Corporate Compliance

St. Mary’s Healthcare System for Children’s Commitment to Corporate Compliance

St. Mary’s Healthcare System for Children is committed to providing quality services that comply with all applicable federal and state laws. As a recipient of federal healthcare program funds, St. Mary’s is required under the Federal Deficit Reduction Act (2005) to include in our policies and to provide all employees, agents, and contractors detailed information regarding the Federal False Claims Act and applicable state laws intended to prevent and detect fraud, waste, and abuse in federal health care programs.

False Claims Act (Federal and NY State)

The False Claims Act (FCA), 31 USC §§3279-3733 is a federal law that strictly prohibits a person or organization from knowingly submitting a false claim or using a false record to receive payment or property from the federal government, whether the payment is received directly or indirectly. Knowingly means that someone actually knew that the claim was false, deliberately ignored whether the claim was false, or acted with reckless disregard for the truth of the submitted claim.

New York State recently enacted the New York State Finance Law, Article 13, §§187-194, that created a State False Claims Act (SFCA) very similar to the Federal FCA. The SFCA prohibits a person or organization from knowingly submitting a false claim or making a false record or statement in order to receive payment from the state or a local government agency.

Examples of False Claims

Some examples of false claims are: submitting a bill to Medicaid for services that were never provided; submitting a bill for services that were provided on a different day and time than stated in the claim; or filing a false cost report at the end of the year to avoid returning Medicaid funds that were improperly received.

Penalties for Violating the False Claims Act

If the Federal FCA is violated, a person or organization will be fined between $5,500 and $11,000 for each false claim submitted, fined up to three times the total amount of losses the false claim created for the government, and will face potential exclusion from participation in federally funded programs.

A person or organization found guilty of violating the New York SFCA will be fined between $6,000 and $12,000 for each false claim submitted, fined up to three times the total amount of losses the false claim created for the state or local government, and may be required to pay for the cost of the lawsuit brought by the state or local government.

Administrative Remedies for False Claims

The Program Fraud Civil Remedies Act of 1986, 31 USC §§3801-3812, is similar to the FCA in that it prohibits the submission of false or fraudulent claims to the federal government in order to receive payment or property. However, in addition to any action taken by the United States Department of Justice, this law allows a federal administrative agency, such as the Department of Health and Human Services, to conduct a hearing and impose fines of up to $5,500 per false claim and additional fines of two times the amount of the false claim.

New York Social Service Law §145-b allows the local social service district or the state to recover monies for false claims submitted to the state to receive payments from any social service program, including Medicaid. The law also allows the New York State Department of Health to fine any person or organization who provides unnecessary services or equipment, who bills for services never provided, or who bills for services ordered or provided by an unqualified or unlicensed individual. Penalties include fines up to $2,000 for first violations, $7,500 for repeat violations, and exclusions from participation if the violator is a recipient of Medicaid.

NY State Criminal Laws

New York State has several laws that make it a misdemeanor or a felony to obtain medical services through false statements, false records, or false claims. These laws include those specific to monies or property received from government social programs, such as Social Services Law §145, Social Services Law §366-b, and Penal Law Article 177 (Health Care Fraud). Also included are laws that generally prohibit theft and fraud, such as Penal Law Article 155 (Larceny), Penal Law Article 175 (False Written Statements) and Penal Law Article 176 (Insurance Fraud).

Protections for Whistleblowers

Under Federal and State False Claims Acts Both the Federal FCA and the New York SFCA have provisions that allow individuals with first-hand knowledge of fraud involving government funds to file a lawsuit on behalf of the government. These individuals are known as “whistleblowers,” and the suits filed on behalf of the government are called “qui tam” suits. If the suit is successful, the whistleblower may receive a portion of the money received by the government.

Any whistleblower who files a lawsuit under either the Federal FCA or the New York SFCA is protected from being fired, demoted, threatened or harassed by his or her employer as a result of filing the lawsuit. If a whistleblower believes he or she has been retaliated against, he or she may file a suit against the employer to be reinstated to his or her former position, recover twice the amount of any pay owed, interest on any pay owed, and compensation for any special damages that occured as a result of the discrimination.

Under NY Labor Laws

New York Labor Law §§740-741 also protects employees who notice and report inappropriate activities or suspected violations. A New York employer cannot retaliate against any employee who discloses or threatens to disclose illegal or fraudulent activity that presents a substantial or specific danger to public health or safety. Also, an employee cannot be retaliated against for refusing to participate in any unlawful activity. Under these laws, an employee must first alert St. Mary’s Healthcare System of the alleged violation and provide a reasonable opportunity for St. Mary’s to investigate and remedy the problem.

Employees who reasonably believe that they were retaliated against may file a civil suit for reinstatement or any wages owed.

St. Mary’s Corporate Compliance Program

St. Mary’s maintains a compliance program as evidence of our commitment to operating with the highest degree of integrity. The Compliance Program includes the Employee Code of Conduct, the Annual Mandatory Training Requirement documents, Employment Orientation materials, and policies and procedures with detailed information on auditing, monitoring and reporting mechanisms to detect and prevent fraud, waste, and abuse.

Whether you are an associate, contract worker, vendor, volunteer, or employee of St. Mary’s Healthcare System for Children and/or its individual entities, you are required to:

Perform all business activities and duties with honesty and integrity according to St. Mary’s Code of Conduct;
Follow all laws and regulations that apply to your business activities and duties, including requirements of government social service or health care programs. These requirements generally include, but are not limited to, maintaining complete and accurate records and submitting only complete and accurate claims for medically necessary services or equipment actually provided; and
Contact an immediate supervisor, senior administrative member, or St. Mary’s Compliance Officer, Adam Waxer (718) 281-8585 if you have knowledge of or a concern about a potential false claim or other violation.
St. Mary’s policies strictly prohibit retaliation, in any form, against an individual reporting an issue or concern in good faith. Retaliation is subject to discipline, including termination of employment or termination of the business relationship with St. Mary’s Healthcare System for Children and any of its entities.

Please contact St. Mary’s Compliance Officer above if you have any questions. For additional information on any of the laws mentioned above, please see the New York State Office of the Medicaid Inspector General (OMIG) at the following web address:

https://omig.ny.gov/compliance/compliance

Thank you for your commitment to maintaining our high ethical standards and assisting us in our efforts to prevent and eliminate fraud, waste, and abuse in the provision of our quality services.

Revised and Distributed as of September 28, 2007