RESPONSIBLE DEPARTMENT: Compliance and Privacy Office

RESPONSIBLE DEPARTMENT: SUBJECT: Compliance and Privacy Office COM 01.019 Compliance with the Deficit Reduction Act of 2005 NUMBER OF PAGES: REPLACES POLICY (NUMBER/DATE): 7 EFFECTIVE DATE: SFMC POLICY NUMBER: 05/01/2013 COM 01.019 POLICY REVIEWED/REVISED ON: 12/31/2015

SCOPE: Applies to St. Francis Medical Center and its wholly owned sponsored organizations.

PRINCIPALLY AFFECTED DEPARTMENTS: All members of the organization including business partners, board members/trustees, employees and other workforce members.

PURPOSE: The purpose of this policy is to abide by the requirements of Section 6032 of the Deficit Redution Act of 2005 to implement and and enforce St. Francis Medical Center’s policies and procedures to detect and prevent fraud, waste, and abuse with respect to payments to St. Francis from federal or state healthcare programs and to provide protections foer those who report actual or suspected wrongdoing.

POLICY: This policy is included in the St. Francis employee handbook and communicated to business partners through vendor packets, contracting processes, and via the organization’s website.

The policy includes the following information related to applicable fraud and abuse laws, the rights of employees to be protected as whistleblowers and St. Francis’ p[olicies and procedures for detecting and preventing fraud, waste, and abuse.

I. A summary of the Federal FAsle claims Act including a summary of protections for employees (qui tam/whistleblowers) who report suspected violationso of these federal laws. II. A summary of administrative remedies found in the Program Fraud civil Remedies Act III. State False Claims Acts IV. The role of federal and state laws in preventing and detecting fraud, waste, and abuse in federal and state health care programs V. St. Francis’ existing policies and procedures for preventing and detecting fraud, waste and abuse VI. St. Francis’ prohibitions against retaliation and whistleblower rights and protections.

1. Federal False Claims Act 31 U.S.C. §§ 3729-3733

The federal False claims Act, also known as the “Lincoln Law”, was first enacted during the Civil War to address fraudulent activity in supplyihg goods to the Union Army. The law now applies to any federally funded contract or program and establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the United Staes government for payment. In 1986, the False Claims Act was expanded to include Medicare and Medicaid programs.

Summary of Provisions:

The False Claims Act prohibits knowingly making a false claim against the government. False claims can take the form of overcharing for aproduct or service, delivering less than the promised amount or type of service, delivering less than the promised amount or type of goods or services, underpaying money owed to the government and charging for one thing while providing another.

The False claims Act imposes civil liability on any person or entity who:

 Knowingly files a false or fraudulent claim for payments to Medicare, Medicaid or other federally funded health care program;  Knowingly uses a false record or statement to obtain payment on a false or fraudulent claim ferom Medicare, Medicaid or other federally funded health care program; or  Conspires to defraud Medicare, Medicaid or other federally funded health care program by attempting to have a false or fraudulent claim paid.

“Knowingly” means:

 Actual knowledge that the information on the claim is false;  Acting in deliberate ingnorance of whether the claim is true or false; or  Acting in reckless regard of whether the claim is true or false.

Penalties

The False Claims Act is not a criminal statute and thus imposes civil penalties. No proof of specific intent is required. A person or entity, such as a hospital, found liable under the False Claims Act is subject to a cvil money penalty of between $5,500 and $11,000 plus three times the amount of damages that the government sustained because of the illegal act. In health care cases, the amount of damanges sustained si the amount paid for each false claim that is filed.

Qui Tam “Whistleblower” provision

To encourage individuals to come forward and report misconduct involving false claims the FCA includes a qui tam or whistleblower provision. Anyone may bring a qui tam action under the federal False Claims Act in the name of the United States in federal court. A qui tam action is defined as a claim brought by an informer/relator under a statute which establishes a penalty for the commission or omission of a certain act. Part o the penalty paid by the wrongdoer is paid to the informer with the remainder going to the government.

Qui Tam Procedure

The case is initiated by an informer filing his or her lawsuit in a federal district court on behalf of the government for false or fraudulent claims submitted by an individual or an entity doing business with, or reimbursed by the United Stes government. The lawsuit is filed “under seal” and is not served on (presented to) the defendant at this time to enable the government to investigate the claim. The government has 60 days to investigate and decide whether it will pursue the action, in which case the complaint is unsealed nd the Department of Justice or a Untied States Attorney’s office begins prosecuting the claim. If the government decides not to pursue the case, the person who filed the action has the right to continue withteh case on his or her own. The government may join the action at a ltaer date if it can demonstrate good cause for doing so. Any case must be brought within six years of the filing of the false claim.

Qui Tam Whistleblower Awards

If the government proceeds with the lawsuit and is successful, the person who filed the action will receive between 15 and 25 percent of any monies recovered for the government plus attorney fees and costs. The amount of the award depends on the contributions of the individual to the success of the case. If the government declines to pursue the case, the qui tam whistleblower will be entitled to between 25 and 30 percent of the proceeds of the case, plus reasonable expenses and attorney’s fees and costs awarded against the defendant. The award may be reduced, however, if the court finds that the whistleblower planned and initiated the violation.

Qui Tam Whistleblower Anti-retaliation Protections

Individuals within an organization who observe activities or behavior that may violate thelaw in some manner and who report their observations either t management or to governmental agencies are provided protections under the law. Whistleblowers initiating a qui tam ction may nt be discriminated or retaliated against in any manner by their employer. Employees, who are discharged, demoted, harassed, or confront discrimination in furtherance of a qui tam action or as a consequence of whistleblowing activity, are entitled to all relief necessary to make the employee whole.

2. Federal Program Fraud civil Remedies Act 31 U.S. C. §§ 3801 -3812

The Program Fraud Civil Remedies Act of 1986 (PFCRA) provides administrative remedies for making false claims to certain federal agencies, including the Department of Health and Human Services (HHS) separate from and in addition to, the judicial r court remedy for false claims provided by the Civil False claims Act. The Act is quite similar to the Civil False claims Act in many respects, but is broader andmore detailed, with differeing penalties. The Act deals with submission of improper “claims” or “written statements” to a federal agency. PFCRA was enacted as a means to address lower dollar frauds and generally applies to claims of $150,000 or less.

Summary of Provisions

The PFCRA imposes liability on people or entities who file a claim that they know or have reason to know:

 Is false, fictitious, or fraudulent;  Includes or is supported by any written statement that contains false, fictitious, or fraudulent information;  Includes or is supported by a written statement that omits a material fact, which causes the statement to be false, fictitious, or fraudulent, and the person or entitiy submitting the statement has a duty to nclude the omitted fact; or is for payment for property or services not provided as claimed.

Penalties

A violation of this section of the PFCRA is punishably by a $5,000 civil penalty for each wrongfully filed claim, plus an assessment of twice the amount of any unlawful claim that has been paid.

In addition, a person or entity violates the PFCRA if they submit a written statement which they know or should know:

 Asserts a material fact that is false, fictitious or fraudulent; or  Omits a material fact that they had a duty to include, the omission caused the statement to be false, fictitious, or fraudulent, and the statement contained a certification of accuracy.

Violations are investigated by the HHS Office of the Inspector General and enforcement actions must be approved by the Attorney General. PFCRA enfoercement can begin with a hearihng before an administrative law judge. Penalties may be recovered through a civil ction broughrtbythe Attorney General or through an administrative offset against “clean” claims. Because of the availability of other criminal, civil and administrative remedies, cases are not routinely prosecuted under PFCRA.

3. State False claims Acts

Many states have enacted statutes like the Federal claims Act that provide a cvil remedy for the submission of false and fraudulent claims to state health care programs, including Medicaid. As of November 2006, at least twenty-five states have enacted civil false claims laws. Louisiana does have a state false claims law. It is titled, ACT NO. 1373, S.B. No. 1559 “Medical Assistance Programs Integrity law – Claims Review and Administrative Sanctions; Civil Actions; “Qui Tam” actions”. The Act intends for the Secretary of the Department of Health and Hospitals, the Attorney General , and private citizens of Louisiana to be agents of the state with ability, authority and resources to pursue civil monetary penalties, liquidated damages, or other remedies to protect theintegrity of federal medical assistance programs from fraud, misrepresentation and abuse.

4. The Role of False Claims Laws

The laws described in this policy create a comprehensive scheme for controlling waste, fraud and buse in federal and state health care programs by giving appropriate governmental agencies the authority to seek out, investigate and prosecute violations. Enforcement activities are pursued in criminal, civil and administrative forums. This provides a broad spectrum of remedies to battle this problem. IN addition, whistleblower statutes and anti-retaliation policies protect individuals who in good faith report waste, fraud, and abuse. Whistleblower statutes, such as the federal Civil False claims Act create reasonable incentives for this purpose. Employment protections create a level of security employees need to help in prosecuting these cases.

5. St. Francis’ Policies and Procedures for Detecting and Preventing Fraud

St. Francis is dedicated to furthering the mnission, while ensuring complance with all applicable laws, rules, regulations and promoting adherence to thehighest standards of ethical conduct. St. Francis has developed a compliance plan and program, which is intended to identify areas of risk and potential liability and institute steps to minimize or eliminate those risks by:

 Emphasizing our commitment to conducting business in an ethical manner,  Providing education, training, and guidance to all employees to meet increasingly complex statutory and regulatory requirements,  Monitoring and overseeing compliance efforts on a proactive basis,  Providing an avenue for reporting instances of potential non-compliance or unethical behavior;  Investigating instances of potential non-compliance; and  Preventing or reducing instances of accidental or intentional non-compliance, particularly in this time of increased government scrutiny. The Compliance Plan provides the operational structure for how ethical conduct and integrity in our business practices is encouraged and promoted throughout the facility. You can find St. Francis’ compliance plan and applicable documents on the organization’s electronic document management system housed on the website.

In addition, St. Francis has a compliance hotline. The Compliance Line is a 24-hur, 7 day a week telephone resource that allows you to report workplace concerns, including suspected illegal or unethical behavior; non-compliance with laws, regulations and policies; safety violations; criminal offenses; or other concerns. Callers may remain anonymous if they so choose.

The Compliance Line 888-400-4517 or www.fmolhsintegritylink.com is designed to give you an avenue for reporting serious concerns and violations to St. Francis’ management in a confidential manner, without fear of reprisal.

6. St. Francis’ Prohibitions Against Retaliation and Whistleblower Rights and Protections

Employees are protected from retribution by the Federal Whistleblowers Act. Therefore, you may report any concerns without fear of retaliation. St. Francis encourages all employees to utilize our reporting process for any concerns no matter how trivial they may seem.

St. Francis’ administration, vice presidents, directors, managers, supervisors or any employees, are not permitted to engage in retaliation or any form of harassment directed against an employee who reports any concern in good faith. Any employee who engages in retaliation or harassment is subject to discipline, up to and including discharge, on the first offense. All reported concerns are presumed to be in good faith. Only when an investigation reveals strong evidence that someone reported a concern that had no factual basis and the concern was reported to embarrass or otherwise defame an employee or other entity, might adverse action be appropriate.

Compliance policies and procedures regarding reporting and retaliation can be found on the St. Francis website.

DEFINITIONS:

REFERENCES (including statutory/regulatory authority): ATTACHMENTS: A. Statement of Compliance and Ethics for Business Partners

Approved by: St. Francis Medical Center Board of Directors

Jamie Hohlt, Compliance and Privacy Officer Statement of Compliance and Ethics for Business Partners

St. Francis Medical Center and its Affiliates (St. Francis Medical Center) are committed to operating ethically and in a compliant manner with all pertinent federal, state, and local laws. St. Francis Medical Center will only maintain association with Business Partners that conduct themselves in an ethical and compliant manner.

St. Francis Medical Center is required by the Deficit Reduction Act of 2005 to maintain a viable compliance program. The purpose of a compliance program is to provide structure needed to assure that compliance with applicable laws is maintained.

General Structure

St. Francis Medical Center’s Compliance and Ethics program includes the following general elements as recommended by the Office of Inspector General Guidance for Compliance Programs and the Federal Sentencing Guidelines:

1. Designation of a Compliance and Privacy Officer – Jamie Hohlt, RHIA, CHC (318) 966-4879

2. Written policies and procedures – The hospital maintains a hospital wide Compliance Manual, a Privacy Manual as well as hospital wide, departmental and medical staff policy and procedures. The hospital maintains a set of business ethics called the Code of Conduct that all employees as well as business partners are expected to abide by. Pertinent policies and procedures are available to business partners for training and reference purposes.

3. Education and training – St. Francis Medical Center provides Compliance orientation to all new employees, medical staff, and other workforce members. Departmental education is provided relative to the department’s specific needs. . As new regulations come into effect, action is taken to provide training regarding the new or revised regulations as appropriate. Additional training is provided throughout the year on various targeted subjects to maintain a state of awareness with workforce members.

4. Reporting system that protects against retaliatory acts – St. Francis provides various means for reporting internally. (See reporting section below)

5. Mechanism for investigation and remediation of suspected noncompliant activity --Investigations of Compliance Issues should be routed to the Compliance Office for coordination and documentation. The Compliance Officer either performs investigations personally or delegates to appropriate Administrative or Department Director level.

6. Development of corrective action in response to identification of noncompliant activity – The involved departments work with the Compliance Officer to develop and implement corrective action plans. Corrective action may include education, revision or implementation of processes, or disciplinary action including verbal and written warnings, suspension, and termination.

7. Auditing and monitoring programs – Departments are responsible for implementing preventative monitoring programs. Auditing is considered a formal process that must be coordinated and reported to the Compliance Office. High risk areas are regularly scheduled for auditing with emphasis on prevention of billing fraud. 8. Monitoring for incidence of exclusion from governmental programs – All prospective employees, medical staff members, and business partners are screened to assure they have not been excluded from participation in any governmental programs.

Substantive Areas

The Compliance Program includes all pertinent and relevant federal, state, and local laws with emphasis on the following areas:

1. False Claims Act – St. Francis Medical Center is committed to billing accurately and honestly for patients and our business partners. We will abide by Federal and state laws concerning submission of accurate claims. a. Federal False Claims Act: 31 U.S.C. 3729- 3733: The False Claims Act (FCA) is a federal law which imposes civil liability on organizations and individuals for knowingly submitting to the federal government a false or fraudulent claim for payment. It applies to all federal programs, from military procurement contracts to welfare benefits to health care benefits. i. The False Claims Act prohibits, among other things: 1. Knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval; 2. Knowingly making or using, or causing to be made or used, a false record or statement in order to have a false or fraudulent claim paid or approved by the government; 3. Conspiring to defraud the government by getting a false or fraudulent claim allowed or paid; and 4. Knowingly making or using, or causing to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government. ii. A person or entity found liable under the Civil False claims Act is subject to a civil money penalty of between $5,500 and $11,000 plus three times the amount of damages that the government sustained because of the illegal act. In health care cases, the amount of damages sustained is the amount paid for each false claim that is filed.

b. ACT No. 1373 S.B. No. 1559 “Medical Assistance Programs Integrity Law – Claims Review and Administrative Sanctions; Civil Actions: “Qui Tam” Actions”. This is the state of Louisiana’s False Claim Act. This act provides for the protection of the integrity of the Federal medical assistance programs from fraud, misrepresentation and abuse. The Act intends for the Secretary of the Department of Health and Hospitals, the Attorney General, and private citizens of Louisiana to be agents of the state with ability, authority and resources to pursue civil monetary penalties, liquidated damages, or other remedies to protect the integrity of Federal medical assistance programs from fraud, misrepresentation and abuse.

c. Federal Program Fraud Civil Remedies Act 31 U.S.C. 3801-3812. The Program Fraud Civil Remedies Act of 1986 (PFCRA) authorized federal agencies such as the Department of Health and Human Services (“HHS”) to investigate and assess penalties for the submission of false claims to the agency. The conduct prohibited by the PFCRA is similar to that prohibited by the False Claims Act. A violation of this section of the PFCRA is punishable by a $5,000 civil penalty for each wrongfully filed claim, plus an assessment of twice the amount of any unlawful claim that has been paid.

It is acknowledged that certain areas of billing are problem prone or otherwise high risk areas for false claims and effort such as specialized training and regular auditing and monitoring activity will be directed to these areas for prevention of this activity. Examples include: Duplication of billing Upcoding to higher reimbursable codes Unbundling of codes to achieve higher reimbursement Lack of medical necessity Billing for services performed by individuals not licensed to provide the service. Billing for substandard care Filing fraudulent cost reports Filing of claims associated with kickbacks or inappropriate referrals Billing for unapproved drugs or devices

2. Deficit Reduction Act: The purpose of the Deficit Reduction Act is to reduce the deficit through increased emphasis on detecting and preventing fraud, waste and abuse within the states’ Medicaid programs. In order to increase awareness of the laws regarding false claims under the Medicaid program, Section 6032 of the Act require entities to establish written policies for all their employees and the employees of their contractors and agents, which provide: detailed information regarding the Federal False Claims Act; the administrative remedies for false claims and statements; any state law with civil or criminal penalties for false claims or statements; and the whistleblower protections under such law.

3..Anti-Kickback – St. Francis Medical Center does not condone the receipt of cash or gifts by employees from patients or businesses for services rendered or in order to influence the selection process for any future services.

4. Ethics in Referral Act – St. Francis Medical Center recognizes a patient’s right to choose and does not participate in nor condone the development of business relationships that direct patient services to any entity of which there is personal or family ownership or for which their would be a personal financial gain under which they do not fit into any allowable safe harbor.

5. Emergency Medical Treatment and Labor Act – St. Francis Medical Center accepts all patients that present to the hospital for emergency treatment and will provide the appropriate screening to determine the need for further medical care. An on-call physician roster will be maintained by our Emergency and Women’s Center Departments and physicians are required to respond to requests by qualified screeners for further assessment. Patients will be transferred to another medical facility only after being administratively and medically accepted by that facility and all consents have been received and documented in accordance with the hospital policy. All patients are logged into a central log for tracking purposes.

6. Safe Haven Law – St. Francis Medical Center is designated as a Safe Haven site and maintains processes for handling the relinquishment of infants by their parent to the State of Louisiana. The hospital will take care of medical needs of the infant and the Social Services Department will work with the Office of Community Services for awarding of custody.

7. Health Insurance Portability and Accountability Act (HIPAA) and HITECH – St. Francis Medical Center maintains a privacy and security program and is committed to the protection of patient confidentiality for all patients. In the event a patient requests extra precaution in the form of restrictions on the use and disclosure of their health information, St. Francis will work with the patient and their family as is reasonable in order to meet these restrictions. Security measures are in place for the prevention of unauthorized access to electronic patient information. St. Francis maintains business associate agreements with all business partners that use, disclose, maintain or when authorized, are responsible for the destruction of our patient’s protected information.

Reporting and Prohibition against Retaliation of Whistleblowers

St. Francis Medical Center maintains structure for internal reporting of suspected noncompliant behavior. Employees may report to their immediate supervisor, any member of the Compliance Committee, or the Compliance Officer. Employees may submit reports by e-mail, in written form via the hospital mail system, by telephone (Integrity Link hotline number is 888-400-4517), via Integrity Link Website fmolhsintegritylink.com, or in person.

Governmental entities as well as private payers strive to maintain Integrity Programs for the prevention and detection of noncompliant activity including fraud, waste, and abuse. As part of their Integrity Programs, they provide communication systems for receiving reports of suspected noncompliant activity. Reports of suspected noncompliant activity are reviewed and acted upon based upon investigation results. Employees as well as other individuals have the right to report directly to the entity any suspicion of noncompliant activity. Employees and individuals acting as Whistleblowers, who in good faith report any suspicion of noncompliant activity relative to federal law are protected from retaliation by law through various Compliance laws.

A private person may file a Qui Tam lawsuit on behalf of the Government. If the government does not decide to intervene, the relator may still continue the lawsuit independently. If a Qui Tam lawsuit is successful, the relator may receive a percentage of the recovery, depending on the level of the government’s participation and other factors as well as reasonable attorney’s fees and costs. The Qui Tam “Whistleblower” provisions protect against retaliation. There can be no retaliation against the relator for filing and participating in the lawsuit in good faith. At the same time, however, any person who brings a clearly frivolous case can be held liable for the defendant’s attorney’s fees and costs.

Whistleblowers reporting suspicion of noncompliant activity relative to state law or to oversight agencies of the State of Louisiana are required to first advise the employer of the violation of the law in order to be protected against retaliation by the Louisiana Whistleblower laws. The State of Louisiana Whistleblower Protection statutes qualify an individual for whistleblower protection if the employee in good faith:

1. Discloses or threatens to disclose a workplace act or practice in violation of state law 2. Provides information or testifies before a public body investigating a violation of law 3. Objects or refuses to participate in an employment act or practice that is in violation of the law.

Penalties

Penalties for noncompliant activity by external oversight entities may include civil penalties of fines, criminal penalties of incarceration or jail time, and possible exclusion from participation in government programs.

Additional Information

For further information concerning St. Francis Medical Center’s Compliance and Privacy Program including the Standards of Conduct, you may access the Compliance Resource Center maintained on the hospital website or you may contact the Compliance Office of St. Francis Medical Center.

Compliance Office St. Francis Medical Center 309 Jackson Street P.O. Box 1901 Monroe, LA 71210-1901 (318) 327-4879 Compliance Acknowledgement

Contractor acknowledges having received and reviewed the St. Francis Medical Center Statement of Compliance and Ethics for Business Partners. Contractor further agrees to comply with the same as it pertains to the Deficit Reduction Act of 2005.

Company name: ______

Address: ______

______

Date of acknowledgement: ______

By: ______

Title: ______

Signature: ______