CareSphere has a longstanding practice of fair and truthful dealing with its participants, their families, the government, health professionals and others. No individual associated with CareSphere shall engage in any act of fraud, abuse or waste, such as knowingly making false statements of material fact, in the preparation or submission of any claim for reimbursement under the Medicaid program. This policy applies to all CareSphere employees, contractors or other agents. Compliance with this Policy is a condition of employment or business relationship with CareSphere. Violation of this policy is grounds for immediate termination of employment or agency relationship.
A. Definitions of Fraud, Abuse and Waste
Fraud is an intentional misrepresentation that, when relied on by a payer or other person, deceives that person to his or her detriment. Abusive tactics are broader than fraud and may include submitting deceptive or misleading claims to a government program like Medicaid, or using a false statement to support a claim. Waste may include other deceptive tactics, such as over-utilization of otherwise necessary services.
Types of fraud, abuse, or waste which may lead to liability are:
- Knowingly filing a false or fraudulent claim for payments to Medicaid or another governmentally funded health care program, such as billing for services not actually provided;
- Knowingly making or using a false record or statement to obtain payment on a false or fraudulent claim from Medicaid or other governmental program, such as documenting clinical care not actually provided;
- Conspiring to defraud Medicaid or other governmentally funded health care program by attempting to have a false or fraudulent claim paid; or
- Knowingly making or using, or causing to be made or used, a false record to statement to conceal, avoid or decrease an obligation to pay or transmit money or property to the government.
Examples of the above include but are not limited to:
- Completing timesheets for services not actually provided;
- Paying an invoice known to be false;
- Accepting or soliciting kickbacks or illegal inducements from vendors of services, or offering or paying kickbacks or illegal inducements to vendors of services;
- Paying, offering gifts, money, remuneration or free services to entice a Medicaid recipient to use CareSphere services;
- Using Medicaid reimbursement to pay a personal expense;
- Ordering and charging for medical services not necessary for the participant.
B. Mandatory Reporting Requirement.
If any individual subject to this policy has reason to believe that anyone associated with CareSphere has engaged in any fraud, abuse or waste, the individual has a duty to report any such observations and concerns immediately to Malky Neiman. CareSphere shall not retaliate against anyone submitting a timely report pursuant to this policy.
All reports shall be investigated under the supervision of Malky Neiman. All employees and contractors have a duty to cooperate with any investigation conducted by CareSphere.
CareSphere will take any necessary action to respond appropriately to any substantiated offense and to prevent any further offenses, including but not limited to terminating employees or contractors. Offenses will be evaluated for voluntary self-disclosure under applicable laws, and when warranted, they will be referred to federal and state authorities. CareSphere will cooperate with government officials investigating or prosecuting any individual referred by CareSphere.