Fraud & Abuse Policy

Nursing and Therapy Services of Colorado, Inc.

Policies and Procedures

SUBJECT: Fraud and Abuse Policy

APPROVED BY: Board of Directors

DATE EFFECTIVE: June 24, 2013

DATE REVISED: July 24, 2013

REVISION APPROVED BY: Board of Directors


MANUAL: Corporate Compliance/Human Resources,


Purpose: The purpose of this policy is to set forth the manner in which NTSOC complies with the requirements of Department of Health and Human Services and OIG compliance program. Information will be provided to employees about the Federal False Claims Act, any applicable state False Claims Act, the rights of employees to be protected as whistleblowers, and the organization’s policies and procedures for detecting and preventing fraud, waste and abuse.

This policy provides guidance regarding NTSOC’s responsibilities under the OIG compliance program. This policy also provides detailed information about the whistleblower protections under these laws and contracts, and the roles of these laws to prevent and detect fraud, waste and abuse in Federal and state health care programs.

Policy: NTSOC provides a written copy of policies at orientation to its Employees and Contractors about NTSOC’s policies and procedures for detecting and preventing fraud, waste and abuse and the rights of its Employees and Contractors to protection as whistleblowers. In addition, all employees and contractors must execute a copy of NTSOC’s Code of Conduct.

  1. NTSOC is committed to complying with all applicable laws, including but not limited to the Fraud & Abuse laws described in this policy. As part of this commitment, NTSOC has established and will maintain a Corporate Compliance Program that includes a Fraud & Abuse program. Employees and Contractors are expected to immediately report any potential false, inaccurate or questionable claims to their supervisors, or the Compliance Officer or the Hotline 719-219-0031, all in accordance with this Policy.
  2. NTSOC is prohibited by law from retaliating in any way against any Employee or Contractor who reports a perceived problem, concern or Fraud & Abuse issue in good faith.

False Claims:

Examples of potential false claims may include the following; when they are done intentionally and knowingly:

  1. Claiming reimbursement for services that have not been rendered;
  2. Characterizing the service differently than the service actually rendered;
  3. Falsely indicating that a particular health care professional attended a procedure;
  4. Billing for services/items that are not medically necessary;
  5. Failing to provide medically necessary services/items;
  6. Forging or altering a physician order; and
  7. Improperly obtaining a physician order for controlled substances.

NTSOC’s Employees, affiliates, professional staff members, contractors or agents who prepare, process and/or review claims should be alert for these and other errors.

Procedure: NTSOC has developed an internal Fraud & Abuse program, as part of its Compliance Program to prevent and detect program violations. As part of this program, and in compliance with federal requirements, NTSOC provides compliance training at the time the employee or contractor begins work and annually.

  1. Employees and Contractors must immediately report any false, inaccurate or questionable claims or actions as well as questions, concerns or potential Fraud or Abuse to:
    • Immediate supervisor
    • NTSOC’s Compliance Officer
    • NTSOC’s confidential, toll free Hotline 719-219-0031hours/day, 365 days/year (Information may be left on the Hotline anonymously)
  2. All activity reported pursuant to this Policy will be investigated in accordance with the NTSOC Compliance program.
  3. NTSOC will not discriminate or retaliate against any Employee or Contractor for reporting a potential fraudulent activity or for cooperating in any government or law enforcement authority’s investigation or prosecution.
  4. NTSOC will make diligent efforts to recover improper payments or funds misspent due to fraudulent or abusive actions by NTSOC or its Contractors, and/or refund improper reimbursements received by NTSOC.
  5. NTSOC will conduct its Compliance program in accordance with the OIG compliance program requirements.

Responsibility and Accountability

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.