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Understanding the Deficit Reduction Act (DRA)

Understanding the Deficit Reduction Act (DRA)

Deficit Reduction Act of 2005

Background

The Deficit Reduction Act of 2005 (DRA) mandates compliance programs for those institutions receiving $5 million or more annually in Medicaid payments. The DRA’s False Claims Act Amendment is intended to reduce the amount of fraud, waste, and abuse in state and federal health care programs through employee education about the federal False Claims Act, state false claims acts, civil and criminal penalties, and protections from retaliation for those employees who report wrongdoings, misconduct, or violations of laws and regulations in good faith.

Federal False Claims Act:

The federal False Claims Act covers fraud involving any federally funded contract or program, such as Medicare or Medicaid and establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment.

Virginia Fraud Against Taxpayers Act:

The Virginia Fraud Against Taxpayers Act is our state’s version of the federal False Claims Act and contains parallel provisions. This state law helps the Commonwealth combat fraud and abuse and recover losses resulting from fraud in programs, purchases, and contracts.

Federal False Claims Act Liability:

Violations of the False Claims Act can result in civil monetary penalties ranging from $5,000 to $10,000 for each false claim submitted and repayment of three times the amount of damages sustained by the U.S. government. A provider or supplier found in violation may also be excluded from participation in federal health care programs.

Examples of Medicare and Medicaid Fraud Committed by Employees:

  • Fabricating claims or changing provider addresses to intercept payments
  • Providing false information on employment application
  • Identity theft
  • Accepting or offering a kickback or bribery in exchange for money

Examples of Medicare and Medicaid Fraud Committed by Providers:

  • Participating in kickbacks (payments or other types of compensation made in order to influence and gain profit from an individual or company).
  • Forgery of a physician's signature.
  • Billing for medical services that were not given.
  • Billing for undocumented or medically unnecessary services.
  • Duplicate billing
  • Assigning incorrect codes to secure a higher reimbursement (upcoding)
  • Unbundling codes with the intent to increase reimbursement

Examples of Medicare and Medicaid Fraud Committed by Vendors:

  • Participating in kickbacks (payments or other types of compensation made in order to influence and gain profit from an individual or company).
  • Providing services to a healthcare provider while ineligible to participate in federal health care programs due to suspension or debarment from such programs or because the vendor was convicted of a health care related crime.
  • A conviction of filing false claims with state and/or federal agencies.

Qui Tam Whistleblower Provisions:

 As a means to encourage individuals to come forward and report misconduct involving false claims, the False Claims Act’s “whistleblower” provision allows any person with actual knowledge of allegedly false claims, who has first made a good faith effort to exhaust internal reporting procedures, to file a lawsuit on behalf of the government and potentially share in a percentage of the amount recovered.

No Retaliation:

The Federal False Claims Act grants protection from retaliation for filing a lawsuit or assisting in a False Claims Act action. VCU Health System (VCUHS) policy prohibits any type of retaliation against those who report concerns. This policy works in conjunction with the Federal False Claims Act and the Virginia Fraud Against Taxpayers Act in protecting those who report misconduct.

Reporting Mechanisms:

Any VCUHS Workforce member who has knowledge of actual or potential wrongdoing is encouraged to report their concerns to their department supervisory chain-of-command (supervisor, manager, director, Vice President) or the VCUHS Chief Compliance and Privacy Officer at (804) 828-0500. You may also report concerns directly to the Compliance Help Line at (800) 620-1438 or via the web at https://www.compliance-helpline.com/welcomePageVCUHS.jsp.

VCUHS Commitment to Integrity

The VCU Health System (VCUHS) is committed to conducting business in accordance with all applicable laws, regulations, policies, and procedures.  VCUHS has implanted a Compliance Program to articulate for all workforce members (e.g., employees, Board Members, physicians, faculty, contractors, vendors, etc.) our commitment to ethical standards and our responsibilities for compliance with regulatory and privacy policies.

Our Compliance Program includes a Code of Ethics, Standards of Professional Conduct, policies and procedures, education and training, auditing and monitoring, and reporting mechanisms (such as our Compliance Helpline) by which VCUHS Workforce members may report concerns anonymously and without fear of retaliation.

VCUHS has also developed a Compliance and Privacy Manual to summarize the VCUHS Compliance Program, Code of Ethics, Standards of Professional Conduct and organizational privacy policies.  The Compliance and Privacy Manual describes the legal and ethical obligations of workforce members and requires each member to maintain compliance with the laws and regulations governing our businesses.  This manual provides you with information concerning the process behind making the VCU Health System Compliance Program work and how it applies to you.

Your Obligations to Act with Integrity

All VCUHS Workforce members (whether you are an employee, physician, faculty, Board Member, Vendor or other business associate) must:

  1. Conduct all business with honesty and integrity
  2. Obey all the laws and regulations—as well as VCUHS policies and procedures—that apply to your work at VCUHS
  3. Report illegal or unethical conduct by calling our Compliance Helpline at (800) 620-1438. All calls to the Helpline are confidential, and you may also call anonymously if you wish.

Where to Get Help or Information

 

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