False Claims Act

The Federal False Claims Act* and Program Fraud Civil Remedies Act**. The False Claims Act is a national law that was created to eliminate fraud against the federal government and protect the people who help the government in this effort. “Fraud” is a crime that happens when someone is deceiving someone for personal gain. The False Claims Act makes it a crime for any person or organization to submit a record or claim for payment for services, property or other items to the government, knowing that the information is not true. This is called a “False Claim.” “Knowing” means that the person or organization:

• knows the record or claim is false, or
• is asking for payment and is deliberately ignoring whether or not the record or claim is false, or
• is asking for payment and does not care if the record or claim is false.

Sometimes an inaccurate Medicare, Medicaid, VA, Federal Employee Health Plan or Workers’ Compensation claim could become a False Claim. For example, if a hospital knowingly bills for services that were not provided or were not ordered by a physician or overcharges for a product or service, these would be examples of False Claims.

A person who “knows” that an organization has filed a False Claim for payment can file a lawsuit in Federal Court on behalf of the government. These cases are known as “qui-tam” lawsuits and the person who files the lawsuit is called a “whistleblower.”   In some cases, the whistleblower can receive a portion of the damages awarded from a successful False Claim lawsuit. The damages can be large - up to three times the value of the False Claim, plus $5,500 to $11,000 in civil fines per False Claim. An individual who makes a false claim or written statement is also subject to $5,000 in civil fines per false claim or statement.

Federal Whistleblower Protections**. The federal False Claims Act protects an employee who files a False Claim lawsuit from being fired, demoted, threatened or harassed by his or her employer in retaliation. An employee who is harmed by their employer for filing a False Claims lawsuit must file a lawsuit against employer in Federal Court. If the court finds that the employer retaliated, the court can order the employer to re-hire the employee at the same level and to pay the employee twice the amount of back pay that is owed, plus interest and attorney’s fees.

State Laws and Whistleblower Protections. Each state where SSM Health is located – Missouri, Illinois, Oklahoma and Wisconsin – has laws that are very similar to the federal False Claims Act. These laws make it illegal to make or present False Claims or commit fraud against Medicaid and other state programs. Usually these laws can be found on each state’s Medicaid website as a way to help find and prevent health care fraud. Each state also gives some level of protection against employer retaliation to employees who report False Claims.

Our Policy. SSM Health’s Corporate Responsibility Process (CRP) monitors and audits compliance to help us find and prevent errors in coding or billing, False Claims or other activities that may be fraudulent. Employees can find these CRP Policies and Procedures on the SSM Health Intranet homepage under “Policies and Procedures” or through their department managers. SSM Health vendors and contractors are also given information about these CRP Policies and Procedures.

• SSM Health expects that our employees and agents who create and file claims for payments for services, property or any other item will only use true, complete and accurate information to make the claim.
• SSM Health expects that anyone with a concern about a possible False Claim at an SSM facility will use the Corporate Responsibility reporting process immediately so that SSM can investigate and correct any errors.
• SSM Health's non-retaliation policy protects our employees from harm when they do the right thing and report any genuine concern through the Corporate Responsibility reporting process.
• SSM will investigate any allegation of retaliation against an employee for speaking up, and will protect and/or restore rights to anyone who raised a genuine concern.

Our Promise. Our employees, contractors, and agents work hard to ensure that every claim for payment for the care we provide is true and accurate, so that we don’t break the law or the trust our patients and communities have placed with us.

*To read the law, please see US Code Title 31, Subtitle III, Chapter 37, sections 3729-33 (31 USC §§3729-33)
 **To read the law, please see US Code Title 31, Subtitle III, Chapter 38, sections 3801-08 (31 USC §§3801-3808)

Standards of Ethical Conduct & Relevant Policies for Vendors, Temporary and Contract Employees

COMMITMENT TO OUR PATIENTS AND THEIR FAMILIES – Everything we do is designed to provide exceptional care for our patients, their families, and the communities we serve. We reflect ethical and proper business practices in all we do.

BUSINESS ETHICS – All employees must represent SSM Health accurately and honestly and must not engage in any activity intended to defraud anyone of money, property, services, or care. All SSM Health employees must pay careful attention to business transactions with suppliers, contractors, and other third parties. Employees must not accept offers that would result in personal benefit. This includes gifts, favors and other incentives to perform work in a way that benefits outside parties. Only trivial items like pens and pencils may be accepted from a vendor.

LEGAL COMPLIANCE – SSM Health is committed to conducting all of its activities in compliance with applicable federal, state and local laws. These laws pertain to human resource activities, fraud and abuse in the Medicare and Medicaid programs, lobbying and political activity and many other areas.

CONFIDENTIALITY: PRIVACY & SECURITY OF INFORMATION – All SSM Health employees must maintain the confidentiality of patient information and of confidential information concerning employees.

CONFLICTS OF INTEREST - A conflict of interest is any situation where an employee has a financial or business interest that might be in conflict with the financial or business interests of SSM Health. All employees must avoid conflicts of interest or the appearance of conflicts of interest. If a potential conflict of interest exists, make people aware of it, as well as the impact it could have on our patients and their families or on the organization. Talking about conflict-of-interest issues with your supervisor, other entity managers, or the System Vice President – Corporate Responsibility, can clarify whether a true conflict exists.

HARASSMENT – SSM Health policies forbid harassment or sexual harassment and all individuals shall refrain from engaging in any of the activities including, but not limited to: intimidation, hostile acts relating to employee’s race, color, gender, religion, national origin, age or disability, unwelcome sexual flirtation, propositions or sexual degrading words.

DUTY TO REPORT – Employees and contract employees are obligated to report to their immediate SSM supervisor, senior manager, Corporate Responsibility Office (314-989-2647) or the CRP Help Line (1-877-4CRP-ASK), any matter which they believe is an ethical, legal, regulatory or policy matter which may be a violation. It is prohibited in any way to harass, discipline or apply pressure from any source in the organization to any employee who reports a matter he or she believes in good faith requires investigation.

ONE LEVEL OF PATIENT CARE – All SSM Health operating entities will provide patient care services at the same level to all patients with the same health care problems regardless of the source of payment. Furthermore, it is our policy that insurance status, ability to pay, race, and other such issues are irrelevant to the need to provide emergency medical services.