ADMINISTRATIVE POLICY
Policy Statement
It is Tulane’s policy to educate our employees, agents, and contractors about the provisions of the federal and state laws that prohibit the submission of false claims and false statements as well as about the whistleblower protections contained in these laws and the role that these laws play in detecting and preventing fraud, waste, and abuse.
Purpose and Scope
This policy evidences the commitment of Tulane University (“Tulane”) and its employees, agents, and contractors to full compliance with all laws and regulations regarding billing for health care services. Tulane is committed to ensuring that billing to and reimbursement from the Medicare program, Medicaid program, and all other federal health care programs are in compliance with the regulations and guidance for billing such programs.
Applicability of this Policy
This policy applies to all Tulane employees, agents and contractors; however, health care providers and individuals supporting health care providers are more likely to encounter the situations described in the policy. Those employees, agents and contractors who provide health care services, are members of Tulane University Medical Group, or who provide administrative, managerial, financial or other support for Tulane’s health care functions should ensure that they fully understand this policy.
Contacts
Billing and Reimbursement of Health Care Services
Definitions
Federal law defines a “false claim” as knowingly presenting false or fraudulent claims for payment or making or using a false record or statement to receive payment for a claim. Louisiana law defines a “false or fraudulent claim” as a claim that a health care provider (or their agent) submits knowing the claim to be false, fictitious, untrue, or misleading regarding any material information.
Federal and state laws contain certain protections for “whistleblowers” who alert the appropriate governmental authority of a violation of the false claims acts. Under these laws, any person with actual knowledge of an allegedly false claim, including employees, agents and contractors, may, under certain conditions, become a whistleblower under these statutes and is free to notify the appropriate state or federal governmental authorities if they do not believe that Tulane is responding appropriately when notified about potential violations.
Policy and Procedures
State and Federal Laws
Both federal and Louisiana law prohibit Tulane from knowingly presenting a false or fraudulent claim to Medicare, Medicaid, or other federal health care programs. Federal law defines a “false claim” as knowingly presenting false or fraudulent claims for payment or making or using a false record or statement to receive payment for a claim. Louisiana law defines a “false or fraudulent claim” as a claim that a health care provider (or their agent) submits knowing the claim to be false, fictitious, untrue, or misleading regarding any material information. Examples of false claims could include billing for services not rendered or goods not provided, falsifying certificates of medical necessity, falsifying medical records, unauthorized use, or unauthorized assignment of provider billing numbers, and failing to report overpayments or credit balances. All data elements that must be included in submissions for reimbursement from Medicare, Medicaid and other federal health care programs must be accurate. Violations of these federal and state laws can subject Tulane to significant fines and penalties.
Protection of Whistleblowers
The federal and state laws contain certain protections for “whistleblowers” who alert the appropriate governmental authority of a violation of the false claims acts. Under these laws, any person with actual knowledge of an allegedly false claim, including employees, agents and contractors, may, under certain conditions, become a whistleblower under these statutes and is free to notify the appropriate state or federal governmental authorities if they do not believe that Tulane is responding appropriately when notified about potential violations. Employers are prohibited from taking adverse or retaliatory action against a whistleblower who in good faith notifies the appropriate governmental authority of an alleged violation. Whistleblowers may also be entitled to relief, including employment reinstatement, back pay, and other compensation arising from retaliatory conduct against the whistleblower.
Tulane’s Policies and Procedures
Tulane University is committed to promoting ethical practices and to preventing and detecting fraud, waste, and abuse. Tulane systematically reviews its compliance with the rules and regulations of Medicare, Medicaid, and other federal payors. Tulane also has compliance procedures in place for audits, personnel training, and continuing education. Tulane’s compliance personnel regularly apprise themselves and the organization of current state and federal statutory and regulatory developments to ensure that Tulane is compliant with the rules governing federal and state health care programs claims submissions.
In addition, Tulane relies on its employees to notify it of any potential inaccurate billing so that we are not accused of violating the laws that prohibit the submission of false claims to the government. Tulane makes it a part of the duty of all employees to assist this commitment to accurate billing by reporting any potential improprieties without fear of retaliation. Policy Against Retaliation Policy. Tulane employees may report potential billing violations directly to their supervisor or to the Compliance Hotline (Compliance Hotline | tulane ) maintained by Tulane for this purpose, which can be reached at 504-314-2899. Alternatively, information on the helpline and reporting any potential improprieties can be found at https://internalaudit.tulane.edu/content/compliance-hotline.
For more information on this topic, please refer to Tulane’s Health Care Compliance Program Policy Manual located at https://counsel.tulane.edu/compliance/healthcare.
Consequence of Violating the Policy
Violation of this policy may result in disciplinary action, up to and including termination and/or criminal prosecution.
