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Detection of Fraud

Detection and Prevention of Fraud, Waste, and Abuse and Applicable Federal and State Laws
POLICY PURSUANT TO THE FEDERAL DEFICIT REDUCTION ACT OF 2005
Detection and Prevention of Fraud, Waste, and Abuse and Applicable Federal and State Laws 

SUMMARY
Ohel Children’s Home and Family Services, Inc. (“Ohel”) is committed to complying with the requirements of Section 6032 of the Federal Deficit Reduction Act of 2005 and to preventing and detecting any fraud, waste, or abuse in its organization. To this end, Ohel maintains a compliance program and strives to educate our work force on fraud and abuse laws, including the importance of submitting accurate claims and reports to the Federal and State governments. Ohel’s compliance policies and procedures are set forth in detail in our compliance plan, which is available through the Department of Quality Assurance.

In furtherance of this policy and to comply with the Deficit Reduction Act, Ohel provides the following information about its policies and certain relevant Federal and State laws. Please note that guidance regarding the requirements of Section 6032 of the Deficit Reduction Act has not yet been promulgated. This policy is intended to comply with the requirements of the Deficit Reduction Act and will be modified as necessary to do so.

In particular, Ohel prohibits the knowing submission of a false claim for payment from a Federally or State funded health care program. Such a submission is a violation of Federal and State law and can result in significant administrative and civil penalties under the Federal False Claims Act, a Federal statute that allows private persons to help reduce fraud against the United States government. Please see more information about the Federal False Claims Act below.

In addition, in New York State the submission of a false claim can result in civil and criminal penalties under portions of the New York State Social Services Law and Penal Law, among other State statutes. Please see more information about these New York State laws below.

OHEL’S POLICIES AND PROCEDURES
To assist Ohel in meeting its legal and ethical obligations, any employee who reasonably suspects or is aware of the preparation or submission of a false claim or report or any other potential fraud, waste, or abuse related to a Federally or State funded health care program is required to report such information to his/her supervisor or Ohel’s compliance officer. Any employee of Ohel who reports such information will have the right and opportunity to do so anonymously and will be protected against retaliation for coming forward with such information both under Ohel’s internal compliance policies and procedures and Federal and State law. However, Ohel retains the right to take appropriate action against an employee who has participated in a violation of Federal or State law or agency policy.

As an organization, Ohel commits itself to investigate any suspicions of fraud, waste, or abuse swiftly and thoroughly and requires all employees to assist in such investigations. If an employee believes that Ohel is not responding to his or her report within a reasonable period of time, the employee shall bring these concerns about Ohel’s perceived inaction to Ohel’s compliance officer. Failure to report and disclose or assist in an investigation of fraud and abuse is a breach of the employee’s obligations to Ohel and may result in disciplinary action.

FEDERAL AND STATE STATUTES
The following is a summary of relevant Federal and State laws.

I. FEDERAL LAWS
False Claims Act (31 USC §§3729-3733)
The False Claims Act ("FCA") provides, in pertinent part, that:

(a) Any person who (1) knowingly presents, or causes to be presented, to an officer or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval; (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 approved by the Government; (3) conspires to defraud the Government by getting a false or fraudulent claim paid or approved by the Government;. . . or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government, is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person . . . .

(b) For purposes of this section, the terms "knowing" and "knowingly" mean that a person, with respect to information (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required. 31 U.S.C. § 3729. While the False Claims Act imposes liability only when the claimant acts “knowingly,” it does not require that the person submitting the claim have actual knowledge that the claim is false. A person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information, also can be found liable under the Act. 31 U.S.C. 3729(b).

In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false. An example may be a physician who submits a bill to Medicare for medical services she knows she has not provided. The False Claims Act also imposes liability on an individual who may knowingly submit a false record in order to obtain payment from the government. An example of this may include a government contractor who submits records that he knows (or should know) is false and that indicate compliance with certain contractual or regulatory requirements. The third area of liability includes those instances in which someone may obtain money from the federal government to which he may not be entitled, and then uses false statements or records in order to retain the money. An example of this so-called “reverse false claim” may include a hospital who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare program. 

In addition to its substantive provisions, the FCA provides that private parties may bring an action on behalf of the United States . 31 U.S.C. 3730 (b). These private parties, known as “qui tam relators,” may share in a percentage of the proceeds from an FCA action or settlement.

 Section 3730(d)(1) of the FCA provides, with some exceptions, that a qui tam relator, when the Government has intervened in the lawsuit, shall receive at least 15 percent but not more than 25 percent of the proceeds of the FCA action depending upon the extent to which the relator substantially contributed to the prosecution of the action. When the Government does not intervene, section 3730(d)(2) provides that the relator shall receive an amount that the court decides is reasonable and shall be not less than 25 percent and not more than 30 percent.

 Administrative Remedies for False Claims (31 USC Chapter 38. §§ 3801 – 3812)
 This statute allows for administrative recoveries by federal agencies. If a person submits a claim that the person knows is false or contains false information, or omits material information, then the agency receiving the claim may impose a penalty of up to $5,000 for each claim. The agency may also recover twice the amount of the claim.

Unlike the False Claims Act, a violation of this law occurs when a false claim is submitted, not when it is paid. Also unlike the False Claims Act, the determination of whether a claim is false, and the imposition of tines and penalties is made by the administrative agency, not by prosecution in the federal court system.

 II. NEW YORK STATE LAWS
 New York ’s false claims laws fall into two categories: civil and administrative; and criminal laws. Some apply to recipient false claims and some apply to provider false claims, and while most are specific to healthcare or Medicaid, some of the “common law” crimes apply to areas of interaction with the government.

 A. CIVIL AND ADMINISTRATIVE LAWS
 NY False Claims Act (State Finance Law, §§187-194) The NY False Claims Act closely tracts the federal False Claims Act. It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. The penalty for filing a false claim is $6,000 -$12,000 per claim and the recoverable damages are between two and three times the value of the amount falsely received. In addition, the false claim filer may have to pay the government’s legal fees.

The Act allows private individuals to file lawsuits in state court, just as if they were state or local government parties. If the suit eventually concludes with payments back to the government, the person who started the case can recover 25-30% of the proceeds if the government did not participate in the suit of 15-25% if the government did participate in the suit.

Social Services Law §145-b False Statements
It is a violation to knowingly obtain or attempt to obtain payment for items or services furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment or other fraudulent scheme or device. The State or the local Social Services district may recover three times the amount incorrectly paid. In addition, the Department of Health may impose a civil penalty of up to $2,000 per violation. If repeat violations occur within 5 years, a penalty up to $7,500 per violation may be imposed if they involve more serious violations of Medicaid rules, billing for services not rendered or providing excessive services.

Social Services Law §145-c Sanctions
If any person applies for or receives public assistance, including Medicaid, by intentionally making a false or misleading statement, or intending to do so, the person’s, the person’s family’s needs are not taken into account for 6 months if a first offense, 12 months if a second (or once if benefits received are over $3,900) and live years for 4 or more offenses.

B. CRIMINAL LAWS
Social Services Law §145 Penalties

Any person who submits false statements or deliberately conceals material information in order to receive public assistance, including Medicaid, is guilty of a misdemeanor.

Social Services Law § 366-b, Penalties for Fraudulent Practices.
 a. Any person who obtains or attempts to obtain, for himself or others, medical assistance by means of a false statement, concealment of material facts, impersonation or other fraudulent means is guilty of a Class A misdemeanor.

b. Any person who, with intent to defraud, presents for payment and false or fraudulent claim for furnishing services, knowingly submits false information to obtain greater Medicaid compensation or knowingly submits false information in order to obtain authorization to provide items or services is guilty of a Class A misdemeanor.

Penal Law Article 155, Larceny.
The crime of larceny applies to a person who, with intent to deprive another of his property, obtains, takes or withholds the property by means of trick, embezzlement, false pretense, false promise, including a scheme to defraud, or other similar behavior. It has been applied to Medicaid fraud cases.

a. Fourth degree grand larceny involves property valued over $1,000. It is a Class E felony.

b. Third degree grand larceny involves property valued over $3,000. It is a Class D felony.

c. Second degree grand larceny involves property valued over $50,000. It is a Class C felony.

d. First degree grand larceny involves property valued over $1 million. It is a Class B felony

Penal Law Article 175, False Written Statements.
Four crimes in this Article relate to filing false information or claims and have been applied in Medicaid fraud prosecutions:

a. §175.05, Falsifying business records involves entering false information, omitting material information or altering an enterprise’s business records with the intent to defraud. It is a Class A misdemeanor.

b. § 175.10, Falsifying business records in the first degree includes the elements of the §175.05 offense and includes the intent to commit another crime or conceal its commission. It is a Class E felony.

c. §175.30, Offering a false instrument for filing in the second degree involves presenting a written instrument (including a claim for payment) to a public office  knowing that it contains false information. It is a Class A misdemeanor.

d. §175.35, Offering a false instrument for filing in the first degree includes the elements of the second degree offense and must include an intent to defraud the  state or a political subdivision. It is a Class E felony.

Penal Law Article 176, Insurance Fraud,
Applies to claims for insurance payment, including Medicaid or other health insurance and contains six crimes.

a. Insurance Fraud in the 5th degree involves intentionally filing a health insurance claim knowing that it is false. It is a Class A misdemeanor.

b. Insurance fraud in the 4th degree is filing a false insurance claim for over $1,000. It is a Class E felony.

c. Insurance fraud in the 3rd degree is filing a false insurance claim for over $3,000. It is a Class D felony.

d. Insurance fraud in the 2nd degree is filing a false insurance claim for over $50,000. It is a Class C felony.

e. Insurance fraud in the 1st degree is filing a false insurance claim for over $1 million. It is a Class B felony.

f. Aggravated insurance fraud is committing insurance fraud more than once. It is a Class D felony.

Penal Law Article 177, Health Care Fraud,
Applies to claims for health insurance payment, including Medicaid, and contains five crimes:

a. Health care fraud in the 5th degree is knowingly filing, with intent to defraud, a claim for payment that intentionally has false information or omissions. It is a  Class A misdemeanor.

b. Health care fraud in the 4th degree is filing false claims and annually receiving over $3,000 in aggregate. It is a Class E felony.

c. Health care fraud in the 3rd degree is filing false claims and annually receiving over $10,000 in the aggregate. It is a Class D felony.

d. Health care fraud in the 2nd degree is filing false claims and annually receiving over $50,000 in the aggregate. It is a Class C felony.

e. Health care fraud in the 1st degree is filing false claims and annually receiving over $1 million in the aggregate. It is a Class B felony.

III. WHISTLEBLOWER PROTECTION
Federal False Claims Act (31 U.S.C. §3730(h))

The FCA provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the FCA. 31 U.S.C. 3730(h). Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.

NY False Claim Act (State Finance Law §191)
The False Claim Act also provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the Act. Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.

New York Labor Law §740
An employer may not take any retaliatory action against an employee if the employee discloses information about the employer’s policies, practices or activities to a regulatory, law enforcement or other similar agency or public official. Protected disclosures are those that assert that the employer is in violation of a law that creates a substantial and specific danger to the public health and safety or which constitutes health care fraud under Penal Law §177 (knowingly filing, with intent to defraud, a claim for payment that intentionally has false information or omissions). The employee’s disclosure is protected only if the employee first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation. If an employer takes a retaliatory action against the employee, the employee may sue in state court for reinstatement to the same, or an equivalent position, any lost back wages and benefits and attorneys’ fees. If the employer is a health provider and the court finds that the employer’s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer.

New York Labor Law §741
A health care employer may not take any retaliatory action against an employee if the employee discloses certain information about the employer’s policies, practices or activities to a regulatory, law enforcement or other similar agency or public official. Protected disclosures are those that assert that, in good faith, the employee believes constitute improper quality of patient care. The employee’s disclosure is protected only if the employee first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation, unless the danger is imminent to the public or patient and the employee believes in good faith that reporting to a supervisor would not result in corrective action. If an employer takes a retaliatory action against the employee, the employee may sue in state court for reinstatement to the same, or an equivalent position, any lost back wages and benefits and attorneys’ fees. If the employer is a health provider and the court finds that the employer’s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer.

The agency is committed to compliance in all aspects of the organization. As such, the agency maintains a confidential hotline for employees to report any compliance concerns, including inappropriate documentation and billing. The hotline's number is 718-438-0941. To best respond to all calls and issues raised in a timely basis, it would be most helpful if staff provide as much information as possible (contact name and phone number, residence, name of client, name of staff,). While staff are welcome to leave an anonymous message, it may be difficult for us to follow-up on anonymous calls. We will make every effort in good faith to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports a concern. No adverse action will be taken against such individuals. If you prefer, staff may call the agency's Human Resources or Quality Assurance Department directly at 718-851-6300.

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  • 5/21/13 - Oklahoma Tragedy, OHEL Provides Pointers to Parent...
  • 4/4/13 OHEL Bais Ezra’s Annual Chol Haomoed Adventure...
  • 3/14/13 Socialize and Find Your Bashert...
  • 3/6/13 OHEL’S New Five Towns Office...
  • 2/18/13 OHEL Annual Gala 2013...
  • 2/6/13 OHEL Bais Ezra’s Sibshops Program Empowers Siblings...
  • 11/19/2012 - New Project Hope Crisis Counseling Program...
  • 11/14/2012 - OHEL Provides Comfort to Evacuated Residents...
  • 11/13/2012 - Free Carnival...
  • 11/12/2012 - Hurricane Sandy...
  • 11/11/2012 - Rosh Hashana ...
  • 10/31/2012 - Robert Katz as the New Chief Development Office...
  • 10/31/2012 - Etta Israel Center of L.A. Merges with OHEL...
  • 09/14/2012 - Bais Ezra Hosts Community-Wide BBQ...
  • 08/20/2012 - Camp Kaylie Inaugurates the Kleinman Bais Medra...
  • 08/03/2012 - Ruach K’tonton in West Hempstead...
  • 08/02/2012 - OHEL Congratulates Our Own Misayim HaShas...
  • 07/24/2012 - NBA Greats Thrill Campers...
  • 06/19/2012 - Golf Classic...
  • 05/26/2012 - Getting Older...
  • 05/21/2012 - Day of Remembrance...
  • 03/07/2012 - Challenges of Anger Disorders...
  • 03/06/2012 - Bais Ezra 30th Anniversary...
  • 02/14/2012 - Ohel Draws Capacity Crowd...
  • 01/25/2012 - Mel Zachter Named OHEL Co-president...
  • 01/16/2012 - Gary Schaer To Receive the “Legislator of the...
  • 01/02/2012 - Cherish the Children...
  • 10/05/2011 - OHEL Bais Ezra’s Sibshops Program Empowers Si...
  • 08/30/2011 - Kaylie Day: A Dream Fulfilled...
  • 06/28/2011 - Pomegranate’s Chef Boris Grills Up a Great T...
  • 06/24/2011 - OHEL Golf Classic...
  • 05/25/2011 - OHEL Institute for Training Workshop Addressing...
  • 04/13/2011 - OHEL Institute for Training Addresses Eating Di...
  • 03/17/2011 - Over 400 Celebrates Purim with Matisyahu...
  • 03/11/2011 - New OHEL Video Colorizes the World ...
  • 03/11/2011 - OHEL Appoints New Director of Development...
  • 03/02/2011 - Reggae Star Matisyahu To Perform ...
  • 12/20/2010 - OHEL Regional Family Center of Northern NJ Tra...
  • 12/16/2010 - OHEL Provides Training on Addictions ...
  • 12/16/2010 - OHEL Residents and Neighbors Gather for a BBQ ...
  • 12/07/2010 - OHEL Insitute Provides Training On Short-Term T...
  • 11/24/2010 - OHEL Sixth Annual Benefit Concert ...
  • 11/21/2010 - OHEL Benefit Concert November 21st...
  • 11/11/2010 - Team OHEL Wins For OHEL Bais Ezra Kids...
  • 11/10/2010 - OHEL Working Breakfast Addresses Student-Issues...
  • 11/09/2010 - Gaining Couple Therapy Expertise at OHEL...
  • 07/19/2010 - Large Turnout at First Camp Kaylie Open House...
  • 07/13/2010 - “Building Resiliency in Our Children”...
  • 06/28/2010 - OHEL Golf Classic Benefits Children!...
  • 06/08/2010 - Training for Parents of Children with ADHD...
  • 04/28/2010 - Long Islanders Ride for OHEL Residents of the 5...
  • 04/07/2010 - “Reaching Out to Special Friends” Competit...
  • 03/11/2010 - Shloime Dachs Annual Siyum and BBQ...
  • 03/01/2010 - OHEL Draws Capacity Crowd To Celebrate 40 Years...
  • 02/12/2010 - Malky Giniger Presents a Star-Studded New Show...
  • 02/05/2010 - Meeting the Challenge of Postpartum Depression...
  • 01/21/2010 - OHEL 40th Anniversary Annual Dinner...
  • 01/10/2010 - Professionals Prepare to Address Teen Behaviors...
  • 01/08/2010 - Record Number of OHEL Bais Ezra Day Trips ...
  • 01/03/2010 - OHEL Celebrates Purim with Le Cirque Du Purime...

ARTICLES

  • Overnight Respite...
  • Employment: The Power of a Paycheck...
  • After the Brooklyn fire tragedy in which seven children died...
  • Rav Elya Brudny and Others Address Over 200 at Conference to...
  • Does Alan Turing have Aspergers Syndrome?...
  • Foster Parenting: How will it affect my children?...
  • “Hard to Place,” Not Hard to Love...
  • The Ties That Bind: Keeping Siblings Together in Foster Car...
  • Confronting Abuse in the Frum World ...
  • Understanding the Educational and Behavioral Needs of Childr...
  • When Divorce Can Save a Marriage...
  • Jewish Kids are in Foster Care, Too...
  • A Fulfilling Life ...
  • Richard Bernstein to Become First Blind State Supreme Court ...
  • Ask the Expert: Eligibility Specialist...
  • Meachorei Hapargod: Lessons for Elul, Courtesy of Summer Ca...
  • Early Parental Loss...
  • Are Gedolim Stories Good Chinuch?...
  • Is Recovery From Mental Illness Possible?...
  • Helping Your Child Accept a New Baby...
  • Self-Esteem or Self-Validation?...
  • “Knock, Knock” “Who's There?” OPWDD: Welcoming the F...
  • Developmentally Disabled Employees Shine In The Workplace...
  • “I Take Care” — Mrs. Miriam Lubling, a”h...
  • The Hallmark of Klal Yisrael: A Caring Heart… Foster care ...
  • Redefining strength...
  • Sustaining the Excitement of the First Year of Marriage...
  • No Complaints...
  • No Shidduch Left Behind...
  • Statewide Project Continues Offering Services to Sandy Victi...
  • 75th Anniversary of the Horrors of Kristallnacht...
  • Etta at OHEL Dedicates Fourth Group Home...
  • Staten Island Jewish victims of Hurricane Sandy Still in Nee...
  • A Slice of Home: Through the eyes of a foster child...
  • Ask Sarah: Newly Married & Worried About Divorce...
  • As New Year Approaches, N.Y. Community Devastated by Hurrica...
  • Oniomania: A Look into the Minds of Compulsive Shoppers...
  • Teens and Saturday Nights: A Parenting Approach...
  • The Loss of a Dream...
  • Help! My Adolescent is Out of Control!...
  • Protecting Our Children: Does a Bakery Have a Soul?...
  • Who Am I? Standing at the precipice of death longing for sta...
  • Nobody Quite Knew What to do With Yaakov...
  • Understanding the Coordination between Early Intervention an...
  • Understanding your "peckel", your packet of problems...
  • Life for Frum Women in domestic violence shelters...
  • United We Stand: The Impact of Disabilities on Marriage...
  • Unique Needs of Children in Foster Care...
  • The Success Story that Finally Happened...
  • It’s a painful process to watch. We joke about it all the ...

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