Horizon Blue Cross Blue Shield of

New Jersey










FALSE CLAIMS POLICY

DOCUMENT INFORMATION



Property/Name Value

Title False Claims Policy

Policy Reference CO-004

Effective Date January 1, 2017

Full Compliance Date January 1, 2017

Owner Timothy Susanin, Vice President, Chief Compliance and Risk Officer

Approved by (Signature) and

Date
/s/ Timothy Susanin

Director Responsible For

Implementation
Vice President, Chief Compliance and Risk Officer

Applies To All Horizon BCBSNJ divisions and subsidiaries

Original Effective Date January 1, 2007

Prior Review Date(s)
January 1, 2007, December 1, 2012, August 1, 2015, November 18, 2015,

December 19, 2016

Recertification Date January 1, 2018

REGULATORY, LEGAL, ACCREDITATION AND POLICY INDEX



Regulatory References Legal References
Accreditation

Reference
Policy Reference

Federal Program Fraud

Civil Remedies Act,

31U.S.C. 3802 (as

amended by 28 C.F.R 85.3

(a) (10-11))



42 C.F.R. 1001.901

The Federal False

Claims Act, 31 U.S.C.

3729-3733

PPACA, 42 U.S.C.

1320a-7a

Social Security Act

1128A(a)

New Jersey False

Claims Act 2A:32C-1

N.J.S.A. 2C:21-4.2

N.J.S.A. 30:4D-17

New York False Claims

Act (State Finance Law,

??187-194)

Code of Business

Conduct and Ethics

CO-002, Interested

Party Complaint

Procedures for

Accounting, Auditing

and Other Compliance

Matters Policy

CO-011, Non-

Retaliation Policy





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TABLE OF CONTENTS

1. PURPOSE ....................................................................................................................3

2. SCOPE AND APPLICABILITY ...............................................................................3

3. POLICY .......................................................................................................................3

4. DEFINITIONS ............................................................................................................5

5. SANCTIONS ...............................................................................................................5

6. EXCEPTIONS.............................................................................................................5

7. APPENDICES AND ATTACHMENTS ...................................................................5








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1. PURPOSE

To ensure that Horizon Blue Cross Blue Shield of New Jersey?s (?Horizon BCBSNJ?
or the ?Company?) employees comply with federal and state false claims laws and
regulations that prohibit the submission of false claims for reimbursement by the

government.

2. SCOPE AND APPLICABILITY


This policy applies to any claim submitted to the state or federal government for

reimbursement.



3. POLICY


3.1. General

Various federal and state laws and regulations, including the federal False Claims

Act, have been enacted to recover money that was paid by the government as a

result of fraud, waste, or abuse. Horizon BCBSNJ and its employees are

prohibited from knowingly submitting, or causing others to submit, false claims

for services that would be reimbursed by the federal or state government,

including health care services reimbursed by the Medicare and Medicaid

programs. No proof of intent to defraud the government is required to be held

liable. All that is required is that the person or organization had knowledge, or has

acted with deliberate ignorance or reckless disregard of, the truth or falsity of his

or her claim.

Violation of this policy may have serious consequences for both the Company and

any individual involved, including possible exclusion from participation in

Medicare, Medicaid or other government health care programs, as well as

substantial fines and criminal penalties.

Examples of false claims include, but are not limited to:

? falsifying medical records submitted;

? billing for services not rendered or goods not provided;

? upcoding;

? revenue-maximizing practices;

? over-utilization and under-utilization schemes;

? duplicate billing to obtain double compensation; and

? billing, certifying, or prescribing services that are medically unnecessary.

3.2. Non-Retaliation

False claims laws protect employees who come forward to report suspected fraud

from retaliation by their employers. In addition, Horizon BCBSNJ?s Code of
Business Conduct and Ethics prohibits retaliation against any employee who



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reports, in good faith, any violation or suspected violation of the Code of Business

Conduct and Ethics or applicable laws and regulations.

3.3. Civil Monetary Penalties

The Social Security Act authorizes the Secretary of the Department of Health and

Human Services to seek civil monetary penalties and assessments against anyone

who knowingly presents or causes to be presented a claim that is improperly filed.

These penalties apply to a claim:

? For a medical service or item that the person knows, or should know, was not

provided as claimed, including a claim for an item or service that is based on a

code that the persons knows, or should know, will result in greater

reimbursement than applicable to the service provided;

? For a medical service or item and the person knows, or should know, is

fraudulent or false;

? For a service that is not medically necessary;

? For a medical service or item that was provided when the provider of service

was excluded from participation in the Medicare, Medicaid or other federal

program to which the claim was made; or

? Presented for a physician?s service by a person who knows, or should know,
that the physician was not licensed as a physician; was licensed, but the

license was obtained through misrepresentation; or misrepresented that the

physician was certified in a medical specialty.



3.4. Patient Protection and Affordable Care Act



The Patient Protection and Affordable Care Act (?PPACA?) provides that
overpayments by federal health care programs, such as Medicare and Medicaid,

may be considered false claims. PPACA requires providers, suppliers, and health

plans to report and refund an overpayment by the later of 60 days after the date on

which the overpayment was identified or the date any corresponding cost report is

due. The PPACA makes reporting and repaying any overpayment an obligation

under the federal False Claims Act, so that failure to report and return an

overpayment within the applicable deadline may in itself result in liability under

the False Claims Act, including program exclusion.



The federal Anti-Kickback Statute has been amended through the PPACA to

provide that claims which include items or services resulting from a violation of

the Anti-Kickback Statute also constitute a false or fraudulent claim for purposes

of the False Claims Act. Therefore, a violation of the Anti-Kickback Statute could

subject Horizon to the penalties under the False Claims Act discussed above.

3.5 The New Jersey False Claims Act

The New Jersey False Claims Act has a wider statutory application than its

federal counterpart. While the New Jersey False Claims Act includes the federal

False Claims Act?s language of imposing liability upon people who submit false



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or fraudulent claims for payment or approval to an employee or officer of the

government, the New Jersey False Claims Act also imposes liability on those who

submit a false claim to an agent of the State, and to any contractor, grantee or

other recipient of State funds.



In addition, while the federal False Claims Act defines ?claim? as a request or
demand for money or property, the New Jersey False Claims Act?s definition of
?claim? also includes a request for services.

3.6 Obligation to Report Violation

The Horizon BCBSNJ Code of Business Conduct and Ethics requires every

employee to be vigilant in monitoring for fraudulent activities and to immediately

report any suspected fraud, waste or abuse by hospitals, physicians, other

healthcare professionals, members, subcontractors, agents, vendors and/or

employees.

Any employee who knows of an actual or suspected violation of this policy or an

instance of fraud, waste or abuse must immediately report the activity by

contacting:



? The Compliance and Ethics Office at 973-466-7100; or

? The Company?s Investigations Department at 973-466-8724.


Anonymous reports of violations can be made to:



? The Compliance Integrity Help Line at 1-800-658-6781;

? The Medicare Advantage Fraud Hotline at 1-800-624-2048

? The Part D Fraud Hotline at 1-888-889-2231

? The Medicaid Fraud Hotline at 1-855-372-8320

? The Fraud Hotline at 1-800-624-2048; or

? The Chief Security Officer or the Compliance and Ethics Office, in
writing, at Riverfront Plaza, P.O. Box 200145, Newark, New Jersey

07102.



4. DEFINITIONS


A ?false claim? is a falsely or fraudulently filed demand for money or property in
response to which the government provides any portion of the money or property

requested.



An ?overpayment? is defined under the PPACA amendment as any funds received or
retained under Medicare or Medicaid to which the provider, supplier, or plan is not

entitled after an applicable reconciliation.









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5. SANCTIONS

Any employee who violates this policy will be subject to disciplinary action, up to

and including termination of employment.

6. EXCEPTIONS


There are no exceptions to this Policy. Any questions regarding this policy should be

directed to the Compliance and Ethics Office, the Investigations Department or Legal

Affairs.



7. APPENDICES AND ATTACHMENTS


N/A