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Liability for False or Fraudulent Claims

POLICY TITLE:    Liability for False or Fraudulent Claims

CATEGORY:    Corporate Compliance
INDEX NUMBER:    COC-00014
ORIGINAL DATE:    1/1/2007
LAST REVIEW DATE:    3/2/2011
SUPERCEDES:    2/1/2007


POLICY PURPOSE:

To comply with certain requirements set forth in the Texas Medicaid Fraud Prevention Act with regard to liability for false or fraudulent claims.

POLICY STATEMENT:

Memorial Hermann Healthcare System will ensure that all employees, including management, and any contractors or agents are educated regarding the state false claims statutes and the role of such laws in preventing and detecting fraud, waste and abuse in federal health care programs.

DEFINITIONS:

"Knowing" and "Knowingly" - Under the statute [31 U.S.C. § 3729(b)], "knowing" and "knowingly" mean that a person, with respect to information:

  1. Has actual knowledge of the information;
  2. Acts in deliberate ignorance of the truth or falsity of the information; or
  3. Acts in reckless disregard of the truth or falsity of the information and no proof of specific intent to defraud is required.

TEXAS MEDICAID FRAUD PREVENTION ACT:

Unlawful Acts-§ 36.002 (Texas Human Resources Code)

  1. Any of the following actions will constitute a violation of the Medicaid Fraud Prevention Act:
  2. Knowingly or intentionally making or causing to be made a false statement or misrepresentation of a material fact to permit a person to receive an unauthorized benefit or payment under the Medicaid program;
  3. Knowingly or intentionally concealing or failing to disclose an event that the person knows will affect the right to a Medicaid benefit or payment;
  4. Knowingly or intentionally applying for and receiving a Medicaid benefit or payment on behalf of another person and failing to use the benefit or payment on behalf of such person;
  5. Knowingly or intentionally inducing or seeking to induce the making of a false statement or misrepresentation of material fact concerning: i) the conditions or operation of a facility that may qualify for certification or recertification under the Medicaid program or ii) information required to be provided by a federal or state law, rule, regulation, or provider agreement pertaining to the Medicaid program;
  6. Knowingly or intentionally charging, soliciting, or accepting a gift, donation, or other consideration as a condition for continued service to a Medicaid recipient, whose costs are paid for, in whole or in part, by the Medicaid program;
  7. Knowingly or intentionally presenting (or causing to be presented) a claim for payment under Medicaid for a product or service rendered by a person who is not licensed to provide such a product or service or if licensed, not licensed in the manner claimed;
  8. Knowingly or intentionally submitting a claim under Medicaid for a product or service that has not been approved by a health care practitioner or is substantially inadequate or otherwise inappropriate when compared to generally recognized standards within the particular discipline or within the health care industry;
  9. Knowingly or intentionally submitting a claim under Medicaid and failing to indicate the type of license and identification number of the health care provider;
  10. Knowingly or intentionally conspiring to defraud the state by obtaining an unauthorized payment or benefit from the Medicaid program; or
  11. A managed care organization that provides (or arranges to provide) health care benefits or services to Medicaid eligible individuals who knowingly and intentionally fails to provide the individual with such benefits or services, fails to provide the appropriate state agency with required information, or engages in fraudulent activity in connection with the enrollment of Medicaid eligible individuals.

 

APPROVED:                       Bernard A. Duco, Jr.                                  
                                              Chief Legal Officer


DATE:                                  
February 28, 2011