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The Office of Privacy and Corporate Compliance is committed to providing Yale New Haven Health System, and all of its individual delivery networks, with respect to its vision, mission and values, with clear and ethical compliance direction relating to all federal and state health care program requirements and regulations.


About Us

The YNHHS Compliance Program is designed to prevent and detect violations of applicable law, Code of Conduct and company policies. While it is expected that employees, contractors and agents will comply with applicable laws, Code of Conduct and policies, the System understands that the implementation of the Compliance Program cannot eliminate all risk of improper conduct. In the event that the System becomes aware of possible violations of law or Code of Conduct or policies, the Office of Privacy and Corporate Compliance will investigate the matter and, where appropriate, recommend disciplinary action and implement corrective measures to prevent future violations.

Compliance is not a “policing” action, but a way to ensure everyone is “doing the right thing”. To support this, YNHHS’ Corporate Compliance Department works with departments all across the health system to carry out primary functions such as:

  • Establishing compliance policies and procedures
  • Business structure and responsibility that includes a Compliance Officer and committee
  • Education and training
  • Reporting mechanisms that include effective lines of communication
  • Response/prevention and enforcement through well publicized disciplinary guidelines
  • Monitoring and Auditing
  • Responding to detected offenses and developing corrective actions
  • Comprehensive Fraud and Abuse Plans—procedures to voluntarily self-report potential fraud or misconduct

Once an issue is identified, the Compliance Department works with the applicable departments to investigate and resolve the issue. All issues are recorded and tracked for timely resolution.

Contact Us

We encourage you to call the Office of Corporate Compliance at 203-688-8416 or email us at [email protected] to discuss any potential compliance concerns. In addition, the Compliance Hotline is available to everyone 24 hours a day, seven days a week by calling 888-688-7744 or visiting www.ynhhscomplianceprogramhotline.com.

You can make a report either anonymously or by using you name. All reports received by either the Office of Privacy & Corporate or Hotline are appropriately investigated.

Index

  1. Financial Policies
  2. Fraud, Waste Abuse and Misconduct
  3. Language Assistance Policy
  4. Non-discrimination
  5. Privacy Policies
  6. Vendor Policy
  7. YNHHS Code of Conduct


Financial Policies

Billing and Collection

Purpose

To ensure that outstanding balances on patient accounts are pursued fairly and consistently by the Hospital and its agents in a manner consistent with its charitable mission.

Definitions

"Collection agent" means any person, either employed by or under contract to, the Hospital, who is engaged in the business of collecting payment from consumers for medical services provided by the Hospital, and includes, but is not limited to, attorneys performing debt collection activities.

"FAP" means the Hospital's Financial Assistance Policy.

"FAP-eligible individual" means an individual eligible for financial assistance under the hospital's FAP, without regard to whether the individual has applied for assistance under the FAP.

"Hospital bed fund" or "free bed fund" means a special donation received by the Hospital to subsidize, in whole or in part, the cost of medical care, including inpatient or outpatient care, incurred by patients at the hospital, whose financial circumstances render them unable to pay their hospital bills.

"Patient" means those persons who receive care at the Hospital and the person who is financially responsible for the care of the patient.

"Uninsured patient" means any person who is liable for one or more hospital charges whose income is at or below two hundred fifty percent (250%) of the poverty income guidelines who: (1) has applied and been denied eligibility for any medical or health care coverage provided under the state-administered general assistance program or the Medicaid program due to failure to satisfy income or other eligibility requirements, and (2) is not eligible for coverage for hospital services under the Medicare or CHAMPUS programs, or under any Medicaid or health insurance program of any other nation, state, territory or commonwealth, or under any other governmental or privately sponsored health or accident insurance or benefit program including, but not limited to, workers' compensation and awards, settlements or judgments arising from claims, suits or proceedings involving motor vehicle accidents or alleged negligence.

Applicability

This policy applies to each licensed hospital affiliated with Yale New Haven Health System (YNHHS), including Bridgeport Hospital, Greenwich Hospital, Yale New Haven Hospital and any other hospital that may affiliate with YNHHS from time to time, Northeast Medical Group and its subsidiaries, Yale New Haven Care Continuum (d/b/a Grimes), and any other providers of health care services owned by or under common control with YNHHS.

Policy

It is the Hospital's policy to treat all patients equitably with respect and compassion, from the bedside to the billing office. The Hospital will pursue patient accounts, directly and through its collection agents, fairly and consistently taking into consideration demonstrated financial need. As part of its collection process, the Hospital will make reasonable efforts to determine if an individual is eligible for financial assistance under its FAP. In the event of nonpayment, where based on information in its possession a person is not FAP-eligible individual, the Hospital (and any collection agency or other party to which it has referred debt) may engage in extraordinary collection actions as defined on Attachment I.

Procedures

  1. General & Limitation on Billing
    1. In accordance with Connecticut law, before a bill is sent to a patient the Hospital will:
      1. determine (based on information in its possession) (i) if the patient is an uninsured patient as defined herein; and (ii) eligibility for free bed funds; and
      2. notify the patient in writing of this insurance determination and the reasons for the determination.
      3. If a patient is determined to be an uninsured patient as defined herein, the patient will be eligible for free care under the Hospital's FAP.
    2. Following a determination of eligibility for financial assistance under the Hospital's FAP, the Hospital will charge all FAP-eligible individuals: (a) for emergency or other medically necessary care, the costs of such care (which the Hospital ensures is no more than amounts generally billed (AGB) to persons who have insurance covering emergency or other medically necessary care), and (b) no more than gross charges for all other care.
    3. Each bill and all collection notice from the Hospital, or any collection agent acting on behalf of the Hospital, must include the YNHHS Summary of Financial Assistance Programs. In addition, at Greenwich Hospital the Availability of Hospital Funds notice must be disseminated in accordance with the Greenwich Hospital Bed Fund Agreement.
    4. Throughout the billing and collections cycle, the Hospital will provide financial counseling to patients about their Hospital bills and respond promptly to patient's questions about their bills and to requests for financial assistance.
  2. Reasonable efforts – Accounts Receivable ("A/R") Collections The Hospital will follow its A/R billing cycle in accordance with internal operational processes and practices. As part of such processes and practices, the Hospital will, at a minimum, notify patients about its FAP from the date care is provided and throughout the A/R billing cycle (or during such period as is required by law, whichever is longer) by posting signs throughout the Hospital, distributing a plain language summary of its FAP in all billing statements, and discussing the FAP with eligible patients.
  3. Outside Collections
    1. The Hospital will seek to maintain written contractual relationships with one or more collection agents and attorneys for collection of past due accounts that will require compliance with the standards and scope of collection practices set out in this Policy.
    2. At the end of the Hospital's internal (pre-collection) billing cycle, outstanding balances may be referred to an approved outside collection agent under the following guidelines:
      1. Hospital has billed all third-party payers that may, based on hospital's records, be responsible for paying the claim;
      2. Hospital has provided patient information on how to arrange for a payment plan if the patient cannot afford to pay the entire bill at once and patient has not qualified for, arranged for, or complied with a payment plan;
      3. Hospital has notified patient that it has free bed funds and other free or discounted care for which the patient may be eligible;
      4. (a) No financial assistance application has been completed that establishes the patient's eligibility for hospital bed funds or other financial assistance nor is an application in process, or (b) patient has applied and qualified for partial financial assistance, but has not paid his/her responsible part then the ineligible portion of the account may be referred for collection;
      5. A representative of the Hospital's Finance Department or a Turnover Expeditor concludes, based on the results of an internal review and in accordance with the Hospital's eligibility criteria for its financial assistance programs, that the patient has the financial ability to pay for all or a portion of his or her bill; and
      6. The referral is reviewed and approved by the Credit & Collections staff under the direction of the Manager, Credit & Collections and using criteria & procedures permitted by the Director of Patient Accounts, the VP, Corporate Business Services and/or the Sr. VP, Finance.
    3. If at any point in the debt collection process, the Hospital, including any employee or agent of the Hospital, or a collection agent acting on behalf of the Hospital, receives information that a patient is eligible for hospital bed funds, free or reduced price hospital services, or any other program which would result in the elimination of liability for the debt or reduction in the amount of such liability, the Hospital or collection agent will promptly discontinue collection efforts and, if a collection agent, refer the account back to the Hospital for determination of eligibility. The collection effort will not resume until such determination is made.
    4. The Hospital will annually file a debt collection report with the Office of Health Care Access as required by Connecticut law.

Responsibility

Sr. VP, Finance, VP, Corporate Business Services, Director of Patient Accounts, and Manager, Credit & Collections

References

Conn. Gen. Statutes §19a-673 and §19a-673(a) – (d) Internal Revenue Code §501(r)(6) Fair Debt Collection Practices Act Connecticut Not-For-Profit Acute Care Hospital Voluntary Guidelines for Debt Collection AHA – Statement of Principles and Guidelines - Hospital Billing & Collection Practices

Related policies

YNHHS Financial Assistance Programs

Attachment I
Standards & scope of collection practices

  1. Prior approval of extraordinary collection action and reasonable efforts to determine if FAP-eligible individual. The Hospital (and any collection agency or other party to which it has referred debt) shall not engage in any extraordinary collection action ("ECA") before making reasonable efforts to determine if a patient is an FAP-eligible individual, and further must obtain written approval from the Manager of Credit/Collections, prior to the initiation of any ECA, including as set forth below.
  2. ECA Defined:
    1. Commencement of a legal action concerning a referred account
    2. Property Liens & Foreclosures.
      Liens on personal residences are permitted only if:
      1. The patient has had an opportunity to apply for free bed funds and has either failed to respond, refused, or been found ineligible for such funds;
      2. The patient has not applied or qualified for other financial assistance under the Hospital's Financial Assistance Policy, including sliding scale discounts to assist in the payment of his/her debt, or has qualified, in part, but has not paid his/her responsible part;
      3. The patient has not attempted to make or agreed to a payment arrangement, or is not complying with payment arrangements that have been agreed to by the Hospital and patient;
      4. The aggregate of account balances is over $1000 and the property(ies) to be made subject to the lien are at least $125,000 in assessed value; and
      5. The lien will not result in a foreclosure on a personal residence. Except in unusual circumstances (e.g. where there is evidence of an ability to pay, multiple homes or properties, or the existence of significant assets), the Hospital will not pursue foreclosures for property liens.
    3. Wage Garnishments.
      Garnishments of wages are permitted only if:
      1. The patient is not an uninsured patient;
      2. The criteria in (i) – (iii) above under Property Liens are met;
      3. A court determines that the patient's wages are sufficient for garnishment and enters a judgment against the patient; and
      4. The Hospital has notified the patient in writing of the foregoing.
      5. Wage garnishments, if approved, will only apply to account balances over $500. Additionally, any State Marshall fee for administering the wage garnishment will be absorbed by the Hospital as a cost of collection. No interest will accrue on wage garnishments.
    4. Bank Executions.
      All bank executions, in addition to pre-approval, require special review by the Hospital for verification that the execution will not cause undue financial hardship on the patient. If this cannot be determined, no bank execution will be ordered.
    5. Writs of Capias.
      The Hospital will not pursue and will not initiate a writ of capias (i.e., a petition to have a debtor arrested as a result of a debt collection activity). The Hospital may ask for examinations of patients but the Hospital itself will specifically indicate that the Hospital does not request any writ of capias.
    6. Interest and Court Costs.
      Interest will be allowed to accrue on accounts after legal court judgment is received. Interest will accrue at the current statutory rate. The Hospital will not allow interest to accrue greater than 50% of the account balance. If the principal is paid in full, the Hospital will waive payment of interest. Court costs will be assumed by the Hospital as a cost of collections and not charged to the patient.
    7. Credit Reports.
      No accounts or account activity will be directly reported to Credit Bureaus or rating agencies. Credit Bureaus may obtain information from court records.

Financial Assistance Program

Purpose

Yale New Haven Health System (“YNHHS”) recognizes that patients may not be able to pay for medically necessary health care without financial assistance. Consistent with its mission, YNHHS is committed to assuring that the ability to pay will be considered carefully when setting amounts due for emergency and other medically necessary hospital services.

In recognition of its role to help those in need of financial assistance, YNHHS has established the Financial Assistance Programs (“FAP”) to assist with emergency and other medically necessary care. The objectives of the FAP are to:

  1. Specify all financial assistance available under the FAP;
  2. Provide clear information regarding eligibility criteria, application requirements and the method
  3. for applying for financial assistance under the FAP;
  4. The basis for calculating amounts charged to patients for emergency or other medically
  5. necessary care; and
  6. The YNHHS measures to widely publicize this FAP within the communities served by YNHHS.

Applicability

This policy applies to each licensed hospital affiliated with Yale New Haven Health System (YNHHS), including Bridgeport Hospital, Greenwich Hospital, Yale New Haven Hospital and any other hospital that may affiliate with YNHHS from time to time, Northeast Medical Group and its subsidiaries, Yale New Haven Care Continuum (d/b/a Grimes), and any other providers of health care services owned by or under common control with YNHHS.

Policy

  1. Scope of FAP
    The FAP apply to emergency and medically necessary inpatient and outpatient services billed by Bridgeport Hospital, Greenwich Hospital, or Yale New Haven Hospital (each, a “Hospital”) to patients without insurance. The FAP exclude (a) routine waivers of deductibles, co-payments and coinsurance imposed by third party payers; (b) private room or private duty nurses; (c) services that are not medically necessary, such as elective cosmetic surgery; (d) other elective convenience fees, such as television or telephone charges, and (e) other discounts or reductions in charges not expressly described in this Policy.

  2. Eligibility for Financial Assistance
    Individuals who are uninsured and who have applied, but do not qualify for, State medical assistance, may be eligible for financial assistance under YNHHS FAP as more specifically described in Section IV below. The award of financial assistance shall be based on an individual determination of financial need. In addition, YNHHS has Bed Funds available.

  3. Amounts Billed to FAP-Eligible Patients
    Federal law requires that amounts billed by a hospital to an approved FAP-eligible patient must be less than the amounts generally billed (“AGB”) by that hospital for any emergency or medically necessary care it provides, and less than the gross charges for any medical care. Under this FAP, YNHHS bills FAP-eligible patients no more than the costs of care, and ensures that the cost of care billed to FAP-eligible patients is less than the AGB for each Hospital. YNHHS calculates AGB prospectively, based on current Medicare fee-for-service rates, including Medicare beneficiary costsharing amounts.

  4. Notice/Access to FAP
    Each Hospital provides notice and information to patients about its FAP in a number of ways, including publishing notices in newspapers of general circulation; posting notices and FAP applications on the Hospital website; posting notices throughout the Hospital and at all points of patient registration; ensuring the availability of a one-page summary description of FAP and applications at all points of registration, billing and collection; providing written notice of FAP in all billing statements; providing notice of FAP in all oral communications with patients regarding the amount due; and holding open houses and other informational sessions. Each Hospital will provide notice and information in a manner that complies with the requirements of all applicable laws, including IRC Section 501(r) and Connecticut law concerning hospital bed funds. Patients may ask Patient Registration, Patient Financial Services and Social Work/Case Management about initiating the Application process. Information about applying for financial assistance is also available on YNHHS Hospitals’ websites.

  5. Application and Eligibility Determinations
    To be eligible for financial assistance, the patient must complete an application for financial assistance (“Application”). Each Hospital has its own Application that sets forth (i) its FAP available programs and eligibility requirements, (ii) the documentation requirements for determinations of eligibility, and (iii) the contact information for FAP assistance. The Application also specifies (i) that the Hospital will respond to each Application in writing, (ii) that patients may re-apply for FAP at any time, and (iii) that additional free bed funds become available every year. Hospitals must make reasonable efforts to determine eligibility and document any determinations of financial assistance eligibility in the applicable patient accounts. Hospitals may not deny financial assistance under the FAP based on failure to provide information or documents that the FAP or the Application do not require as part of the Application. Hospitals may not engage in any extraordinary collection action, as defined in Hospital’s Billing and Collection Policy, before making reasonable efforts to determine if a patient is eligible for financial assistance, within any legally required time-frames.
    Once Hospital identifies a patient is FAP-eligible, Hospital shall:

    1. Provide a billing statement indicating amount owed as FAP-eligible patient, including the AGB for care provided and the Hospital’s calculation of amounts owed or instructions how to obtain such information;
    2. Refund any excess payments made by patients on FAP eligible accounts, as required by law; and
    3. Take reasonable measures to reverse any extraordinary collection actions.

  6. Programs
    YNHHS Hospitals offer the financial assistance programs described below to uninsured patients and each program must be managed by YNHHS Hospitals in accordance with this Policy. The eligibility criteria and specific documentation requirements for each program must appear in each Hospital’s Summary of Financial Assistance Programs and Application. YNHHS Hospitals may have different eligibility criteria and application processes for the different financial assistance programs

    1. A. Free Care. The Free Care program provides care at no cost to YNHHS Hospital patients with gross annual family income less than 250% of the Federal Poverty Level, and who have applied for, and been denied, State medical assistance.
    2. B. Restricted Bed Funds. Restricted Bed Funds are funds that have been donated to the Hospital to provide free or discounted care that are restricted to patients that meet certain eligibility criteria, such as certain town residency, church membership, or specific medical conditions. Information about these specific eligibility requirements is included on each YNHHS Hospital’s Application.
    3. C. Discounted Care. If a patient’s gross annual family income is 251% or above the Federal Poverty Level, the Hospital will discount care to the lessor of (a) its cost of care, or (b) the Hospital’s AGB.

  7. Management Oversight Committee
    The FAP will be overseen by a management oversight committee chaired by a Senior Vice President, YNHHS and comprised of representatives from the System Business Office, patient financial services, patient relations, finance, and the medical staff, as necessary. This committee will meet on a bi-monthly basis to discuss specific cases of patient financial hardship, collection matters, and the status of the FAP.

References

Internal Revenue Code 501(c)(3)
Internal Revenue Code 501(r)
Conn. Gen. Stat. § 19a-673 et seq.


Detecting and Preventing Fraud, Waste, Abuse and Misconduct

Although no precise measure of health care fraud exists, those intent on abusing the system can cost taxpayers billions of dollars while putting beneficiaries' health and welfare at risk. Medicare fraud and abuse increases the strain on the Medicare Trust Fund. The impact of these losses and risks magnify as Medicare continues to serve a growing number of people.  
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CMS Medicare Learning Network

It is the policy of the Yale New Haven Health System to provide healthcare services in a manner that complies with all applicable federal and state laws. Such compliance is critical to the Health System's commitment to operating pursuant to the highest business, professional and ethical standards. In compliance with the Federal Deficit Reduction Act of 2005, YNHHS maintains a vigorous Compliance and Privacy Program and has implemented a system-wide policy regarding the detection and prevention of fraud, waste, abuse and misconduct.

Contact Us
We encourage you to call the Office of Corporate Compliance at 203-688-8416 or email us at [email protected] to discuss any potential compliance concerns. In addition, the Compliance Hotline is available to everyone 24 hours a day, seven days a week by calling 888-688-7744 or by visiting www.ynhhscomplianceprogramhotline.com

You can make a report either anonymously or by using your name. All reports received by either the Office of Privacy amp; Corporate Compliance or the Hotline are appropriately investigated.

False Claims and Fraud Protection Policy

PURPOSE

The purpose of this policy is to inform employees, contractors, volunteers and agents of Yale New Haven Health System of the Federal False Claims Act (referenced in this policy as "FCA") the Federal Program Fraud Civil Remedies Act, the Connecticut False Claims Act (“CFCA”), and all other State False Claims Acts; to provide general information regarding YNHHS’s efforts to combat fraud, waste, and abuse; and to describe the remedies and fines for violations that can result from certain types of fraudulent activities.

In addition, this policy conforms to The Deficit Reduction Act (DRA) “Employee Education Provision” intended to bolster Medicaid fraud and abuse enforcement with the following:

  1. Establish fraud and abuse policies and an effective and comprehensive education plan; Included in annual Health Stream training “Corporate Compliance: A Proactive Stance Course.”
  2. Provide detailed explanation of administrative remedies pertaining to civil or criminal penalties for false claims.
  3. Provide specific discussion to the rights of employees regarding whistleblower protection under such laws.
  4. Ensure the entity has a non-retaliation policy available to all employees.

APPLICABILITY

This policy applies to YNHHS, and each of its affiliated entities, its affiliated hospitals (Bridgeport Hospital, Greenwich Hospital, Yale New Haven Hospital, Lawrence + Memorial Hospital, Westerly Hospital, and any other hospital that affiliates with YNHHS), its affiliated providers (including but not limited to Northeast Medical Group and Visiting Nurse Association of Southeastern Connecticut), and each of their subsidiary entities.

POLICY

All employees, contractors, agents, and volunteers of YNHHS must not create any false or misleading documents or financial or electronic records for any purpose. No one may instruct you to so.

Reporting Fraud, Waste, or Abuse

All employees, contractors, agents, and volunteers of YNHHS must immediately report any suspicion of fraud, waste, or abuse in connection with the business of YNHHS to the Office of Privacy and Corporate Compliance. YNHHS engages in specific compliance efforts to detect and prevent fraud, waste, and abuse, such as the Corporate Compliance Program. It is the policy of YNHHS that an employee, contractor, or agent of YNHHS who knowingly and intentionally submits a false claim will be reported to the necessary authorities by the Office of Privacy and Corporate Compliance.

Specific reporting requirements are noted in Attachment A:

  1. Wellcare Suspected Fraud Waste Abuse (FWA) Reporting form

PROCEDURES

If you would like more information on the Corporate Compliance Program and specific compliance policies or on how to report any concerns, please contact the Office of Privacy and Corporate Compliance (203-688-8416). Compliance Policies may also be accessed via the YNHHS Intranet at https://ynhh.ellucid.com/manuals/binder/1892/1.

Detailed Information of the Federal False Claims Act [31 U.S.C. 3729-3733}

The Federal False Claims Act (FCA) imposes civil penalties on people and companies who knowingly submit a false claim or statement to a federally-funded program or otherwise conspire to defraud the government in order to receive payment. Failure to report and return overpayments from Medicare and Medicaid within certain timeframes might also constitute a violation of the FCA. The FCA also protects people who make efforts to stop the suspected fraud.

The FCA is not confined to healthcare claims, but extends to any payment requested of the federal government or the federal government’s contractor, grantee, or other party, if the payment is to be spent or used on the government’s behalf or to advance a government program or interest and the government provides any portion of the payment or will reimburse the contractor, grantee, or other party. The FCA applies to billing and claims sent from YNHHS to any government payor program, including Medicare and Medicaid.

It is the policy of YNHHS that an employee, contractor, or agent of YNHHS who knowingly and intentionally submits a false claim will be reported to the necessary authorities. Anyone or any company that submits a false claim or statement to the government may be fined under the FCA between $10,957 and $21,916 for each such claim submitted, regardless of the size of the false claim, and the person or company could be required to pay an additional fine of three times the value of any charges. Where a person who violated the FCA reports the violation to the government under certain conditions, the FCA provides that the person shall be liable for not less than double damages.

Part of the FCA's purpose is to create an environment where employees and others feel safe reporting concerns about fraud. Any person, who lawfully attempts to stop any FCA violations or reports information about false claims or suspected false claims that are submitted by others, may not be retaliated against, demoted, suspended, threatened, or harassed for such actions. The FCA also protects individuals who assist in an investigation, provide testimony, or participate in the government's handling of a false claim. Individuals have the right to FCA whistle blower protection from retaliation in any form as to the result of their whistle blowing. These protections include reinstatement without loss of seniority if fired, recovery of two times lost wages plus interest and recovery of attorney fees and other reasonable costs in connection with pursuing retaliation claim. Confidentiality will be maintained to the extent possible.

The FCA’s provisions are generally enforced by the U.S. Department of Justice. The FCA provides that an individual may initiate a formal claim under certain circumstances. If any funds are recovered, a portion of the funds may be paid to the person who initiated the formal claim, at the discretion of a federal court. This amount, if awarded, generally is between 15% and 30% of the total damage amount.

If a person wishes to file a claim regarding fraud or suspected fraud related to a healthcare payment directly with the government, he or she must first present a formal complaint, along with all material evidence relating to the alleged fraud, to the authorities at the U.S. Department of Justice. The authorities have 60 days to investigate, during which time the complaint is kept confidential. Upon completion of the investigation, the government will decide either to pursue the case on its own or decline to proceed with the case. If the federal government declines the case, the individual may still proceed with the case on his or her own, but without the government's assistance, and at his or her own expense.

A private legal action under the FCA must be brought within six years from the date that the false claim was submitted to the government. (A government-initiated claim may be brought up to ten years after the false claim, depending on the circumstances.)

Detailed Information of the Federal Program Fraud Civil Remedies Act

Persons or companies that commit fraud on the federal government, by false claim or statement, can be assessed monetary penalties in addition to the penalties of the False Claims Act because of a law called the Program Fraud Civil Remedies Act (referenced in this policy as "PFCRA"). Specifically, PFCRA penalties of $5,000 per false claim or statement apply if a person or company submits a claim to the federal government that: the person or company knows or has reason to know is false, fictitious, or fraudulent; includes or is supported by written statements containing false, fictitious, or fraudulent information; includes or is supported by written statements that omit a material fact, which causes the statements to be false, fictitious, or fraudulent and the person submitting the statement has a duty to include the omitted fact; or is for payment of property or services that are not provided as claimed.

The $5,000 penalty also applies if a person or company provides written back-up or materials relating to the claim in which the person or company asserts a material fact that is false, fictitious, or fraudulent; or omits a fact that the individual had a duty to include, the omission causes the statement to be false, fictitious, or fraudulent, and the statement contains a certification of accuracy.

State Laws

Connecticut

In 2009, the Connecticut General Assembly enacted the Connecticut False Claims Act (“CFCA”). The CFCA is very similar to the FCA and prohibits any individual or entity from knowingly presenting or causing to be presented a false or fraudulent claim for payment or approval under the medical assistance programs administered by the Connecticut Department of Social Services or knowingly making or causing to be made a false statement in order to get such a claim approved, or knowingly concealing, avoiding, or decreasing any obligation to pay or transmit money or property to the state. Any individual or entity that violates this prohibition can be subjected to civil monetary penalties of $5,000 to $10,000 per violation as well as up to three times the damages sustained by the state as a result of the false claim.

The CFCA provisions are generally enforced by the Connecticut Attorney General. However, like the FCA, under certain circumstances, the CFCA permits private individuals to initiate civil actions and protects these individuals from workplace retaliation. If any funds are recovered, a portion of the funds may be paid to the person who initiated the formal claim, at the discretion of a court. This amount, if awarded, general is between 15% and 30% of the total damage amount. A legal action under the CFCA cannot be initiated more than six years after the date the violation occurs or more than three years after the date when a state official knew or should have reasonably known the violation, but in no event more than ten years after the date that the violation occurs.

In addition, there are also other Connecticut laws that prohibit fraudulent billing. It is a crime in Connecticut to fraudulently bill Medicaid or general assistance programs. All employees, contractors, and agents of YNHHS must immediately report suspicion of any criminal activity, including criminal fraud, to the System Compliance Operations Officer.

Anyone who provides services to a state Medicaid beneficiary and seeks or accepts payment for unnecessary or improper services is subject to possible imprisonment and/or criminal fines under state law. Depending upon the extent of the fraudulent services involved, such offenses carry potentially significant penalties, with a maximum of 20 years in prison and a maximum fine of $15,000.

Anyone who provides services to a recipient of Connecticut's general assistance program and seeks or accepts payment for unnecessary or improper services is also subject to civil and criminal penalties. Depending upon the amount of the fraudulent services involved, such offenses carry a minimum one-year prison sentence and a maximum of 20 years, as well as a maximum fine of $15,000. Any person who defrauds Connecticut's general assistance program is also excluded from participating in the program for a minimum of one year.

Connecticut law protects employees who report suspected violations of state or federal law, including reports of criminal fraud. An employer may not discharge, discipline, or otherwise penalize an employee for reporting a violation of the law, or suspected violation, as long as the employee does not know the information being reported is false.

Other States

Additional other state laws inclusive of New York, New Jersey, Massachusetts and Rhode Island will be reviewed as required for compliance purposes.

Non-Retaliation

YNHHS is dedicated to creating an environment where employees and others feel safe reporting concerns about fraud. YNHHS shall not unlawfully retaliate against individuals who: lawfully attempt to stop fraudulent billing practices or violations of the FCA, CFCA, or any other federal or state law or regulation regarding false or fraudulent claims; report information about false claims or suspected false claims that are submitted by YNHHS; or assist in any investigation, provides testimony, or participate in the government’s handling of a false claim investigation.

REFERENCES

Relevant Connecticut Laws and Regulations

Connecticut General Statutes § 4-61dd (Whistle blowing)
Connecticut General Statutes § 17b-25a (Toll Free Vendor Fraud Telephone Hotline)
Connecticut General Statutes § 17b-99 (Vendor Fraud)
Connecticut General Statutes § 17b-102 (Financial Incentive for Reporting Vendor Fraud)
Connecticut General Statutes § 17b-127 (General Assistance Fraud)
Connecticut General Statutes § 17b-301a et seq. (Connecticut False Claims Act)
Connecticut General Statutes § 31-51m (Protection of Employee Who Discloses Employer's
Illegal Activities or Unethical Practices)
Connecticut General Statutes § 31-51q (Liability of Employer for Discipline or Discharge of
Employee on Account of Employee's Exercise of Certain Constitutional Rights) Connecticut
General Statutes § 53-440 et seq. (Health Insurance Fraud) Connecticut General Statutes § 53a118 et seq. (Larceny)
Connecticut General Statutes § 53a-155 (Tampering with or Fabricating Physical Evidence)
Connecticut General Statutes § 53a-157b (False Statement Intending to Mislead Public
Servant)
Connecticut General Statutes § 53a-290 et seq. (Vendor Fraud)
Regulations of Connecticut State Agencies § 4-61dd-1 et seq. (Rules of Practice for
Contested Case Proceedings under the Whistleblower Protection Act)
Regulations of Connecticut State Agencies § 17-83k-1 et seq. (Administrative Sanctions)
Regulations of Connecticut State Agencies § 17b-102-01 et seq. (Financial Incentive for
Reporting Vendor Fraud and Requirements for Payment for Reporting Vendor Fraud)

Relevant New York State Laws and Regulations

New York State Finance Law §§187-194
New York State Social Services Law, Title 1 §145b (False Statements)

Relevant Massachusetts Laws and Regulations

MassHealth Regulation 130 CMR 450.205(F) (1)
MassHealth Regulation 130 CMR 450.223(C) (7)

Federal Law Cross References

Section 6032 of the Deficit Reduction Act of 2005
31 U.S.C. §§ 3729-3733 (Federal False Claims Act)
31 U.S.C. §§ 3801-3812 (Administrative Remedies for False Claims and Statements)

 

Effective date 1/1/2007 | Revised policy approved 6/19/2018


Language Assistance

Language Assistance Policy

All patients and visitors at Yale New Haven Health and its member organizations have the right to receive information in a language they understand, free of charge. YNHHS complies with the Department of Health and Human Services' Section 1557 rule of the Affordable Care Act — which sets guidelines about language assistance for people with limited English proficiency or those who are deaf or hard-of-hearing — and takes reasonable steps to provide meaningful access to people with limited English proficiency who may require assistance within the health system.

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