False Claims Policy
Tikka Attach
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