Section 145-b of the New York Social Services Law makes it unlawful for any person to knowingly by means of a false representation, statement or other fraudulent scheme or device, obtain or attempt to obtain payment (including by means of false representations or material omissions in an acknowledgment, certification, claim, ratification or report of data which serves as the basis for a claim or a rate of payment, in a cost report or otherwise) from the state (or public funds) for services or supplies furnished or purportedly furnished.  Liability under the law includes repayment of funds improperly paid and monetary penalties of no more than $2,000 for each item or service or, where a penalty under this section has been imposed on any person within the previous 5 years, $7,500 for each item or service.  In addition, the State has the right to recover civil damages equal to three (3) times the amount by which any figure is falsely overstated, or in the case of non-monetary false statements or representations, three (3) times the amount of damages which the state sustained as a result of the violation or $5,000, whichever is greater.

New York Health Care Fraud Laws:

Article 177 of the New York State Penal Law (the "Health Care Fraud" Laws) makes it a crime for any person to, with the intent to defraud any publicly or privately funded health insurance or managed care plan, including the Medicaid program, to knowingly and willfully provide materially false information or omit material information, on one or more occasions, for the purpose of requesting payment for a health care item or service when such person, or any other person, receives payment as a result of such information or omission.  Violators may be subject to fines, imprisonment, or both.

Section 366-b of the New York Social Services Law makes it a crime for any person to, with intent to defraud, present for allowance or payment any false or fraudulent claim for furnishing services or supplies, or knowingly submit false information for the purpose of obtaining greater compensation than that to which he is legally entitled, or knowingly submit false information for the purpose of obtaining authorization for furnishing services or supplies under the medical assistance program.   

Billing and Claims Activities That May Violate the Law:

The following are examples of improper billing and claims activities, but are not meant to be exhaustive:

• Billing for services or supplies that were not provided;
• Submitting a claim containing known false information or omitting material information;
• Filing a claim for services not medically necessary, or, if medically necessary, not to the extent rendered (e.g., a battery of diagnostic tests is given where, based on diagnosis, only a few are needed);
• Altering claim forms to increase payments;
• Arranging to get paid twice for the same service by billing both Medicare/Medicaid and the patient or both Medicare/Medicaid and another insurer (i.e. duplicate billing);
• Revising a claim for a service that is not covered so it will be covered;
• Misrepresenting the services performed, the fee for the services, the date of the services, or the identity of the patient;
• Falsifying records to appear to meet conditions of participation or conditions of coverage;
• Omitting material information when making a claim or when submitting a written statement in support of such claim
• Scheming with another person to manipulate claims and increase payments (e.g. upcoding);
• Using the adjustment payment process to generate fraudulent payments; 
• Billing services over a period of days when all treatment occurred during one visit;
• Improperly completing certificates of medical necessity (CMN);
• Providing incomplete, false, or misleading information about ownership of a laboratory or facility;
• Repeatedly charging Medicare/Medicaid patients more than the permitted amounts  or repeatedly violating a participation agreement or assignment agreement;
• Excessive charges for services or supplies;
• Improper billing practices, including submission of bills to Medicare instead of third-party payers which are primary insurers for Medicare beneficiaries;

•       Increasing charges to Medicare beneficiaries but not to other patients; 
•       False or misleading documentation regarding services provided; and
•       Billing for Adult Day Health Care services without meeting the daily program

            requirements.

Reporting:

All employees, contractors and agents are required to promptly report all known or suspected violations of Four Seasons billing and claims submission policies to the Administrator, Compliance Officer, immediate supervisor or other designated party, in writing or through the anonymous telephone hotline at 866-249-5264.
There will be no retaliatory action taken against employees or agents who report in good faith to the facility or any governmental official or agency.  Retaliation or any form of reprisal based upon an employee‘s or agent’s good faith reporting of potential fraudulent claims activity is strictly prohibited, and will not be permitted or tolerated by Four Seasons.  Further, the Federal False Claims Act, New York False Claims Act, and New York State Labor Law § 740 specifically prohibit and provide remedies for such retaliatory action.  Improper retaliation includes actual or threatened discharge, demotion, suspension, harassment, discrimination or other adverse employment action.  Activities protected against retaliation by federal and New York State law and regulation include: disclosing or reporting (or threatening to disclose or report) to a supervisor, the facility or to a governmental official or agency an activity, policy or practice that is in violation of the law; testifying or providing information for a hearing, investigation or inquiry; initiating or assisting in any action or investigation; and/or objecting to or refusing to participate in any such illegal activity.  Employees and agents are expected to report any possible instances of retaliatory action immediately to the Administrator and/or Compliance Officer or other designated party.

Detecting and Preventing Fraud, Waste and Abuse:

In accordance with the requirements of relevant false claims laws, and to further ensure the accuracy and appropriateness of claims submitted, Four Seasons has adopted the following rules that its employees, contractors and agents must strictly follow:

• Detect and prevent the filing of claims for services not rendered.  All documentation must be reviewed and checked for accuracy by clinical staff prior to submission. Furthermore, billing staff must review the completeness and check for inconsistencies in the documentation supporting the bill prior to submitting a claim;
• Detect and prevent the filing of claims for services rendered that were not medically necessary.  Documentation submitted by the clinical departments must be consistent with medical necessity requirements ("reasonable and necessary" in the context of Medicare).  All clinical and billing staff shall communicate effectively to ensure that documentation is consistent;
• Detect and prevent the submission of any claim which contains false information. All claim forms must be reviewed for accuracy prior to presentation for payment;

Detect and prevent any claim for inadequate or substandard services. Clinicians must review services rendered and supporting documentation to determine that the level of services provided is adequate to support a claim for payment.

The clinical and billing staff, in coordination with the Compliance Officer or other designated party, will conduct periodic reviews to determine the accuracy of documentation utilized to support claims for reimbursement.

Four Seasons has adopted Policies and Procedures for preventing and detecting fraud, waste and abuse of the federal health care programs, including Medicare and Medicaid.  All employees, contractors and agents must strictly follow these policies. These policies and procedures are available for review upon request.  To review these policies and procedures, contact the                                     
Compliance Officer.  The following represents a summary of relevant policies and procedures:

Policy and Procedures:  Designation and Responsibilities of the Compliance Officer

It is the policy of Four Seasons to ensure that it conducts itself in compliance with all applicable laws, rules, regulations and other directives of the federal, state and local governments, departments and agencies.  In this regard, and in furtherance of this policy, Four Seasons shall at all times have an individual designated as a Compliance Officer to oversee and monitor its Compliance Program.

Coordination and communication are the key functions of the Compliance Officer with regard to planning, implementing, and monitoring Four Seasons' Compliance Program. The Compliance Officer shall develop and assist the facility in putting appropriate compliance processes in place to implement the Compliance Program.  Examples of these activities and processes include, but are not limited to, the following:

• serve as a trusted source of guidance for employees and contractors with regard to compliance related matters;
• test the billing and claims reimbursement staff on their knowledge of applicable program requirements and claims and billing criteria;
• conduct or oversee unannounced audits of claims and billing information;
• assess contractual relationships with contractors, consultants and potential referral sources;
• determine whether individuals who previously have been reprimanded for compliance issues are now conforming to policies;
• develop, coordinate and participate in compliance educational and training programs; and
• coordinate internal compliance review and monitoring activities, including annual or periodic reviews and oversee any resulting corrective action.

 

Policy and Procedures:  Retention of Records

It is the policy of Four Seasons that all employees and contracted health professionals and agents maintain and preserve all documents, including compliance, business and medical records, and secure them against loss, destruction, unauthorized access, unauthorized reproduction, corruption or damage.  Four Seasons will also comply with regulations concerning document retention periods.

The primary components of Four Seasons record maintenance, access and retention policies and procedures include, but are not limited to, the following:

• Records will only be accessible by authorized personnel on a need-to-know basis or legally authorized individuals, and in strict conformance with applicable federal, state, and local laws and regulations, including those relating to privacy and confidentiality.
• Resident medical records may only be accessed by authorized individuals and personnel. Questions as to whether medical records should be released and/or distributed should be directed to the facility’s Privacy Officer and/or the Administrator where appropriate.
• Records will be stored in a systemized manner that preserves confidentiality and takes into consideration environmental elements.
• Security of electronic records shall be in compliance with HIPAA regulations.

 

Policy and Procedures:  Individuals Excluded from Federal
and State Health Care Benefit Programs

It is the policy of Four Seasons not to enter into employment, contractual or business arrangements, in any capacity, with individuals or entities that are barred or excluded from participating in federal or state health care benefit programs.  This shall be accomplished through screening programs, which include reviewing the U.S. Office of Inspector General's (OIG) List of Excluded Individuals/Entities (LEIE) and other applicable sources of such information prior to hiring, engaging or otherwise transacting business with any person or entity, and by conducting such review periodically after employing, contracting with or otherwise engaging any individual or entity.

Policy and Procedures:  Conflicts of Interest

It is the policy of Four Seasons that all staff members avoid any and all activities that conflict with their responsibilities and obligations to Four Seasons and its Residents.

The policies and procedures relating to conflicts of interest include, but are not limited to, the following:

• Staff members must not have an interest in or serve as director, officer, manager or member of any entity in competition with Four Seasons, without permission.
• Any employee and agent who performs work or renders services for any competitor of Four Seasons or for any organization which does business with or seeks to do business with Four Seasons outside of the normal course of his or her employment shall notify the Administrator.
• Business with any Four Seasons vendor, supplier, contractor, or agency, or any of their officers or employees that is not conducted on behalf of Four Seasons is prohibited, unless previously authorized by the Administrator.
• Staff members shall not permit their names to be used in any fashion that would tend to indicate a business connection with any organization which does business with or seeks to do business with Four Seasons without the prior approval of the Administrator.
• Four Seasons shall not be represented by an employee or officer in any transaction in which he or she or an immediate family member has a personal financial interest.
• Staff members should not discuss any confidential information with anyone outside of Four Seasons.  This confidential information includes, but is not limited to, personnel data, patient lists, clinical information, financial data, research data, strategic plans, potential mergers and acquisitions, marketing strategies, processes, techniques, computer software, any information with a copyright, financial results or other business dealings.  
• Staff members shall not accept any gifts, including discounts, from prospective or current suppliers and/or contractors. 
• Staff members shall not engage in any activities or outside interests that influence their ability to make objective decisions in the course of their job responsibilities. 
• Staff members are expected to disclose potential conflicts of interest involving themselves or their immediate family members (spouse, parents, brothers, sisters, and children) to the Administrator using the facility's “Conflict of Interest Disclosure Statement” form.

 

Policy and Procedures:  Billing and Claims Reimbursement

It is the policy of Four Seasons to comply with all relevant billing and claim reimbursement requirements.  All personnel involved in coding, billing and claims submissions must maintain high ethical standards and must know and adhere to all requirements for the health care industry, including all rules and regulations pertaining to coding, billing, claims submission and reimbursement, including, among others, Medicare and Medicaid regulations.  All billing personnel are expected to attend training and education sessions.  Billing personnel will be regularly monitored to ensure that they are not engaging in any activity which may be fraudulent or abusive under the Medicare and Medicaid regulations.  Examples of such activities are set forth above.

All staff members are required to promptly report all known or suspected violations of Four Seasons billing policies to their immediate supervisor, Administrator, Compliance Officer or other designated party, in accordance with the facility's Policy and Procedures entitled "Internal Reporting of Compliance Related Matters."

Policy and Procedures:  Compliance Training and Education

It is the policy of Four Seasons as part of its continued commitment to compliance with legal requirements, to conduct mandatory annual compliance and policy education and training for all Four Seasons employees, physicians and other health care practitioners.

Each staff member is required to participate in a minimum of one (1) hour annually of basic compliance training and education.  Individuals involved in specialty fields such as coding, claims development and billing will require additional compliance training and education addressing documentation, claims, billing, and fraud and abuse issues.  Additional training attendance may be required as part of an employee performance improvement measure or action plan.  Attendance at educational and training sessions is the responsibility of each staff member and will be documented.  In addition to periodic training and in-service programs, Four Seasons will distribute any relevant new compliance information to affected staff members.

Policy and Procedures:  Employee Screening

It is the policy of Four Seasons to ensure that its employees, agents and independent contractors are properly screened in accordance with facility procedures, and in compliance with applicable laws and regulations, prior to employment or engagement with Four Seasons, and periodically during their tenure with Four Seasons.  Offers of employment or engagement, as well as continued employment and engagement, shall be contingent upon satisfactory screening.

Policy and Procedures:  Monitoring and Auditing

It is the policy of Four Seasons to ensure that Nursing Center, its employees, contractors and agents conduct business and activities in compliance with all applicable laws, rules, regulations and other directives of the federal, state and local governments, departments and agencies. In this regard, and in furtherance of this policy, Nursing Center shall conduct periodic audits designed to address relevant compliance issues.  Audits may be conducted by internal or external auditors, and will be overseen by the Compliance Officer.

Policy and Procedures:  Internal Reporting of Compliance Related Matters

It is the policy of Four Seasons to maintain an internal reporting mechanism for all staff members, contractors and agents to report actual or perceived violations of Four Seasons’ Code of Conduct, Compliance Program, policies and procedures and applicable laws and regulations.

Anyone with current knowledge of an event, occurrence or activity that appears to violate applicable laws and regulations, Four Seasons’ Code of Conduct or any of its policies or procedures should promptly communicate the actual or perceived violation to their immediate supervisor, the Administrator, Compliance Officer or other designated party.

If the individual reporting prefers not to report the matter to a supervisor or the Administrator, he/she should call Four Seasons’ Compliance Hotline at 866-249-5264. Callers to the hotline will remain anonymous.

As explained above, there will be no retaliatory action taken against employees or agents who report in good faith to the facility or any governmental official or agency. Retaliation or any form of reprisal based upon an employee‘s or agent's good faith reporting of potential fraudulent claims activity is strictly prohibited, and will not be permitted or tolerated by Four Seasons. Employees and agents are expected to report any possible instances of retaliatory action immediately to the Administrator and/or Compliance Officer or other designated party.

Policy and Procedures: Investigations of Compliance Reports

It is the policy of Four Seasons to make reasonable inquiry into any report concerning activity which may be contrary to applicable laws and/or regulations. Upon receipt of a report which suggests that improper conduct has occurred, an investigation either under the direction and control of legal counsel or the Compliance Officer may be commenced. The investigative techniques used shall be implemented in order to facilitate the correction of any practices not in compliance with applicable laws and/or regulations and to promote, where necessary, the development and implementation of policies and procedures to ensure future compliance.