False Claims Act &

Whistleblower Protection

False Claims Act

The False Claims Act (FCA) was established in 1863 by President, Abraham Lincoln, to curb contract fraud during the Civil War by incentivizing integrity through awards based on the size of the fraud brought to the US Government.

The False Claims Act (FCA) is a Federal law that establishes criminal and civil liability when any covered person or covered entity improperly receives reimbursement from or avoids payments (excluding tax fraud) to the Federal government.

False Claims Act

How is the FCA applicable to GT?We receive federally funded dollars for providing our

fiscal intermediary service. GT pays a participant's employee for their work

performed.

GT bills the participant's referring agency for costs plus

our fee.

The referring agency pays our bill from federally funded dollars allocated for the

participant .

False Claims Act

Basic Points of the FCA• Not a Tip Line - FCA cases are evidence driven

• Not Easy or Fast - Successful cases often require years of investigation, putting tremendous strain on whistleblowers and lawyers. Big cases can require big investments from private law firms.

• Triple Damages – Person or entity committing fraud can be responsible for up to triple damages plus statutory penalties and exclusion being able to provide federally funded services.

• Cheaters Pay Whistleblower Awards – The triple damages collected pay for the stolen government money, cost of investigations, lost interest, and whistleblower awards.

False Claims Act

FCA Success 1987-2011

False Claims Act

The False Claims Act has been so

successful that it has been replicated:

• In 29 states including MI, NC, WI, and FL

• The Securities and Exchange Commission,

Internal Revenue Service, and Commodities

Future Trading Commission have all

created a whistleblower program modeled

on the FCA

Comprehension Check

The False Claims Act is only applicable at

the Federal level. True or False?

FALSE

Many states have implemented a False Claims Act.

Whistleblower Employee Protection

Whistleblowers are private citizens who file suit on

behalf of the State or Federal government to

recover damages incurred by the government as a

result of contractor fraud or other false claims.

Whistleblowers may be entitled to a significant

portion of the proceeds from a successfully

prosecuted claim.

Whistleblowers are protected from retaliation

because of their participation in filing or testifying

in a claim.

Comprehension Check

The Whistleblower’s Act protects employees

from retaliation in reporting. True or False?

TRUE

False Claims Act – OUR RESPONSIBILITY

At GT Independence, it is our policy to minimize the opportunities for fraud, waste, abuse, and neglect and report incidents as required by all applicable federal and state laws.

All employees, including management, and any contractors or agents are educated in and should maintain familiarity with the types of fraud and any other action (or inaction) that results in fraud, waste or abuse of public resources.

GT Independence will not retaliate against any employee, contractor, or agent who reports or testifies regarding fraud, abuse, or neglect.

Comprehension Check

It is the policy of GT to minimize fraud, waste,

abuse, and neglect. True or False?

TRUE

False Claims Act – Our RESPONSIBILITY

Examples of Fraud* • Billing for goods or services that were never provided

• Submitting false service records in order to show better-than-

average performance

• Performing inappropriate or unnecessary medical procedures

• Billing inflated charges instead of actual charges

• Inflating bills by using a code that suggests a more expensive

service was preformed

• Charging more than once for the same service

• Prescribing a medication or service in order to win kickbacks from

hospitals, labs or pharmaceutical companies.

*It is impossible to succinctly list all of the fraud schemes that have been

prosecuted under the FCA. This list is non-exhaustive, but gives an idea of the

scope of frauds that have been uncovered to date.

Comprehension Check

It is okay to bill for goods and services that were

never provided.True or False?

FALSE

This would be a fraudulent activity.

False Claims Act – OUR RESPONSIBILITY

Types of Fraud We See at GT

Independence• Forged signatures on time cards

• Claiming hours not worked

• Claiming hours under another worker’s name

• Claiming hours while a participant is hospitalized

• Impersonation of a participant or worker to

obtain or change personal information, such as

address or bank account

False Claims Act – OUR RESPONSIBILITY

Look for Indicators of Potential Fraud• Time cards that appear to be copied or altered in anyway

• Excessive hours being claimed for a pay period

• No hours claimed over a 3 month period

• High employee turnover

• Indications participants or workers are over-controlling services such

as only the participant calling about the employee’s

paycheck/employee never makes contact

• Purchasing excessive fuel that is not consistent with mileage logs

• Inconsistent and/or suspicious information from caller such as the

caller keeps changing the information provided or cannot verify their

identity

• Severe complaints or episodes of aggressive behavior

• Any other behaviors that are not consistent with the program

False Claims Act – OUR RESPONSIBILITY

Reporting Fraud – Incident

Reporting

• An Incident Report will be

completed if you become aware

of any actual or suspected fraud,

waste, or abuse.

• This form is available at P:\GFS

File Server\Fiduciary Services\

Common Forms & Letters- all

states\Internal Forms\Incident

Report for GT Independence

False Claims Act – OUR RESPONSIBILITY

Reporting Fraud – Incident Reporting

When documenting an incident : Use objective language, no assumptions or opinions Fully complete the form with no missing information Within 24 hours the report must be completed,

faxed to the agency contact, as well as, a verbal notification made

Submit to your supervisor/team leader within 5 calendar days

You must gain follow-up or corrective action information from the agency contact.

False Claims Act – OUR RESPONSIBILITY

Reporting Fraud – Corporate Compliance• The Compliance Officer will review all incident reports

and determine if an internal investigation should be conducted.

• The Quality Management Team will review collective incident reports to identify trends and overall improvements needed.

• The Compliance Officer is the main contact for any outside (state, federal, or agency) investigation.

False Claims Act – OUR RESPONSIBILITY

Reporting Fraud – Outside Reporting• Fraud can also be reported outside GT Independence

through the Office of Inspector General, http://oig.hhs.gov/fraud/report-fraud/index.asp

• And/Or by state via− Michigan Department of Community Health− Wisconsin Department of Justice− North Caroline Department of Health and Human

Services− Florida Agency for Health Care Administration

• Or any other appropriate agency

Comprehension Check

Reporting fraud, abuse, or neglect is optional

at GT Independence. True or False?

FALSE

We are required to report all incidents of fraud, waste, abuse, and neglect.

Questions More information on the FCA is available at:• http://www.taf.org/• http://www.whistleblowerlaws.com/• http://oig.hhs.gov/fraud/

You play an important role in upholding the public trust. If you suspect fraud or ethical violations that involve GT Independence, you are encouraged to contact the CEO and Compliance Officer.

This training is meant to define and clarify fraudulent activities making it recognizable to the employees and staff of GT Independence.

It should be understood that you may also notify any appropriate regulatory agency without fear of retaliation.

Questions may be directed to your Supervisor, Team Leader, Human Resources Department., Compliance Officer, or CEO.

Acknowledgment

Please complete the quiz and sign,

acknowledging you understand the

False Claims/Whistleblowers material

presented in this training.

Return the quiz to Human Resources.

Thank you for participating in this

training!