Purpose: To advise employees, contractors, and volunteers when and how to report wrong doing and of their protection against reprisal or retaliation for reporting.

Policy: Any person who has knowledge of or, in good faith, suspects any wrongdoing in the documenting, coding, or billing for services, equipment, or supplies, in either our practices or those of our clients, or violation of the Standards of Conduct should report it internally so that an investigation can be conducted and appropriate action taken. Retaliation or reprisal against anyone for such a report is strictly prohibited.

Wrongdoing: In addition to a violation of Federal or state law, wrongdoing includes violation and the impermissible billing practices such as:

• billing for services not performed at all or not performed as described;
• submission of claims for unnecessary or undocumented services, equipment, or supplies;
• double billing;
• up coding;
• unbundling;
• misuse of coding modifiers;
• false cost reports;
• billing for services by an unlicensed or excluded provider;
• paying or accepting money, gifts, or favors in return for referrals.

1. Anyone who becomes aware of or in good faith suspects wrongdoing by another employee, a board member, a client, a vendor, a contractor, or any other person should report it to their supervisor, or the Assistant Superintendent for Business.

2. The individual making the report may do so by reporting the concern in writing or by using any anonymous method such as leaving a note on one of the above person desk, etc. Anyone making an anonymous report must realize that the Compliance Officer will not be able to ask additional questions of the person reporting nor advise the person of the outcome.

We will attempt to maintain the confidentiality of the person reporting the concern.

3. Self-reporting is also encouraged. Anyone who self-reports wrongdoing or a

violation of law will be given due consideration in mitigation of any disciplinary

action that may be taken.

4. Upon a report of wrongdoing, the Compliance Officer will then conduct an

investigation into the allegations to determine the nature, scope, and duration of

wrongdoing, if any, and shall follow the steps set to remedy the situation. These steps are likely to include contacting appropriate state or federal officials when the allegation is confirmed.

6. Retaliation or reprisal in any form against anyone who makes a report of

wrongdoing, cooperates in an investigation, or participates in the compliance

program is strictly prohibited. If an employee or a contractor believes that an

adverse action in the form of reprisal or retaliation has been taken against him or her as the result of making a report or cooperating in an investigation pursuant to this or any other compliance policy, he or she should report it to the Compliance

Officer immediately.

7. The Compliance Officer shall maintain a confidential log in a secure place of all reports of compliance concerns and shall update management as often as necessary.

8. Anyone who makes a report of wrongdoing maliciously, frivolously, or in bad faith will be subject to disciplinary action up to and including termination.

9. We seek to investigate all non-frivolous claims of wrongdoing internally

so that corrective action can be instituted. Bay Shore School District encourages the reporting so that appropriate corrective action can be instituted. However, any person who discovers wrongdoing that is a false claim or statement may report that information to the Department of Justice or the U.S. Attorney by filing a complaint under seal in the court pursuant to the False Claims Act (described in the Appendix). They may also report to the appropriate state’s Medicaid Fraud Control Unit, Medicaid Inspector General, local prosecutors and other law enforcement authorities. If assistance is needed in identifying the appropriate official please contact one of the individuals identifies above.

Purpose: To set forth the standards that are applicable to reimbursement for medical services, supplies and equipment in order to comply with Bay Shore School District’s Standards of Conduct and Federal and state law.

Policy: Each employee, contractor, or vendor involved with providing or obtaining reimbursement for medical services, supplies, or equipment from or on behalf of our clients is responsible for submitting honest and accurate bills to Medicaid, Medicare, and other Federal and state health care programs. In addition to complying with Bay Shore School District’s Standards of Conduct, all employees, contractors, and vendors are expected to comply with Federal and state laws and administrative remedies designed to prevent fraud, abuse, and waste in Federal and state health care programs.

• All services, equipment and supplies billed for will be reasonable and

fully documented.

• All bills will be for services provided by providers who are properly credentialed and licensed and provide services within their scope of practice.

2. Completeness and Accuracy in Medical Records and Billing

• Documentation will be in sufficient detail so that an accurate bill can be submitted for each treatment or procedure performed.

• Provider numbers will be accurate and will not be shared.
• Services performed by therapist who require supervision will be billed only in compliance with Federal and state laws and regulations including the presence of a supervising licensed professional.
• Bills submitted for services performed shall describe the services in sufficient detail, be based on proper documentation in Ksystems (HER), and individual Medicaid files. Should not duplicate bills for the same services, be accurate, be based on the correct provider number, and be in compliance with Federal and state law, as well as, the payor’s contracts.
• Billing and Coding staff will comply with CMS and state program instructions and policies.

2. Impermissible Billing Practices

The following practices are not permitted:

• Billing for services that were not performed at all or not performed as described,
• Submitting claims for medical equipment, supplies, or services that were not necessary,
• Double billing,
• Up coding or assigning a code that secures a higher reimbursement, rather than the code that matches the services performed,
• Unbundling or billing the parts of a global fee separately,
• Knowingly misusing provider numbers,
• Failing to use coding modifiers accurately or appropriately,
• Preparing or submitting false cost reports,
• Billing for services performed by an unlicensed provider or one who has been excluded from a Federal health care program,

2. Compliance with Federal Law

• All employees, contractors and board members will comply with Federal and state law and regulations concerning fraud and abuse in federal health care programs, especially the Federal False Claims Act and administrative remedies associated with their enforcement (see Appendix to this Policy).
• No employee and/or contractor is permitted to give cash, gifts, favors, payment, services, entertainment, tips or any other items of value to anyone in exchange for their signing a contract or reporting services to be billed to Medicaid, Medicare or any other government or private health care program.

2. Government Reporting

• All reports required to be submitted to state or Federal health care programs must be truthful and accurate. No member, manager, officer, or employee shall attest to the accuracy of a submitted report unless he or she has been able to satisfy him or her that the data submitted or the representations made are truthful and accurate.
• If it is determined that a client(s) has been overpaid by a government program or third party payor Kinney, as contracted with the Bay Shore School District will promptly adjust the payment in the future billing to the proper party. If our contractual relationship with client has ended we will notify the former client of their need to return the over payment.
• All cost report data, schedules and worksheets must be truthful, accurate, and complete.
• No employee or contractor will attempt to improperly influence the actions or decisions made by government bodies, officials, employees, or contractors.
• Kinney, as contracted with the Bay Shore School District will cooperate and be truthful in responding to government inquiries, requests, and investigations, including audits, surveys, and certifications reviews.

The False Claims Act is a statute that imposes civil liability (between $5,500 and $11,000 a claim and three times the total damages) on any person or entity who;

• knowingly submits a false claim to the Federal government for payment
• knowingly makes or uses a false record or statement to obtain payment or approval of a claim by the Federal government
• uses a false statement to decrease an obligation to the government.
• Knowingly: actual knowledge of the truth or falsity of a claim or statement

• acting recklessly, or
• acting with deliberate ignorance of the truth or falsity of the claim. Claim: The definition of claim includes a claim submitted to Medicaid, Medicare or Tricare.

Bringing an Action under the False Claims Act:

A private person can bring an action under the False Claims Act in the name of the United States.

• The person can file a complaint "under seal" or confidentially on the court docket. "Under seal" means that the records are kept secret on the docket of the court.
• The U.S. Attorney has sixty days, or more if an extension is requested of the court, to review the complaint and consider the allegations and whether the U.S., through the Department of Justice, will join in and take over the complaint.
• The Department of Justice then investigates the allegations of violations of the False Claims Act and may involve the FBI or the Office of the Inspector General of the Department of Health and Human Services and may issue subpoenas for documents or electronic records, may interview witnesses, and may compel testimony from certain individuals within the organization.
• After the investigation is complete, the Department of Justice decides whether it will intervene in the action filed by the employee, decline to intervene, or dismiss the complaint.
• If the action is pursued and is successful, the employee is entitled to part of the recovery, from 15 to 30%, depending on whether the Justice Department, becomes involved in the case.

These statutes provide administrative remedies and penalties against those who submit false claims or make false statements to Federal agencies.

• The Program Fraud and Civil Remedies Act ("PFCRA") (31 U.S.C. 3801-3812) is another tool the Federal government can use to penalize false claims involving Federal agencies and is designed to provide them with an administrative remedy for losses resulting from false claims. The PFCRA provides for civil penalties of $5,000 per claim for each false claim submitted to a Federal agency and an assessment of twice the amount of the claim against anyone who submits a false, fictitious or fraudulent claim, includes a false statement of material fact or omits a material fact, or makes claims for property or services that were not provided as claimed.
• The Civil Monetary Penalties Law "CMPL" (42 U.S.C. Sec. 1320a-7a) provides for penalties against anyone who presents a claim to a Federal or state officer, employee or agency he knows or should know was not provided as claimed or is based on up coding. CMPL can also be assessed against a provider who:

• -- submits a bill for the services of someone who is not licensed or is excluded from Federal or state health care programs or
• violates the anti-kickback statute or
• is in violation of the Stark self-referral law.

Issued By: Bay Shore School District

Effective Date: October 28, 2009

Purpose: To outline our response to a report regarding a compliance concern.

Policy: The purpose of this policy is to set forth the procedures used to respond to information received by the Compliance Officer that a Board member, member officer, employee, consultant or vendor is engaging in activity that may be contrary to applicable Federal or State law or the requirements Bay Shore School District’s compliance program.

Implementation:

1. Investigation - Purpose of Investigation.

The purpose of an investigation is to:

• identify situations in which applicable Federal or State laws, including the laws, regulations and standards of the Medicare and Medicaid programs, or the requirements of our compliance program may not have been followed,
• to identify individuals or clients who may have knowingly or inadvertently violated the law or compliance program requirements,
• to facilitate the correction of any violations or misconduct,
• to implement procedures necessary to ensure future compliance,
• To protect our clients and Bay Shore School District in the event of civil or criminal enforcement actions.

1. Control of Investigations.

   All reports of alleged non-compliance must be forwarded to the Compliance Officer. Serious or otherwise sensitive matters for investigations should be conducted under the direction of our Compliance Officer. If the involvement of legal counsel is warranted, the Compliance Officer is responsible for determining the extent of their involvement. Regardless the Compliance Officer will (1) initiate an investigation of the conduct in question, (2) report findings to the executives, and (3) recommend the appropriate actions to be taken by the Bay Shore School District. At all times relevant to the investigation, anyone assisting in the investigation will function under the direction and control of the Compliance Officer.

2. Investigative Process.

Upon receipt of information concerning alleged misconduct, the Compliance Officer/Contact will, at a minimum, take the following actions:

• Complete a Compliance Report Form that includes, if known, the name of the employee who made the report, the date of the report, and a detailed narrative of the employee’s concern. Anonymity of the individual who made the report (if requested) and confidentiality will be maintained.
• Notify the Superintendent of Schools of the nature of the alleged improper conduct and, if the involvement of legal counsel is warranted, obtain a memorandum from senior management authorizing legal counsel to initiate an investigation.
• Ensure that the investigation is initiated as soon as reasonably possible but in any event not more than [three (3)] business days following receipt of the information. The investigation shall include, as applicable, but need not be limited to:

1. Interviews of all persons who may have knowledge of the alleged conduct and a review of the applicable laws, regulations and standards to determine whether or not a violation has occurred.
2. Identification and review of relevant documentation, including, where applicable, representative bills or claims submitted to the Medicare/Medicaid programs, to determine the specific nature and scope of the violation and its frequency, duration and potential financial magnitude.
3. Interviews of persons who appeared to play a role in the suspected activity or conduct. The purpose of the interviews is to determine the facts surround the conduct, and may include, but shall not be limited to:

1. The person’s understanding of the applicable laws, rules and standards;
2. Identification of relevant supervisors or managers;
3. Training that the person received;
4. The extent to which the person may have acted knowingly or with reckless disregard or intentional indifference of applicable laws;
5. Preparation of a summary report that (1) defines the nature of the alleged misconduct, (2) summarizes the investigation process, (3) identifies any person who is believed to have acted deliberately or with reckless disregard or intentional indifference of applicable laws, (4) assesses the nature and extent of potential civil or criminal liability, and (5) where applicable, estimates the extent of any resulting overpayment by the government.

d. For all investigations ensure that significant developments are promptly reported to the Compliance Officer. Ensure that the investigation is completed in a reasonable and timely fashion and that the appropriate disciplinary or corrective action is taken, if warranted.

4. Organizational Response.

Non-Compliance/Suspected Criminal Activity.

• In the event the investigation identifies employee misconduct or suspected criminal activity, Bay Shore School District will undertake the following steps.

• As quickly as possible, cease the offending practice.
• If the conduct involves the improper submission of claims for payment, we will immediately cease all billing potentially affected by the offending practice and or client.
• Consult with legal counsel, if necessary, to determine whether voluntary reporting of the identified misconduct to the appropriate governmental authority is warranted.
• If applicable, calculate and process adjustments for any improper payments made by a Federal or State government program as a result of the misconduct.
• Initiate appropriate disciplinary action, which may include, but is not limited to, reprimand, demotion, suspension and/or termination. If the offense involves the action of an employee of a client we will immediately report the instance to the appropriate executive at the client.
• If the investigation uncovers what appears to be criminal conduct on the part of an employee or client, appropriate disciplinary action against the employee or employees who authorized, engaged in or otherwise participated in the offending practice will include, at a minimum, the removal of the person from any position of oversight and may include, in addition, suspension, demotion, and termination. In the case of possible criminal conduct by an employee of a client, referral to the appropriate government official will be made.
• Promptly undertake appropriate training and education to prevent a recurrence of the misconduct.
• Conduct a review of policies and procedures to determine whether revisions or the development of new policies and/or procedures are needed to minimize future risk of noncompliance.
• Conduct, as appropriate, follow-up monitoring and auditing to ensure effective resolution of the offending practice.

This policy and procedure shall be periodically reviewed and updated consistent with the requirements and standards established by Federal and State law and regulations, and review organizations.

Last Update: 10/28/09