud in the 2nd degree is filing a false insurance claim for over $50,000 (Class C felony).
e. Insurance fraud in the 1st degree is filing a false insurance claim for over $1 million (Class B felony).
f. Aggravated insurance fraud is committing insurance fraud more than once (Class D felony).
Penal Law Article 177, Health Care Fraud: Applies to claims for health insurance payment, including Medicaid, and contains five crimes:
a. Health care fraud in the 5th degree is knowingly filing, with intent to defraud, a claim for payment that intentionally has false information or omissions (Class A misdemeanor).
b. Health cam fraud in the 4th degree is filing false claims and annually receiving over $3,000 in aggregate (Class E felony).
c. Health care fraud in the 3rd degree is filing false claims and annually receiving over $10,000 in the aggregate (Class D felony).
d. Health care fraud in the 2nd degree is filing false claims and annually receiving over $50,000 in the aggregate (Class C felony).
e. Health care fraud in the 1st degree is filing false claims and annually receiving over $1 million in the aggregate (Class B felony).
WHISTLEBLOWER PROTECTION
Federal False Claims Act (31 U.S.C. §3730(h)): The FCA provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the FCA. 31 U.S.C. 3730(h). Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.
NY False Claim Act (State Finance Law §191): The False Claim Act also provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the Act. Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.
New York Labor Law §740: An employer may not take any retaliatory action against an employee if the employee discloses information about the employer’s policies, practices or activities to a regulatory, law enforcement or other similar agency or public official. Protected disclosures are those that assert that the employer is in violation of a law that creates a substantial and specific danger to the public health and safety or which constitutes health care fraud under Penal Law §177 (knowingly filing, with intent to defraud, a claim for payment that intentionally has false information or omissions). The employee’s disclosure is protected only if the employee first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation. If an employer takes a retaliatory action against the employee, the employee may sue in state court for reinstatement to the same, or an equivalent position, any lost back wages and benefits and attorneys’ fees. If the employer is a health provider and the court finds that the employer’s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer.
New York Labor Law §741: A health care employer may not take any retaliatory action against an employee if the employee discloses certain information about the employer’s policies, practices or activities to a regulatory, law enforcement or other similar agency or public official. Protected disclosures are those that assert that, in good faith, the employee believes constitute improper quality of consumer care. The employee’s disclosure is protected only if the employee first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation, unless the danger is imminent to the public or consumer and the employee believes in good faith that reporting to a supervisor would not result in corrective action. If an employer takes a retaliatory action against the employee, the employee may sue in state court for reinstatement to the same, or an equivalent position, any lost back wages and benefits and attorneys’ fees. If the employer is a health provider and the court finds that the employer’s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer.
Background: The QSAC Compliance Program was developed in response to the Federal Deficit Reduction Act of 2005 and the New York State Social Services Law Section 363-d. The Program establishes standards of conduct and policies as well as a system for monitoring adherence to those policies and sanctioning noncompliance. The Program also educates and trains QSAC personnel, contractors and agents representing QSAC in their responsibilities. The goal of the Program is to ensure that each employee, contractor and/or agent performs their duties ethically, legally and responsibly.
This Program is an integral part of QSAC's ongoing efforts to achieve compliance as it relates to billing Medicaid, the Federal Deficit Reduction Act of 2005 and the New York State Social Services Law Section 363-d. The Program creates a comprehensive and centralized system of oversight for bill coding, education, chart review, reporting and discipline.
This Program provides for the existence of a Compliance Officer who has ultimate responsibility and accountability for compliance matters. However, each individual employee or agent of QSAC remains responsible and accountable for his or her own compliance with applicable laws. Confirmed acts of non-compliance will be disciplined ("Discipline," as used throughout this policy shall include all steps described in the Employee Policy Manual, up to and including termination of employment).
Although the intent is to encourage compliance through a centralized audit system, it remains the responsibility of each individual, including but not limited to direct care staff, clinical staff and administrative staff, involved with the billing process to comply with the law. The purpose of this Program is to ensure that services are documented correctly and properly coded bills are submitted for actual services provided. Billing will be done in compliance with all applicable state and federal laws and regulations. Specifically, no bill will be issued for a service unless it was actually performed and documented by the staff.
When claiming payment for services, QSAC has an obligation to its consumers, third party payors, and the state and federal governments to exercise diligence, care and integrity. The right to bill Medicaid programs, conferred through the award of provider or supplier number, carries a responsibility that may not be abused. QSAC is committed to maintaining the accuracy of every claim it processes and submits. Many people, throughout QSAC, have responsibility for entering charges and codes for services. Each of these individuals is expected to monitor compliance with applicable billing rules. Any false, inaccurate, or questionable claims should be reported immediately to a supervisor or to the Compliance Officer.
False billing is a serious offense. Medicaid rules prohibit knowingly and willfully making or causing to be made any false statement or representation of a material fact in an application for benefits or payment. It is also unlawful to conceal or fail to disclose the occurrence of an event affecting the right to payment with the intent to secure payment that is not due. Examples of false claims include:
Claiming reimbursement for services that have not been rendered
Filing duplicate claims
"Upcoding" to a different service than were actually performed
Including inappropriate or inaccurate costs on reports
Falsely indicating that a particular staff provided the service or that services were otherwise rendered in a manner they were not
Billing for a length of hours beyond what was provided
Billing for services that were not provided
Failing to provide services or items
Billing excessive charges
QSAC employees and agents who prepare, submit or review timesheets or other billing documents should be alert for these and other errors.
In compliance with federal law, QSAC does not permit charging for any Medicaid service at a rate higher than that approved by the state or accepting any payment as a precondition of admitting a Medicaid consumer to QSAC.
QSAC carefully follows the Medicaid rules on assignment and reassignment of billing rights. If there is any question whether QSAC may bill for a particular service, either on behalf of a provider or on its own behalf, the question should be directed to the Compliance Officer for review. QSAC employees should not submit claims for other entities or claims prepared by other entities, including outside consultants, without approval from the Compliance Officer. Special care should be taken in reviewing these claims, and QSAC personnel should request documentation from outside entities if necessary to verify the accuracy of the claims. In addition to the criminal penalties, the Federal False Claims Act permits substantial civil monetary penalties against any person who submits false claims. The Act provides a penalty of triple damages as well as fines up to $10,000 for each false claim submitted. The person (as well as QSAC) may be excluded from participating in the Medicaid program.
Numerous other federal laws prohibit false statements or inadequate disclosure to the government and mandate exclusion from Medicaid programs. It is illegal to make any false statement to the federal government, including statements on Medicaid claim forms. It is illegal to use the U.S. mail to scheme to defraud the government. Any agreement between two or more people to submit false claims may be prosecuted as a conspiracy to defraud the government.
QSAC promotes full compliance with each of the relevant laws by maintaining a strict policy of ethics, integrity, and accuracy in all its financial dealings. Each employee and professional, including outside consultants, who are involved in submitting charges, preparing claims, billing, and documenting services are expected to maintain the highest standards of personal, professional, and institutional responsibility.
CORPORATE COMPLIANCE PROCEDURES AS IT RELATES TO THE FEDERAL DEFICIT REDUCTION ACT OF 2005 AND THE NEW YORK STATE SOCIAL SERVICES LAW SECTION 363-D
Procedures: A Compliance Officer has been appointed at QSAC and reports to the Executive Director. To avoid any issues related to a conflict of interest regarding legal or financial matters associated with compliance, the Compliance Officer has direct access to the QSAC Board of Directors.
The Compliance Officer oversees the education of personnel regarding proper compliance, the auditing and monitoring of the status of compliance, and the reporting, investigation, discipline and corrective action related to non-compliance. It is also his/her responsibility to ensure programs are in place to guarantee that significant discretionary authority is not delegated to persons with a demonstrated or suspected propensity for improper or unlawful conduct.
The Compliance Officer’s functions include: (1) review of guidelines for documentation and coding of services, (2) development and/or delivery of general and specialty-specific in-service training of billing staff on coding and proper documentation of services, and (3) coordination of agency-wide, department-specific audits of consumer records on an ongoing basis. Following any audit, results are discussed with the staff involved. The Compliance Officer also communicates to staff, via newsletter or other written communication, changes to the laws and regulations regarding billing.
The Compliance Officer reports on QSAC's adherence to this policy on a quarterly basis to the Executive Director and on an annual basis to the QSAC Board of Directors. The report includes but is not limited to: (1) the level of compliance or non-compliance found as a result of monitoring and auditing, (2) the success of efforts to improve compliance, including training and education, (3) and corrective or disciplinary action taken with respect to those found to be non-compliant. The Compliance Officer has full access to all personnel and relevant documentation deemed necessary to perform his/her oversight and reporting duties.
It is not expected that the Compliance Officer will have the knowledge or expertise necessary to ensure compliance with all laws and regulations that affect the various departments of QSAC. He/she is responsible, however, for the overall Policy and must ensure that qualified, knowledgeable personnel within individual divisions or departments of QSAC assist in monitoring and educational functions.
The Compliance Officer may appoint such staff as deemed necessary to assist in the performance of the responsibilities outlined above. Any members of the Compliance Officer's staff will be treated as the Compliance Officer for purposes of cooperation with his/her efforts to perform his/her duties.
Reporting: All employees have the responsibility to comply with applicable laws and regulations and to report any acts of non-compliance and to ensure that others do, as well. Employees must report non-compliance to their supervisors, the Compliance Officer or the Compliance Hotline (See Compliance Hotline).
A written record of every report received will be kept for a period of six years. Every effort will be made to preserve the confidentiality of reports of non-compliance (although calls made anonymously will always preserve the anonymity of the caller). All employees must understand, however, that circumstances may arise in which it is necessary or appropriate to disclose information. In such cases disclosures will be on a "need to know" basis only.
Supervisors are required to report these issues through established channels in Human Resources and/or with the Compliance Officer. Calls may be made anonymously, although QSAC encourages employees to provide their name and telephone number so that reports may be more effectively investigated.
All employees are required to report acts of non-compliance. Any employee found to have known of such acts but who failed to report them will be subject to discipline. Employees uncertain about whether some conduct constitutes non-compliance should contact the Compliance Hotline (See Compliance Hotline).
Personnel who staff the Hotline are instructed to report the information they receive immediately to the Compliance Officer or his/her designee.
Investigation: The Compliance Officer or their designee(s) will investigate every report of non-compliance (and retaliation), whether reported through the Hotline (see Compliance Hotline) or otherwise. Investigations will be done promptly and will consist of interviewing personnel, examining documents, and consulting with legal counsel, if necessary. All employees must cooperate with those investigating such matters and non-cooperation may result in discipline, up to and including termination of employment.
The Compliance Officer or their designee(s) have full authority to interview any employee and review any document he or she deems necessary to complete the investigation.
Once the Compliance Officer completes an investigation, he/she will make a report to the Executive Director. The report will be the basis for the Compliance Officer's Program or recommendation of corrective action or discipline. Reports will be retained for six years. Sanctions for non-compliance may be imposed (See Sanctions).
A written record of each investigation will be created and maintained by the Compliance Officer. He/she will make every effort to preserve the confidentiality of such records and will make any necessary disclosures on a "need to know" basis only.
Compliance Hotline: Any employee or professional associated with QSAC can report suspected ethical or legal violations to the Compliance Hotline, 718-728-8476, EXT. 1020. Reports may be made anonymously, if desired, although all reasonable attempts will be made to preserve the confidentiality of those who give their names when reporting. The Compliance Hotline will be answered by a voice mail system that will be check daily.
All calls are taken seriously and investigated by the Compliance Officer. Where feasible, the investigation results will be conveyed to the person who reported the violation.
Purpose of the Compliance Hotline affords callers easy access to report any improper or unethical behavior that may jeopardize the integrity of the institution or any noncompliance with federal or state regulations. Reports of suspected violations may be made confidentially and anonymously, if you prefer. The Hotline is accessible 24 hours a day.
Any concerns regarding improper or unethical activity such as violations of professional standards of practice or business ethics, breach of consumer privacy or confidentiality, information system security breach, inaccurate billing, conflicts of interest or research fraud can be reported on this hotline. The hotline augments other reporting channels, including an individual's supervisor. For more information regarding compliance, send email to compliance@QSAC.com.
Non-Retaliation: It is the policy of QSAC that no person shall retaliate, in any form, against a person who reports in good faith an act or suspected act of non-compliance (although employees may be disciplined for making intentionally false reports of non-compliance, up to and including termination of employment).
QSAC will not tolerate retaliation against employees and professional staff who report suspected violations in good faith. No employee of QSAC shall in any way retaliate against another employee for reporting an act of non-compliance. Acts of retaliation should also be reported to the Hotline and will be investigated by the Compliance Officer or his/her designee. Any confirmed act of retaliation shall result in discipline, up to and including termination of employment.
In addition, the Federal False Claims Act and the New York State Labor Law provide certain protections to individuals who are discharged, demoted, suspended or threatened, harassed or discriminated against by their employer in retaliation for assisting in the investigation, initiation or prosecution of a False Claims Act violation or which constitutes health care fraud under the New York State Penal Law. The protections may include reinstatement, return of lost back pay plus interest. Any person who attempts to retaliate will be subject to discipline, up to and including termination.
Sanctions - Corrective Action or Discipline: Every confirmed act of non-compliance may result in sanctions which may include corrective action, a requirement to follow a certain process or procedure in the future, restitution, and/or discipline, up to and including termination. The sanction for a single act of non-compliance will be decided by the Executive Director.
Plans of corrective action and discipline may include but are not limited to: (1) a requirement to undergo training; (2) a period of required supervision; (3) expanded auditing, internal or external, for some period of time until compliance improves; and (4) in egregious cases, discipline, up to and including termination of employment.
Education and Training: The Compliance Officer will monitor the education of employees concerning the existence of the compliance program, the contents of this Program, and the need to abide by the specific laws and regulations affecting individual departments and employees of QSAC. The Compliance Officer will ensure that QSAC employees receive a copy of this policy. He/she or members of the Compliance Officer’s staff will inform employees of changes in the laws or regulations periodically and systematically through written communications and/or in-service training.
The Compliance Officer's responsibility is to ensure that every employee involved with the billing process is educated about the applicable laws and regulations governing provider billing and documentation. The Compliance Officer will work with individual departments to acquire information specific to their specialties that will make the training more concrete, specific, and therefore, more effective. The Compliance Officer supervises staff who develop, oversee and/or provide in-service training on billing and documentation requirements. The Compliance Officer oversees a system that tracks staff attendance at the in-service trainings, and he/she has the authority to discipline staff for non-attendance. The Compliance Officer shall also maintain, through his/her designee, a record of each employee's attendance.
All current and new QSAC employees will have access to this Program. Reference to its existence and how to secure a copy will appear in QSAC’s Employee Policy Manual and the QSAC web site at http://www.QSAC.com.
Coding: Bills are coded according to the complexity of a procedure or service, as measured by established components. The Healthcare Financing Administration (HCFA), a division of the U.S. Department of Health and Human Services responsible for administering the Medicaid program, has developed guidelines which identify proper coding for bills submitted to Medicaid for payment.
Monitoring: The Compliance Officer will be responsible for monitoring employees' compliance with applicable laws and regulations. He/she will ensure that the level of compliance in each division or department is audited periodically. He/she will arrange as well for external auditing as deemed necessary. If the Compliance Officer discovers that a department's or individual's level of compliance is unacceptable, he/she may impose corrective actions, which may include future monitoring of an individual or department on a more frequent basis. Corrective actions and sanctions for acts of non-compliance will be managed as outlined previously (See Sanctions).
Auditing/Review: Monitoring of compliance with billing rules is a central feature of this Program. The Compliance Officer must be able to ensure compliance through an understanding of current regulations and overall levels of compliance throughout QSAC at any given time.
Under this Program, there will be both internal and external (i.e. by QSAC’s independent auditor) auditing of proper coding and chart documentation. Internal auditing is done by the professional staff of the Quality Assurance department, who will conduct periodic reviews. Bills for services in QSAC will be subject to annual reviews for proper documentation and coding. The Compliance Office analysts will communicate the results of their reviews to the Compliance Officer. If the level of compliance is found to be low, the Compliance Officer will implement a Program of correction and/or education (See Sanctions).
The Compliance Officer may engage an external auditing firm as deemed necessary to assess QSAC's overall compliance. All employees must cooperate fully with this effort, by making themselves and/or any pertinent documents available, and may be disciplined for not doing so. The external auditor will report to the Compliance Officer concerning the results of its investigation. The Compliance Officer will report, in turn, to the Executive Director.
Ongoing Assessments: The Compliance Officer will make an annual assessment of the success of the Billing Compliance Program. That assessment will be based on the examination of results of internal audits and investigations, reports of any outside audits that may have been conducted and on his/her own personal experience with the functioning of the Program over the previous year. The report will be submitted to the Executive Director and the QSAC Board of Directors.
Code of Conduct: It is the policy of QSAC that all employees and affiliated professional staff will comply fully with all state and federal laws and will conduct themselves in accord with the highest ethical standards. The QSAC Code of Conduct is an important part of our compliance program. It does not replace any policy or procedure, but rather, furnishes a framework for how we deliver services to our consumers. QSAC offers this Policy in conjunction with the Professional Conduct Section of the Employee Policy Manual to help its personnel understand some specific laws they are bound to obey. The Compliance web site contains all compliance Programs and policies. It is available at http://www.QSAC.com.
QSAC policy is to provide services to consumers professionally, ethically and legally. QSAC personnel that fail to do so will be subject to discipline, which may include termination of employment. Any person who learns of or suspects that someone has violated a state or federal law, or has acted unethically or improperly, should report that information to their supervisor or the Compliance Officer. Supervisors also are charged with the responsibility of ensuring compliance by their staff.
If you are uncomfortable discussing your concerns with a supervisor or feel those concerns are being ignored, call the Hotline to report information about unethical or illegal conduct. You do not have to leave your name, although you may if you wish. The Hotline number is 718-728-8476, ext. 1020.
Confidentiality Standards: All consumer information (including medical records) must be kept strictly confidential and not released to anyone outside the provider without written consumer consent or lawful court order (See HIPAA policy). All personnel must avoid discussing confidential information with outsiders, or where others, including family, can overhear them. Internal access to medical records is not appropriate unless there is a legitimate, work-related need to see the information.
Cooperation with Law Enforcement : Federal and State agencies, as well as Medicaid carriers and intermediaries, have broad rights to investigate matters involving consumer care and billing. QSAC policy is to cooperate with law enforcement investigations and activities. Anyone who is contacted, orally or in writing, at home or at work, by a person stating that he or she is investigating on behalf of the government or an insurer, may refer that person to the Compliance Officer. The Compliance Officer will coordinate the disclosure of documentation.
Billing: It is against the law and QSAC policy to knowingly submit false claims for payment. Submitting a false claim might be using the wrong billing codes, falsifying the medical record, or billing for services that are not provided. Violations of these laws can be punished by fines, prison, or both. Providers can also be excluded from the Medicaid program for submitting false claims. QSAC policy is to bill accurately and only for services that are provided and documented. Any subcontractors that perform billing services for QSAC must ensure compliance with billing requirements as well.
Referrals: It is against QSAC policy for employees to refer consumers to providers (such as labs or occupational therapy) in which he or she (or a family member) has a financial interest or relationship.
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