Deficit Reduction Act

The Deficit Reduction Act (DRA) of 2005 mandates compliance programs for those institutions receiving $5 million or more annually in Medicaid payments. The DRA’s False Claims Act Amendment is intended to reduce the amount of fraud, waste, and abuse in state and federal health care programs through employee education about the federal False Claims Act, state false claims acts, civil and criminal penalties, and protections from retaliation for those employees who report wrongdoings, misconduct, or violations of laws and regulations in good faith.

Federal False Claims Act

The federal False Claims Act covers fraud involving any federally funded contract or program, such as Medicare or Medicaid and establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment. 

Virginia Fraud Against Taxpayers Act

The Virginia Fraud Against Taxpayers Act is our state’s version of the federal False Claims Act and contains parallel provisions. This state law helps the Commonwealth combat fraud and abuse and recover losses resulting from fraud in programs, purchases, and contracts. 

Federal False Claims Act Liability

Violations of the False Claims Act can result in civil monetary penalties ranging from $5,000 to $10,000 for each false claim submitted and repayment of three times the amount of damages sustained by the U.S. government. A provider or supplier found in violation may also be excluded from participation in federal health care programs.

Examples of Medicare and Medicaid Fraud Committed by Employees:

• Fabricating claims or changing provider addresses to intercept payments
• Providing false information on employment application
• Identity theft
• Accepting or offering a kickback or bribery in exchange for money

Examples of Medicare and Medicaid Fraud Committed by Providers:

• Participating in kickbacks (payments or other types of compensation made in order to influence and gain profit from an individual or company)
• Forgery of a physician's signature
• Billing for medical services that were not given
• Billing for undocumented or medically unnecessary services
• Duplicate billing
• Assigning incorrect codes to secure a higher reimbursement (upcoding)
• Unbundling codes with the intent to increase reimbursement

Examples of Medicare and Medicaid Fraud Committed by Vendors:

• Participating in kickbacks (payments or other types of compensation made in order to influence and gain profit from an individual or company)
• Providing services to a healthcare provider while ineligible to participate in federal health care programs due to suspension or debarment from such programs or because the vendor was convicted of a health care related crime.
• A conviction of filing false claims with state and/or federal agencies

Qui Tam Whistleblower Provisions

As a means to encourage individuals to come forward and report misconduct involving false claims, the False Claims Act’s “whistleblower” provision allows any person with actual knowledge of allegedly false claims, who has first made a good faith effort to exhaust internal reporting procedures, to file a lawsuit on behalf of the government and potentially share in a percentage of the amount recovered.

No Retaliation

The Federal False Claims Act grants protection from retaliation for filing a lawsuit or assisting in a False Claims Act action. VCU Health policy prohibits any type of retaliation against those who report concerns. This policy works in conjunction with the Federal False Claims Act and the Virginia Fraud Against Taxpayers Act in protecting those who report misconduct.

Reporting Mechanisms

Any VCU Health team member who has knowledge of actual or potential wrongdoing is encouraged to report their concerns to their department supervisory chain-of-command (supervisor, manager, director, vice president) or VCU Health’s Chief Compliance and Privacy Officer at (804) 828-0500. You may also report concerns directly to the Compliance Helpline at (800) 620-1438 or on the web.

Commitment to Integrity

VCU Health is committed to conducting business in accordance with all applicable laws, regulations, policies, and procedures. The health system has implanted a Compliance Program to articulate for all team members (e.g., employees, board members, physicians, faculty, contractors, vendors, etc.) our commitment to ethical standards and our responsibilities for compliance with regulatory and privacy policies.

Our Compliance Program includes a Code of Conduct, policies and procedures, education and training, auditing and monitoring and reporting mechanisms (such as our Compliance Helpline) by which VCU Health team members may report concerns anonymously and without fear of retaliation.

VCU Health has released a refreshed Code of Conduct that highlights some of the laws, regulations and VCU Health System policies and ethical standards that team members are expected to follow. The Code provides guidance for team members to assist the organization in fulfilling its ethical responsibility to patients, each other, payers and other stakeholders that conduct business with us. It demonstrations our belief in service with integrity.

Your Obligations to Act with Integrity:

All VCU Health team members (whether you are an employee, physician, faculty, board member, vendor or other business associate) must:

• Conduct all business with honesty and integrity.
• Follow all the laws and regulations, as well as VCU Health policies and procedures, that apply to your work at VCU Health.
• Report illegal or unethical conduct by calling our Compliance Helpline at (800) 620-1438 — all calls to the Helpline are confidential, and you may also call anonymously if you wish.
• Stay up to date with annual compliance and privacy training.

Where to Get Help or More Information

For more information, read the VCU Health Code of Conduct. 

Contact Compliance Services at:

• ComplianceServices.vcuhealth.org
• Office: (804) 828-0500
• Compliance Helpline: 1-800-620-1438
• Report an Incident via web