POLICY AND PROCEDURE REGARDING PREVENTION OF FRAUD, FINANCIAL ABUSE, AND WASTEFUL FINANCIAL PRACTICES PURPOSE The purposes of this policy are to describe Dungarvin’s commitment to preventing fraud, financial abuse, and other wasteful financial practices in the operation of the organization’s services, and further to describe the obligations of Dungarvin’s employees, subcontractors, and agents to report instances of fraud, financial abuse, or other wasteful financial practices, as required by federal and state laws. Throughout its history, Dungarvin has always been committed to the prevention of fraud, financial abuse, and other wasteful financial practices. The particular tools Dungarvin has implemented to prevent fraud and abuse are found throughout Dungarvin’s administrative, personnel, persons served, and accounting policies and are not repeated in this policy. POLICY Neither Dungarvin nor its employees, subcontractors, or agents shall engage in any act of fraud, financial abuse, or financial waste in the conduct of Dungarvin’s business or services. In the course of dealing with persons served, families, payors, or other healthcare professionals, no employee, subcontractor, or agent of Dungarvin shall knowingly make a false statement of material fact in preparation or submission of any claim for payment, nor engage in any other activity prohibited by this policy. This policy specifically includes, but is not limited to, services funded through the Medicaid program. Any employee, subcontractor, or agent of Dungarvin who knows or has reason to believe that Dungarvin or any person acting on behalf of Dungarvin has violated this policy, must report those observations or concerns to Dungarvin’s national director of operations, immediately. No retaliation shall be permitted against any person who makes such a report in good faith. PROCEDURES I. PROHIBITION OF FRAUD, FINANCIAL ABUSE, OR FINANCIAL WASTE No employee, subcontractor, or agent of Dungarvin shall engage in any act of fraud, financial abuse, or financial waste in connection with Dungarvin’s business or services. Fraud is an intentional misrepresentation that, when relied on by a payor or other person, deceives them to their detriment. Financial abuse includes the submission of deceptive or misleading claims to a government program like Medicaid, or providing for use or using a false statement to support a claim. Financial waste includes other deceptive tactics, such as over-utilization of otherwise necessary services, or requiring kickback arrangements, where contracts are awarded or goods purchased only if the vendor promises to kick back an incentive to the provider. Instances of fraud, financial abuse, or financial waste which are prohibited by this policy include, but are not limited to the following: A. Billing for services not actually provided. B. Documenting clinical care not actually provided. C. Making payments to a phantom vendor or phantom employee. D. Paying a vendor or employee for services not actually provided. E. Paying an invoice known to be false. F. Accepting or soliciting kickbacks or illegal inducements from vendors of services or offering or paying kickbacks or illegal inducements to vendors of services.G. Paying or offering gifts, money, remuneration, or free services to entice a Medicaid recipient to use a particular vendor. H. Using Medicaid to pay for a personal expense. I. Embezzling. J. Theft. K. Ordering and/or charging for medical services that are not necessary for the person served. II. MANDATORY REPORTING A. Any employee, subcontractor, or agent of Dungarvin who knows or has reason to believe that any other employee, subcontractor, or agent of Dungarvin has violated this policy by committing fraud, financial abuse, or financial waste, must report their observation and concern immediately to Dungarvin’s Compliance Officer, who is the chief operating officer, Robert Longo, 1444 Northland Drive, Suite 200, Mendota Heights, MN 55120, (651) 789-5965, [email protected]/* */. B. Upon receipt of any report of known or suspected fraud, financial abuse, or financial waste, Dungarvin’s national director of operations shall cause the report to be fully investigated. If the national director of operations finds that a violation of this policy has occurred, he shall immediately remedy the violation, take appropriate disciplinary action against the violator, and provide additional training as necessary to assure the violation is not repeated. Disciplinary action for violation of this policy may include termination of employment or termination of a subcontractor or agent’s contract with Dungarvin.C. Dungarvin will comply with any state reporting requirements. D. No Dungarvin employee, subcontractor, or agent shall be subject to retaliation for making a good faith report pursuant to this policy. III. APPLICABLE FEDERAL AND STATE LAWS Following are brief summaries of federal and state laws that relate to fraud, financial abuse, and wasteful financial practices. Every Dungarvin employee, subcontractor, or agent must endeavor to be familiar with these laws, and fully comply with them in the conduct of Dungarvin’s business. A. Federal False Claims Act, 31 U.S.C. sections 3729-3733Under the False Claims Act, individuals or organizations that are found to have knowingly submitted false claims to the federal government, including the Medicaid program, are subject to civil liability in the amount of $5,500 to $11,000 per claim, plus triple damages, and can also face exclusion from the Medicaid and Medicare programs. Administrative civil money penalties may be imposed against any person who makes or presents a claim the person knows or has reason to know is false, fictitious, or fraudulent. In addition to other remedies authorized by law, civil money penalties may be levied up to $5,500 for each false claim and double damages. Knowingly submitting a false claim with actual knowledge, reckless disregard, or deliberate ignorance may lead to criminal prosecution and incarceration. B. State LawsWisconsin Statutes § 49.485 provides that any person who knowingly presents a false claim for medical assistance payment may be liable for a civil penalty of $5,000-$10,000, plus three times the damages to the State. Wisconsin Statutes § 49.49 provides that any person who knowingly and willfully makes a false statement or representation in any application for payment under the medical assistance program or who solicits, receives, offers or pays remuneration in return for referring a person for service or for purchasing, leasing or ordering goods paid under the program is guilty of a Class H felony and may be sentenced accordingly, including a fine up to $25,000. In addition, the State may be able to recover treble damages. C. Rights of Employees, Subcontractors and Agents Who Report Fraud, Financial Abuse, or Wasteful Financial Practices Generally, the Federal False Claims Act and Wisconsin laws provide anti-retaliation protections for employees, subcontractors and agents who report fraud, financial abuse, or wasteful financial practices. Specifically, an employee who makes a good faith report under this policy cannot be terminated, disciplined, or harassed as a result of the report. The federal anti-retaliation law is included in the False Claims Act at 31 U.S.C. section 3730(h). The Wisconsin anti-retaliation law is Wisc. Stat. § 20.931(14). The Federal False Claims Act and some state laws also permit private individuals to initiate lawsuits on behalf of the federal government against any party who submitted false claims for payment from the Medicaid program. This type of lawsuit, known as a “qui tam” action, allows the private party to be rewarded with a portion of any penalty recovered from the party accused of submitting the false claim. IV. Policy ExceptionThere will be no exceptions to this policy.