BCFR is committed to preventing and detecting fraud, waste and abuse in connection with federal and state health care programs. It is our intent to provide information to employees, providers, contractors and agents of BCFR about the provisions of federal and state false health care claims laws, penalties for violating the laws, and how to report suspected violations of the laws.
The Federal False Claims Act imposes liability on any person who submits a claim or statement for payment or approval to the federal government that he/she knows or should know is false and receive government funds. Examples of fraudulent and abusive activities are billing for services that were not provided or are not medically necessary, or submitting cost reports that are inaccurate. There are civil penalties for filing false claims and healthcare organizations may be excluded from participation in federal health care programs.
Employees, board members, providers, and contractors are strictly prohibited from engaging in any conduct that violates the False Claims Act, and are expected to report a suspected violations. All such reports will be investigated by the Agency.
Employees have the right to file a suit, known as a “qui tam” action, if they become aware of a violation of the Act. The government then investigates and decides whether to prosecute the matter. If successful, the whistleblower may share in a portion of the recovery. Employees may file such an action, but are encouraged to report suspected violations through internal procedures.
Missouri law contains civil and criminal false claims provisions for combating Medicaid fraud. Specifically, Missouri’s false claim statute prohibits:
- knowingly presenting a claim for payment that falsely states the health care provided was medically necessary;
- knowingly concealing an event affecting payments by a medical assistance program for providing care;
- knowingly concealing or failing to disclose any information in order to obtain a payment from a medical assistance program to which the health care provider is not entitled or improperly increasing the amount of any such payment to which the health care provider is entitled; or
- knowingly making a claim for payment for health care that was provided that has a lesser value than the amount of the claim.
In Missouri, criminal penalties range from imprisonment to restitution and there is the potential of civil penalties of $5,000 to $10,000 per violation plus treble damages for damage sustained by the Medicaid program as a result of the false claims activity. The Missouri Attorney General may initiate civil actions.
You may use this form to report suspected fraud, waste, abuse, ethical violations or compliance issues. You may report anonymously or provide contact information. To report a suspected violation to the Agency, you may contact your supervisor, or the Coordinator of Training and Quality Assurance. Anyone who, in good faith, makes a report will be protected from retaliation and retribution as a result of reporting.