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Medicaid Fraud & Abuse Federal & State False Claims Acts

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Fraud is defined as an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.

Federal and State False Claims Acts Prohibit:

  • Knowingly presenting a false claim for payment or approval.
  • Knowingly engaging in misrepresentation to obtain, or attempt to obtain payment from medical assistance programs.
  • Conspiring to defraud the medical assistance programs through misrepresentation or by obtaining payment for a false or fraudulent claim.
  • Knowingly submitting a claim for services or supplies which were medical unnecessary or which were of substandard quality.

Practical Examples of false claims:

  • Documenting hours worked other than actual hours and for billing for services that were not delivered.
  • Employees or consumers signing timesheets with the knowledge that the hours worked are not correct.
  • Billing for unnecessary services.
  • Knowingly providing inaccurate data on a cost report.

You have a responsibility to report. All employees and contractors are required to report suspected o confirmed fraud immediately to a manager.

Alternative Home care will investigate and take the proper actions per this policy to investigate and report to the proper authorities all fraud and abuse.

Whistleblower Protections:

  • All employees that report suspected or confirmed fraud will be kept anonymous and are protected as whistleblowers.
  • Whistleblowers cannot be discharged, demoted, suspended, threatened, harassed or discriminated against in any manner.
  • Whistleblowers my bring civil suit on behalf of the government for violations of federal and state false claims acts. The government will choose whether or not to intervene in the case. If successful the private citizen may be eligible to receive a portion the funds recovered. If the civil suit is determined to be frivolous or brought primarily for harassment, the whistleblower may be forced to pay all court fees.

Procedures to detect and prevent fraud and abuse:

  • All timesheets are verified by both the employee and the consumer (or the consumer's representative).
  • All notes are matched to the corresponding timesheet. Discrepancies are investigated prior to the employee being paid for the time worked and before the service is billed by Medicaid.
  • The payroll department checks for overlapping shifts. Furthermore our billing software will not allow an overlap in filling.
  • When Case Managers make regular home visits, they ensure that timesheets and notes are not completed in advance.
  • If at any time fraud is suspected and unannounced drop-in visit is made to the consumer's home.
  • Management investigate all reports of fraud and abuse immediately ant the appropriate actions are taken in accordance with this policy.

Consequences for committing fraud:

  • Immediate termination of employment.
  • Arrest and prosecution by authorities.
  • Penalties and fines.
  • Employee is reported to professional boards.
  • Loss of certification or license for the DSW, CNA, LPN, RN.
  • Exclusion from any Medicaid business of five years.
  • Fraud is reported to Medicaid.

Federal- Three times the defrauded amount and civil penalties not less than $5,500 and not more than $11,000 for each offense.

State- The amount defrauded and civil penalties not to exceed $10,000or three times the defrauded amount, whichever is greater.

Alternative Home Care action taken once fraud is confirmed.

  • Employee is terminated and reported to Medicaid.
  • If Medicaid has been billed for the fraudulent act Alternative Home Care immediately notifies Medicaid and completes the proper paperwork for the funds to be recouped.


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Medicaid Fraud & Abuse Federal & State False Claims Acts

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