Administrative Regulation 305.24A
1. Waste, abuse and/or fraud may include, but are not limited to, the following:
- Billing for services not provided
- False cost reports – intentionally including inappropriate expenses not related to service provision in cost reports
- Illegal kickbacks – a provider conspiring with another provider to share part of the monetary reimbursement the providers receive in exchange for services/referrals. Such kickbacks may include cash, vacation trips, automobiles, or other items of value.
2. Fraudulent Practices
Iowa Code defines “fraudulent practices” as knowingly making or causing to be made false statements or misrepresentations of material facts or knowingly failing to disclose material facts in application for payment of services or merchandise rendered or purportedly rendered by a provider participating in the medical assistance program. Filing false claims may result in fines up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act (“FCA”), each instance of an item or a service billed to Medicare or Medicaid counts as a claim. A claim resulting from a kickback may render it false or fraudulent, creating liability under the civil FCA.
- Fraudulent acts include:
- Fraudulent claim for payment or approval
- False records to obtain fraudulent payment
- Conspiring against the government by obtaining fraudulent claims payment
- Possession, control, or custody of items with the intent to defraud the government
- Certifying receipt of property to be used by the government while intending to defraud
- Buying/receiving items from a government member not authorized to sell the item
- False record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government
3. Relevant Law
- a. The False Claims Act, Title 31 of the United States Code, sections 3729 through 3733. The federal FCA provides civil liability for knowing or knowingly committing certain acts. The FCA defines “knowing” and “knowingly” to include not only actual knowledge but also instances in which the person acts in deliberate ignorance or reckless disregard of the truth or falsity of the information.
- b. The FCA, Title 31 of the United States Code, Chapter 38, provides administrative remedies for false claims and statements.
- c. 18 U.S.C. § 287 provides criminal penalties for submitting false, fictitious, or fraudulent claims, which include imprisonment and criminal fines.
- d. The United States Office of the Inspector General may also impose administrative civil monetary penalties for false or fraudulent claims.
- e. Iowa Code section 249A.51 defines fraudulent practice under Chapter 249A, Medical Assistance
- f. Iowa Code sections 714.8(10)-714.14 provide the criminal definition of fraudulent practice
The FCA allows a private individual to file a lawsuit on behalf of the United States and entitles the
individual to a percentage of any recoveries. Private individuals may be current or ex-business partners or
employees, district staff, students, parents, or competitors. Any employee who suspects Medicaid, or
other waste, abuse, or fraud must immediately report his or her suspicion.
1. The employee should report the suspicion to the Special Education Specialist assigned to his or her building or to the Director of Health Services. If the employee suspects the Specialist and Director are involved in the waste, abuse, or fraud, the report should be made to the Director of Special Education or the Director of Human Resources.
- a. An internal investigative review shall be initiated immediately.
- b. Appropriate corrective action shall be taken as a result of the review findings.
- c. The District shall self-report to the Department of Human Services (“DHS”) via the Program Integrity Unit of the Iowa Medicaid Enterprise.
- d. If warranted, appropriate disciplinary action shall be implemented as a result of the internal investigative review.
- e. All documentation related to the investigative review shall be maintained in the District Administrative/Human Resource confidential records.
C. Reporting Protection
1. The False Claims Act contains language protecting “whistleblower employees” who report suspected Medicaid waste, abuse or fraud from retaliation by their employer. Employees who are discharged, demoted, suspended, threatened, harassed, or in any way discriminated against in the terms and conditions of employment by the employer for “blowing the whistle” are entitled to recover all relief necessary to make the employee whole.
2. A whistleblower may be eligible to recover a portion of the government’s recovery from the fraudulent practice. The False Claims Act allows a private person to file a lawsuit on behalf of the United States government against a person or business that has committed the fraud.
3. Any employee who feels he or she is being retaliated against for reporting Medicaid waste, abuse, or fraud should immediately report this concern to the Director of Human Resources. The District shall implement appropriate protective action for the employee.
An internal investigative review shall be initiated immediately with appropriate corrective action taken as a result of the investigative findings. If warranted, appropriate disciplinary action shall be implemented as a result of the internal investigative review. All documentation related to the investigative review shall be maintained in the Human Resource confidential records.
D. Internal Prevention
The District has key mechanisms and procedures in place to detect and prevent waste, abuse, fraud, and improper documentation, including, but not limited to:
1. Annual external audits for the District are completed by an outside Certified Public Accountant (CPA) for all funded services.
2. Certified Annual Reports are submitted by the District to the Iowa Department of Education.
3. Ongoing training and consultation are provided to District employees to facilitate the integrity of the entire Medicaid Claiming Process.
4. Service documentation notes are reviewed each month prior to billing for services internally and by MJ Care; ensuring documentation completion prior to billing for services. Corrective action will be implemented as needed to improve the quality of documentation.
5. District policies have been established and employees are provided an informational fact sheet upon hire and annually thereafter. The fact sheet addresses detection and prevention of Medicaid abuse, waste, and fraud, including reporting and whistleblowing protection.
6. Quarterly, MJ Care will complete random reviews of service documentation notes and files for the Medicaid services rendered and for which claims reimbursement has been sought. The District will receive a report of the review findings including corrective action suggestions for improvement of the quality of documentation.
7. Inquirehire background checks are completed upon hire and on a regular basis throughout the fiscal year to identify individuals who may be excluded from involvement in government funded health programs such as Medicaid.
8. The District maintains its Enrollment Status as a Medicaid Provider with the Iowa Medicaid Enterprise and will continue to comply with the guidelines and constructs of such relationship.
• Adopted 2/24/14
• Legal References: U.S. Code Title 31 sec 3729-3733; U.S. Code Title 31, Chap 38; FCA(18U.S.C.§287); IAC249A.51; IAC714.8(10)-714.14