NTSOC Employees and Contractors: All NTSOC Employees and Contractors are responsible for reporting any potential false, inaccurate or questionable claims or actions as well as questions, concerns of potential Fraud or Abuse.
The Corporate Compliance Officer is responsible for ensuring that all reports of suspected Fraud or Abuse are fully investigated and if appropriate, are reported to the proper authorities.
NTSOC’s Corporate Compliance Officer: The Corporate Compliance Officer is responsible for assessing and strengthening internal controls to insure that claims are submitted and payments properly made; including:
- The Compliance Officer has oversight for the Compliance program, including but not limited to policies/procedures and communications.
- monitoring for under-utilization or over-utilization of services;
- conducting regular reviews and audits of operations to guard against Fraud and Abuse;
- receiving all referrals from employees, patient providers involving cases of suspected fraud and abuse;
- Educating employees about fraud and how to report it, including informing employees of their protections when reporting fraudulent activities, and;
- Establishing mechanisms to receive, process, and effectively respond to complaints of suspected fraud and abuse from employees, providers and patients.
Scope: This policy applies to all employees and contractors of NTSOC.
Whistleblower Protections: Employers are prohibited from preventing employees from helping to prevent the submission of false claims. Under the law, no employer may have any policy preventing an employee from disclosing information to the government or from acting to further a false claims action. No employer may require that any employee agree to limit the employee’s rights to bring an action or provide information to a government or law enforcement agency pursuant to the law.
No employer may discharge, demote, suspend, threaten, harass, deny promotion to, or in any other manner discriminate against an employee in the terms or conditions of employment because of lawful acts done by the employee on behalf of the employee or others in disclosing information to a government or law enforcement agency or in furthering a false claims action. An employer who violates this rule may be liable for damages and may also be required to reinstate the employee and offer two times the amount of back pay, interest on the back pay, and compensation for any special damage sustained plus litigation costs and reasonable attorney’s fees.
NTSOC shall:
- Comply with all federal requirements for employee education about false claims laws under 42 U.S.C. §1396a(a)(68)
- Upon receiving a complaint of fraud or abuse from any source or upon identifying any questionable practices, conduct a preliminary review to determine whether in NTSOC’s judgment, there is sufficient reason to believe that the provider or patient has engaged in fraud or abuse, and where sufficient reason exists;
- Require providers to implement corrective actions or terminate provider Agreements, as appropriate;
Definitions: This Policy only includes those definitions when they do not overlap with other documents.
- Abuse: NTSOC practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary cost to the Medicaid program, including, but not limited to practices that result in Medicaid reimbursement for services that are not Medically Necessary, or that fail to meet professionally recognized standards for health care. It also includes patient practices that result in unnecessary cost to the Medicaid program.
- Fraud: An intentional deception or misrepresentation made by a person or corporation with the knowledge that the deception could result in some unauthorized benefit under the Medicaid program to himself, the corporation, or some other person. It also includes any act that constitutes fraud under applicable Federal or state health care fraud laws.
- Contractor or Agent: Includes any contractor, subcontractor, agent, or other person which or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, health care items or services, performing billing or coding functions, or is involved in the monitoring of health care provided by the entity.
- Employee: Includes any employees and officers of NTSOC.