It is the policy of Johns Hopkins Health Plans to actively engage in efforts to prevent, detect, and mitigate losses related to fraud and abuse. The Johns Hopkins Health System Corporation (JHHSC) and Johns Hopkins Health Plans take health care fraud and abuse very seriously. Johns Hopkins Health Plans is committed to following all applicable laws and regulations, in particular those that address health care fraud, waste and abuse and the proper billing of all government-funded health care programs. This includes the Federal False Claims Act, Maryland False Claims Act (Claims Against State Health Plans and State Health Programs enacted in April 2010), and all applicable State laws and/or related enforcement policies.

Scope

This policy applies to all Johns Hopkins Health Plans product lines of business. It addresses reporting of fraud and abuse committed by or against Johns Hopkins Health Plans, plan providers, enrollees, beneficiaries, members, employees or subcontractors.

Definitions

All Lines of Business for the purpose of this policy refers to the following entities Priority Partners MCO, Employer Health Programs, US Family Health Plan, Hopkins ElderPlus, and Hopkins Health Advantage, Inc.’s Medicare Advantage and other commercial insurance plans.

For the purpose of this policy, fraud and abuse is defined as: “...intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or to some other person” (fraud); and/or “...practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost...or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care” (abuse).

Federal False Claims Act

Federal statute which allows for civil and/or criminal action to be brought against a health care provider who:

1. Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval to any federal healthcare program
2. Knowingly makes, uses or causes to be made or used a false record or statement to get a false or fraudulent claim paid; or
3. Conspires to defraud the government by getting a false of fraudulent claim allowed or paid.

Examples of a false claim are:

1. Billing for procedures not performed
2. Violation of another law, for example a claim was submitted appropriately but the service was the result of an illegal relationship between a physician and the Hospital (physician received kick-backs for referrals)
3. Falsifying information in the medical record
4. Billing of medically unnecessary services
5. Billing for non-covered services
6. Billing for incorrect level of service

In 2010, Maryland passed its own state False Claims Act (codified at Health General §2 601-611). Key Provisions of the Act are:

A person may not knowingly:

1. Present or cause to be presented a false or fraudulent claim for payment or approval
2. Make, use, or cause to be made or used a false record or statement material to a false or fraudulent claim
3. Conspire to commit a violation under this subtitle
4. Have possession, custody, or control of money or other property or on behalf of the State under a State health plan or State health program and knowingly deliver or cause to be delivered to the State less than all of that money or other property
5. Be authorized to make or deliver a receipt or other document certifying receipt of money or other property used or to be used by the State under a State health plan or program and intending to defraud the state or the Department make or deliver a receipt or document knowing that the information contained in the receipt or document is not true
6. Buy or receive as a pledge of an obligation or debt publicly owned property from an officer, employee, or agent of a State health plan or a State health program who lawfully may not sell or pledge the property
7. Make, use, or cause to be made or used, a false record or statement material to an obligation to pay or transmit money or other property to the State
8. Conceal or knowingly and improperly avoid or decrease an obligation to pay or transmit money or other property to the State; or
9. Make any other false or fraudulent claims against a State health plan or program
10. A person who is found to have violated the aforementioned subsection is subject to CMP (civil monetary penalties).

Remedies

A federal false claims action may be brought by the U.S Department of Justice Civil Division, the United States Attorney. An individual may bring what is called a qui tam action. This means the individual files an action on behalf of the government. In certain circumstances, the person who files the lawsuit (known as a relator), may be entitled to share in a percentage of the recovery on behalf of the federal government.

Violation of the federal False claims Act is punishable by a civil penalty of between $12,537 and $25,076 per false claim, plus three times the amount of damages incurred by the government.

A statute of limitations says how much time may pass before an action may no longer be brought for violation of the law. Under the False Claims Act, the statute of limitations is six years after the date of violation or three years after the date when material facts are known or should have been known by the government, but no later than 10 years after the date on which the violation was committed. The submission of false claims may also give rise to criminal liability.

Federal Whistleblower Protections

Federal law prohibits an employer from discriminating against an employee in the terms or conditions or his or her employment because the employee initiated or otherwise assisted in a false claims action. The employee is entitled to all relief necessary to make the employee whole.

State False Health Claims Act

Many states-Florida, Maryland, and many others-have enacted their own False Claim Act. For example, in Maryland, the Maryland False Health Claims Act (MDFCA) prohibits a person from, among other things, knowingly presenting or causing to be presented a false or fraudulent healthcare claim for payment. Unlike the federal law, the MDFCA specifically provides that a mistake or a negligent action that causes a false or fraudulent claim to be presented for payment is not a violation of the MDFCA. Also unlike The Federal False Claims Act, under the MDFCA, qui tam actions must be supported by the intervention of the Office of the Maryland Attorney General in order to proceed.

You are not required to report a possible false claims act violation to Johns Hopkins Health Plans or JHHSC first. You may report directly to the federal Department of Justice or to your state Attorney General.

Johns Hopkins Health Plans or JHHSC will not retaliate against you if you inform anyone of a possible false claims act violation.

Both the Federal and State Acts have Whistleblower Protections which prohibits retaliation against the reporter.

Whistleblower, means an individual who exposes any kind of information or activity that alleges any violation of regulation, statute, contract, policy or unethical behavior that may be indicative of an individual or entity committing fraud, waste or abuse against the Medicaid program.

Responsibility

We will provide information to all employees about the federal and state false claims acts, remedies available under these acts and how employees and others can use them, and about whistleblower protections available to anyone who claims a violation of the federal or state false claims acts. We also will advise our employees of the steps the Health Plan has in place to detect health care fraud and abuse.

What you should do if you think your organization may have made a false claim:

If you see something that is not right, or looks like one of the examples of a false claim discussed earlier, the JHHSC Corporate Compliance Office encourages you to:

• Report it to Johns Hopkins Health Plans Compliance Office at 410-424-4996 / 1-844-422-6957 or Johns Hopkins Advantage MD Compliance Office at 410-762-1575 or toll free at 1-844-697-4071 for further investigation. If you are not comfortable doing this or do not see action in response to your report;
• Call the JHHSC Corporate Compliance Hotline at 1-844-SPEAK2US (1-844-773-2528) or via email at JohnsHopkinsSPEAK2US.com 24 hours, 7 days a week.

All Johns Hopkins Health Plans providers, subcontractors, and vendors are required to report concerns about actual, potential, or perceived misconduct to the Johns Hopkins Health Plans Compliance Department. You may reach the Department using one of the methods listed immediately below.

• Mail: Johns Hopkins Health Plans Corporate Compliance Department
  7231 Parkway Drive, Suite 100
  Hanover, MD 21076
• Call: 410-424-4996 or toll free at 1-844-422-6957
• Fax: 410-762-1527, and
• Email: [email protected]

Beginning October 1, 2015, all Johns Hopkins Advantage MD providers, subcontractors, and vendors are required to report concerns about actual, potential, or perceived misconduct to the Johns Hopkins Advantage MD Compliance Department. You may reach the Department using one of the methods listed immediately below.

• Mail: Johns Hopkins Health Plans Medicare Compliance Department
  7231 Parkway Drive, Suite 100
  Hanover, MD 21076
• Call: 410-762-1575 or toll free at 1-844-697-4071 (TTY: 711)
• Fax: 410-762-1502, and
• Email: [email protected]
• Hours of Operation: Monday through Friday 8 a.m.- 5 p.m. (Voicemail available after hours)
• Medicare Compliance Officer: 410 424 4855

Johns Hopkins Health Plans encourages timely disclosure of such concerns and expressly prohibits any adverse actions directed against any person for making a good faith report of such concerns. No one at Johns Hopkins Health Plans may retaliate against you if you inform the Health Plan or the federal government of a possible false claims act violation. All Johns Hopkins Health Plans workforce members, providers, contractors, subcontractors, and vendors have a right to oppose or refuse to engage in acts that they believe, in good faith, are unethical, improper, or unlawful, provided that the manner of opposition is reasonable and the questionable act is immediately reported to the Johns Hopkins Health Plans Compliance Department using one of the contact methods listed in the previous paragraph.

Training

We will train all new members of our workforce regarding federal and state false claims acts and also provide periodic updates for existing members of our workforce. All members of our workforce are required to participate in training.

All contractors are required to accept educational information offered by a JHHSC institution or to participate in scheduled training.