WESTON UNITED COMMUNITY RENEWAL COMPLIANCE POLICY #5 ~ FRAUD AND ABUSE REPORTING
This policy applies to ALL Weston United Community Renewal Programs.
Purpose of Policy
The purpose of this policy is to promote Weston United Community Renewal’s compliance with applicable laws and government standards by requiring all Weston United employees to report suspected fraud or abuse and ensuring that all reports are investigated and otherwise handled in an appropriate manner.
Fraud means any type of intentional deception carried out or misrepresentation made by a person with the knowledge that the deception or misrepresentation could result in the receipt of an unauthorized benefit by such person, Weston United or another individual or entity.
Abuse means activities that are inconsistent with sound fiscal, business or medical practices and result in (i) an unnecessary cost to the state or federal government or Weston United or (ii) the reimbursement of services that are not medically necessary or fail to meet professionally recognized standards for health care.
Statement of Policy
It is the responsibility of all employees to report suspected fraud, abuse or other improper activity relating to the operation of Weston United, whether committed by Weston United employees, vendors, clients or others. Examples of the types of activity that must be reported by employees include, but are not limited to, the following:
- Intentionally billing Medicaid or other third-party payers for clients to whom Weston United has not rendered services.
- Intentionally billing Medicaid as a primary payor for clients also covered by Medicare or private insurance when not permitted by Medicaid rules.
- Knowingly inflating or otherwise misrepresenting Weston United’s costs on cost reports filed with government agencies or private funders.
- Knowingly submitting inaccurate or misleading data or reports to government agencies.
- Knowingly using grant funds from government agencies such the Office of Mental Health or Office of Mental Retardation and Developmental Disabilities in a manner that is inconsistent with these agencies’ requirements.
- Theft or misuse of client funds held in trust.
Fraudulent, abusive or other improper conduct should be reported to the Compliance Officer. If the Compliance Officer is the subject of the report, then the report should be made to the Chief Executive Officer; in such cases, the Chief Executive
Officer, or his/her designee, will take over responsibility for Internal Investigations as outlined below.
Employees have several options for reporting fraudulent, abusive or other improper conduct. Reports may be made anonymously. Employees are encouraged to file a written report, which may be mailed to the Compliance Officer by internal
interoffice mail or postal mail. Alternatively, the report may be made by leaving a message on the Compliance Officer’s voice mail.
The Compliance Officer is responsible for publicizing his/her contact information and ensuring that all employees are aware that reports may be filed either in writing or through the hotline on an anonymous basis. This is accomplished via regular reminders, posters and organized compliance awareness events.
Employees are protected from retaliation for filing reports of suspected fraud, abuse or other improper conduct under Weston United’s Non-Retaliation Policy.
When a report of fraudulent, abusive or other improper conduct is received, the Compliance Officer, in consultation with the other Weston United staff and legal counsel as appropriate, will determine whether the report warrants an investigation. The Compliance Officer will use best efforts to make this determination within ten days of the receipt of the report. Any determination that a report does not warrant investigation will be reviewed and approved by the Chief Executive Officer.
If the Compliance Officer determines an investigation is warranted, he or she will promptly coordinate the investigation. The Compliance Officer may obtain the assistance of other Weston United staff and outside legal and financial advisors as necessary to carry out a proper investigation. All employees will be required to cooperate in such investigations. The Compliance Officer will monitor the activities of any outside advisors performing investigative services for Weston United. Weston United will make reasonable efforts to protect the identity of any individuals filing non-anonymous reports
except when disclosure of the individual’s identity is necessary to conduct an effective investigation.
The Compliance Officer will provide the Chief Executive Officer with regular reports of all pending investigations. The Compliance Officer, in consultation with the Chief Executive Officer, will have the authority to order the temporary suspension of any Weston United activity that is the subject of a pending investigation.
Upon completion of an investigation, the Compliance Officer will prepare a written report of the investigation’s findings, which will indicate whether fraudulent, Fraud and Abuse abusive or other improper conduct was committed. If such conduct is found, the Compliance Officer will recommend to the Chief Executive Officer and Human Resources Director, if appropriate, any corrective or disciplinary action deemed appropriate.
The Compliance Officer will maintain a log of all compliance-related reports, including reports filed through the hotline and other means. The log will specify the nature of the report, the date of the report, the reporting method (hotline, etc.), the name of the person filing the report (if the report was not filed anonymously), whether an investigation was conducted and if so the outcome of the investigation and the corrective or disciplinary action, if any, taken by Weston United. The log, investigation reports and other related documents (such as witness lists and interview notes) will be maintained by the Compliance Officer for six years, or longer if required by the agency’s Document Retention Policy. These documents will be kept confidential and will be shared with employees or advisors only as necessary to comply with this policy or to otherwise carry out Weston United operations.
Notification of Government Authorities
The Compliance Officer, in consultation with legal counsel and the Chief Executive Officer, will determine whether and in what manner it is appropriate to report any detected fraud, abuse or improper activity to federal, state or local government
agencies. Such reporting may involve, depending on the circumstances, refunding overpayments to Medicaid or other government payers, making a self-disclosure in accordance with formal or informal protocols established by the appropriate government Weston United or alerting law enforcement authorities.
Oversight by Board of Directors
The Compliance Officer will submit regular reports to the Board of Directors at quarterly Board meetings. Reports will include a summary of any reports filed with the Compliance Officer; the status and/or outcome of the investigation(s); and any corrective actions. The Board is not prohibited from delegating this oversight responsibility to one of its committees, provided that the committee reports regularly to the full Board.
Employees who do not comply with this policy will be subject to disciplinary action by Weston United. Depending on the facts and circumstances of each case, Weston United may reprimand, suspend or dismiss any employee who fails to comply
with this policy.