As part of CAMcare’s efforts of comply with Section 6032 of the Federal Deficit Reduction Act of 2005, all employees are to be supplied with the foregoing information. Please forward any questions or concerns to CAMcare’s Compliance Officer at jsunkett@camcare.net.

​

1. False Claims
A. Federal Laws

Civil False Claims Act (31 U.S.C. §§ 3729-3733): The Federal Civil False Claims Act is a set of federal statutes that, among other things, forbids “knowingly:”

• Presenting or causing the presentation of, a false claim for reimbursement by a federal health care program, including Medicare or Medicaid;

• Making, using or causing to be made or used, a false record or statement material to a false or fraudulent claim;

• Repaying less than what is owed to the government;

• Making, using or causing to be made or used, a false record or statement material to reducing or avoiding repayment to the government;

• Avoiding or decreasing an obligation to pay or transmit money or property to the government; and/or

• Conspiring to defraud the federal government through one of the actions listed above.

 

To take one of these prohibited actions “knowingly” means to have actual knowledge of the falsity of the information or to act in deliberate ignorance or in reckless disregard of such falsity.

The U.S. Attorney General may bring an action under this law. In addition, the law provides that any “whistleblower” may bring an action under this act on his/her own behalf and for the United States Government.

​

False Claims Act fines range from $13,946 to $27,894 per false claim, payment of treble damages (i.e., three times the amount of damages sustained by the government due to the violation), and exclusion from participation in federal health care programs such as Medicare or Medicaid. These penalties may be adjusted on an annual basis by the Department of Justice due to inflation.

Civil Monetary Penalties Law (42 U.S.C. § 1320a-7a): Provides for civil fines for knowingly presenting or causing to be presented to the federal or a state government a claim that the person knows or should know the claim is false or fraudulent. Penalties include up to triple damages in addition to $10,000-$50,000 per violation. These penalties may be adjusted on an annual basis by the Department of Justice due to inflation.
 

Criminal Penalties Law (42 U.S.C. § 1320a-7b): Provides for up to 5 years imprisonment and fines up to $25,000 for knowingly and willfully making or causing to be made any false statement or representation of a material fact in any application for any benefit or payment under a federal health care program.

Criminal False Claims Act (18 U.S.C. § 287): Provides for up to 5 years imprisonment and fines for making or presenting a claim to the federal government, knowing such claim to be false, fictitious, or fraudulent.

​

Conspiracy to Defraud the Government with Respect to Claims (18 U.S.C. § 286): Whoever enters into any agreement, combination, conspiracy to defraud the federal government ... by obtaining or aiding to obtain the payment or allowance of any false, fictitious or fraudulent claim, is subject to a separate criminal penalty.

​

Statements or Entries Generally; False Statements Relating to Health Care Matters (18 U.S.C. §§ 1001, 1035): Provide for criminal liability to anyone who “knowing and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact; makes any materially false, fictitious, or fraudulent statement or representation; or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry ...”

​

General Health Care Fraud Statute (18 U.S.C. § 1347): The Government can prosecute an individual or entity who knowingly and willfully executes or attempts to execute a scheme or artifice to: defraud any health care benefit program, or obtain by means of false or fraudulent pretenses, representations or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services. Health care benefit program means “any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual.” Penalties include a fine and/or imprisonment for not more than ten years. If serious bodily injury results, the prison sentence may increase up to 20 years and/or a fine.

​

Federal Program Fraud Civil Remedies Act (31 U.S.C. §§ 3801-3812): Provides federal administrative remedies for false claims and statements, including those made to federally-funded health care programs. Current civil penalties are $10,781 for each false claim or statement, and up to double damages for each false claim for which the government makes a payment.

​

B. State Laws

CAMcare shall ensure compliance with the following state laws and regulations:

 

• New Jersey Medical Assistance and Health Services Act – Criminal Penalties, [N.J.S.A. 30:4D-17(a)–(d)] (Provides criminal penalties for individuals and entities engaging in fraud or other criminal violations relating to Title XIX-funded programs and potential exclusion from Medicaid.)

 

• New Jersey Medical Assistance and Health Services Act – Civil Remedies, [N.J.S.A. 30:4D-7.h.; N.J.S.A. 30:4D-17(e) – (i); N.J.S.A. 30:4D-17.1.a] (Provides civil sanctions for individuals and entities engaging in fraud or other violations relating to Title XIX-funded programs.)

 

• New Jersey Health Care Claims Fraud Act, [N.J.S.A. 2C:21-4.2 and 4.3; N.J.S. 2C:51-5] (Provides for criminal penalties for health care claims fraud, including for the submission of false claims to programs funded in whole or in part with state funds and potential loss of health care professional license.)

 

• New Jersey Conscientious Employee Protection Act, [N.J.S.A. 34:19-1 et seq] (Prohibits an employer from taking any retaliatory action against an employee because the employee discloses or threatens to disclose any behaviors, practices, or policies that violate a law, rule, or regulation).

 

• New Jersey False Claims Act, [N.J.S.A. 2A:32C-1 et seq], New Jersey has its own False Claims Act which contains similar provisions to the federal False Claims Act, allowing the Attorney General to bring an action against an individual or entity that makes a false claim under the NJ Medical Assistance and Health Services Act).

 

• New Jersey Insurance Fraud Prevention Act, [N.J.S.A 17:33A-1 et seq.], (This law addresses the problem of insurance fraud in New Jersey by facilitating the detection and elimination of insurance fraud through the development of fraud prevention programs).

 

• Exclusion Statute [42 U.S.C. § 1320a-7].

​

2. Whistleblower Protections

The “qui tam” or whistleblower provisions of the False Claims Act (and state law, if applicable) allow any person with actual knowledge of allegedly false claims to the government to file a lawsuit on behalf of the United States (and, if applicable under state law, “on behalf of the state”). Such persons are referred to as “relators.”

​

The whistleblower/relator must file his or her lawsuit on behalf of the government in Federal District Court for a False Claims Act claim. The lawsuit will be filed “under seal,” meaning that the lawsuit is kept confidential while the government (federal or (state law may be applicable) reviews and investigates the allegations contained in the lawsuit and decides how to proceed.

If the government determines that the lawsuit has merit and decides to intervene, the prosecution of the lawsuit will be directed by the United States Department of Justice under the False Claims Act.

If the government decides not to intervene, the whistleblower/relator can continue with the lawsuit on his or her own. If the lawsuit is successful, and provided certain legal requirements are met, the qui tam relator or whistleblower may receive a percentage of the amount recovered. The whistleblower may also be entitled to reasonable expenses including attorneys’ fees and costs for bringing the lawsuit.

​

The False Claims Act (and state law, if applicable) provides that any employee who is subject to retaliation or discrimination by an employer in the terms and conditions of employment because the employee lawfully sought to take action or assist in taking action shall be entitled to all relief necessary to make the employee whole. Whistleblowers may not be discharged, demoted, suspended, threatened, harassed, or discriminated against in the terms and conditions of employment because of lawful actions taken by the employee in connection with an action under the False Claims Act. This includes reinstatement with seniority restored to what it would have been without the retaliation or discrimination, double the amount of back pay, interest on back pay, and compensation for any special damages sustained as a result of the employer’s actions, including litigation costs and reasonable attorney’s fees.

​

In addition, under the Pilot Program for Enhancement of Contractor Employee Whistleblower Protections (41 USC § 4712) employees may not be discharged, demoted, or otherwise discriminated against as a reprisal for making a report that s/he reasonably believes is evidence of any of the following:

• Gross mismanagement of a federal grant or contract;

• A gross waste of federal funds;

• An abuse of authority relating to a federal grant or contract;

• A substantial and specific danger to public health or safety; or

• A violation of law, rule, or regulation related to a federal grant or contract
  (including the competition for, or negotiation of, a grant or contract).

 

3. Anti-Kickback

Anti-Kickback Statute and Regulations (42 U.S.C. § 1320a-7b(b); 42 C.F.R. § 1001.952): The Anti-Kickback Statue prohibits the knowing and willful solicitation, receipt, offer or payment of “any remuneration (including any kickback, bribe or rebate), directly or indirectly, overtly or covertly, in cash or in kind” in return for or to induce the referral, arrangement or recommendation of Medicare or Medicaid business. Violation of the Anti-Kickback Statute is a felony and may result in a fine of up to $25,000, imprisonment of up to 5 years, or both. In addition, the Office of the Inspector General (“OIG”) of the United States Department of Health and Human Services (“HHS”) is empowered to suspend or exclude providers or suppliers from participation in the Medicare or Medicaid Programs if it determines, in its discretion, that a provider or supplier has violated the Anti-Kickback Statute.

​

Arrangements that satisfy all of the requirements of a regulatory “safe harbor” are immune from both criminal prosecution and administrative enforcement by the OIG. Arrangements that do not qualify under a safe harbor are scrutinized under the Anti-Kickback Statute to determine whether, through the particular arrangement, remuneration was given or offered as an inducement for referrals.

​

4. Physician Self-Referral

Stark Act (42 U.S.C. § 1395nn): The Stark Act prohibits, with certain statutory exceptions, a physician who has an ownership interest in, or a compensation arrangement with, an entity from referring patients to that entity for the provision of “Designated Health Services” if payment for those services may be made by Medicare or Medicaid.

​

The Stark Act prohibits physicians from referring a patient for “Designated Health Services” to an entity with which the physician has a financial relationship and for which payment may be made by Medicare or Medicaid. “Designated Health Services” include clinical laboratory services; physical therapy services; occupational therapy services; radiology; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment and supplies; outpatient prescription drugs; prosthetics, orthotics, and prosthetic devises and supplies; home health services; and inpatient and outpatient hospital services.

​

Physicians may only own interests in or have relationships with providers or entities that provide Stark services if the relationships or operations are structured to qualify for at least one of the statutory exceptions to the Stark law.

​

Violations of the Stark Law may result in the denial of payment for the services provided in violation of the prohibition, refunds of amounts collected in violation, a civil penalty of up to $15,000 for each service arising out of the prohibited referral, exclusion from participation in the federal healthcare programs, and a civil penalty of up to $100,000 against parties that enter into a scheme to circumvent the Stark Law’s prohibition.

 

5.    Reporting

Suspected Fraud, Waste, and Abuse may be reported to:

• NJ Medicaid Fraud Division Hotline: 888-937-2835 or https://www.nj.gov/comptroller/about/work/medicaid/complaint.shtml; and

NJ Insurance Fraud Prosecutor Hotline: 877-55-FRAUD or https://njinsurancefraud2.org/#report.