False Claims Act
The Medical University of South Carolina, its agents and affiliates as applicable under the Deficit Reduction Act of 2005 (including, but not limited to, the Medical University Hospital Authority and the University Medical Associates), including executive officers, faculty, staff, and other individuals employed by MUSC using MUSC resources or facilities, and volunteers and representatives acting as agents of MUSC is committed to complying with all applicable federal and state laws and regulations. All of these individuals work hard to ensure that we create accurate and truthful patient bills and submit accurate claims for payment from any payer, including Medicare and Medicaid, commercial insurance, and our patients. It’s the right thing to do, and federal and state laws require accuracy in health care billing.
The Federal False Claims Act (31 USC 3729-33) makes it a crime for any person or organization to knowingly make a false record or file a false claim with the government for payment. “Knowing” can include deliberate or reckless ignorance of facts that make the claim false. The South Carolina Presenting False Claims for Payment Statute (S.C. Code Ann. 38-55-170), South Carolina Medicaid False Claims Statute (S.C. Code Ann. 43-7-60), South Carolina Medicaid False Application Statute (S.C. Code Ann. 43-7-70), South Carolina Insurance Fraud and Reporting Immunity Act (S.C. Code Ann. 38-55-510 et seq.), South Carolina Computer Crime Act (S.C. Code Ann. 16-16-10 et seq.), and South Carolina DHHS Administrative Sanctions Against Medicaid Providers Act (S.C. Code of Regulations R. 126-400 et seq.) also provide criminal, civil and administrative penalties and sanctions for providers and individuals who participate with providers in making false statements, misrepresenting facts, concealing facts, and submitting claims for unnecessary services. These laws carry significant sanctions including fines, imprisonment, court costs, attorney’s fees, and full restitution to the victim of the fraud.
Examples of possible False Claims include someone knowingly billing Medicare for services that were not provided, or for services that were not ordered by a physician, or for services that were provided at sub-standard quality where the government would not pay. Another example of a false claim would be billing Medicare or Medicaid for services that are covered or paid for by a study or grant.
A person who knows a False Claim was filed for payment can file a lawsuit in Federal Court on behalf of the government and, in some cases, receive a reward for bringing original information about a violation to the government’s attention. Penalties for violating the Federal False Claims Act can be up to three times the value of the False Claim, plus from $5,500 to $11,000 in fines, per claim. The South Carolina State Criminal False Claims Statute allows a similar lawsuit in state court if a False Claim is filed with the state for payment, such as under Medicaid or Workers’ Compensation.
The False Claims Act protects anyone who files a False Claim lawsuit from being fired, demoted, threatened or harassed by their employer for filing the suit. If a court finds that the employer retaliated, the court can order the employer to re-hire the employee and to pay the employee twice the amount of back pay that is owed, plus interest and attorney’s fees.
Our Compliance Program supports compliance with the False Claims Act by:
- Monitoring and auditing to prevent or detect errors in coding or billing;
- Promoting and enforcing the items included in our compliance policies and procedures: MUHA policy A-67 (Compliance Policy and Code of Conduct), UMA HR policy 14.0 (Compliance Policy), and University Code of Conduct;
- Educating MUSC employees and agents that they are responsible to report any concern about a possible False Claim;
- Investigating all reported concerns and correcting any billing errors discovered; and
- Protecting MUSC employees and agents from adverse action when they do the right thing and report any genuine concern through the Compliance Office or the Confidential Hotline. State employees have additional protection through the State Employment Protection Act (S.C. Code Ann. 8-27-10 et seq.). The Compliance Office will investigate any allegation of retaliation against an employee or agent for bringing forward a legitimate concern.