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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Administration

False Claims Act; Federal Contract Whistleblower Protections (4.50)

False Claims Act; Federal Contract Whistleblower Protections (4.50) - Policies, Administrative, UW Health Administrative, Administration

4.50

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).


Policy Title: False Claims Act; Federal Contract Whistleblower Protections
Policy Number: 4.50
Effective Date: July 3, 2017
Chapter: Administration
Version: Revision


I. PURPOSE

To provide information (a) to employees, contractors, and agents regarding the federal False Claims Act,
and (b) to employees regarding certain protections available to whistleblowers with regard to certain
federal contracts.

II. POLICY

This policy will provide UW Health employees, agents, and contractors with information regarding the
federal False Claims Act and the role of that law in preventing and detecting fraud, waste and abuse in
federal health care programs. This policy will also provide UW Health employees with information
regarding rights and protections available to employees for reporting certain types of concerns regarding
federal contracts (e.g., gross waste of federal funds).

III. FALSE CLAIMS ACT

The False Claims Act prohibits an individual or organization who receives money from the federal
government from submitting a request for payment knowing that such request contains false information.
Individuals and organizations, such as UW Health, may be held liable under the False Claims Act if it
knew, should have known, or disregarded information indicating that a claim submitted to the government
for payment of health care services contained false information. The federal False Claims Act also
permits lawsuits brought by individuals, typically employees or former employees, who have knowledge
of fraudulent activities. These individuals are called "qui tam relators" or "whistleblowers."

A. Examples of actions which violate the False Claims Act.
1. Submitting a claim for services that were not provided;
2. Submitting a claim for services that were not "medically necessary" under federal billing
rules;
3. Coding a service or a patient's diagnosis as "more complex" than documentation supports in
order to receive higher reimbursement; and
4. Submitting a claim for services paid by a source other than the federal government, or paid
for by the government under a different program.


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B. Potential Liability.
Under the federal False Claims Act, the federal government can assess a fine of
between $10,957 and $21,916 per claim plus up to 3 times the total amount of damage sustained
by the government depending on the circumstances (e.g. the organization did not properly
disclose known violations or did not cooperate with the investigation).

C. Federal "Qui Tam" or "Whistleblower" Provisions.
The qui tam provisions under the federal False Claims Act define the requirements that must be
met in order to bring forth a "qui tam" (a private individual) lawsuit on behalf of the federal
government. The federal government may choose to intervene and direct the lawsuit if it believes
there is merit to the case. However, the qui tam relator and his or her attorney may proceed with
the lawsuit on their own even if the government does not join in the lawsuit. If the lawsuit is
successful, qui tam relators may share in a percentage of the total amount of fines.

The federal False Claims Act provides statutory protection to employees from retaliation (e.g.
being fired, demoted, harassed, threatened, etc.) by an employer because of an employee's
participation in a qui tam action. Such protections include, but are not limited to, reinstatement at
the same seniority level, two (2) times the amount of salary back pay with interest, and attorney
fees resulting from bringing forth the employment action.

D. UW Health Measures to Prevent and Detect False Claims and Potentially Fraudulent Behavior.
UW Health strives, and expects, that its employees will do everything they can to prevent and
detect/report false claims and/or potentially fraudulent behavior. The following are examples of
measures that UW Health takes to accomplish this:
1. Providing staff training
2. Providing a confidential reporting “Hotline” (608-821-4130) and online reporting form
(found on U-Connect) through which employees may remain anonymous.
3. Applying "claims scrubbing" software to billing systems that captures claims with
potential billing errors and holds them until they can be manually reviewed
4. Investigating reports of potential violations from staff
5. Investigating complaints regarding potential violations from patients, family members,
friends, and visitors
6. Maintaining internal departmental monitoring process
7. Performing internal audits
8. Performing internal risk assessments
9. Communicating with state and/or federal agencies regarding potential concerns

IV. Retaliation Protection for Health Care Workers in Wisconsin

Wisconsin law protects employees of health care facilities or health care providers from discipline at
work for the good faith reporting of (1) any potential violations of state or federal law by the health care
facility or provider, or (2) any situation where care is provided in a manner that violates state or federal
standards or laws or recognized clinical or ethical standards. Employees are protected under state law for
reports to state agencies; accreditation or standard-setting bodies of the health care provider; and officers,
directors, or other employees who are in a supervisory capacity of the health care provider or are in a
position to take corrective action. Employees who believe they have been wrongfully disciplined may file
a complaint with the Equal Rights Division of the Department of Workforce Development, within
300 days after the retaliation occurred.



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V. WHISTLEBLOWER PROTECTIONS FOR CERTAIN FEDERAL CONTRACTS
Source: 41 U.S.C. § 4712; 48 C.F.R. §§ 3.908–3.908-9, 52.203-17

Under a federal government program, employees of contractors of the federal government, including
UW Health, are afforded protection against reprisal for whistleblowing activities in connection with
certain federal contracts.

Under the program, employees are protected against reprisal for reporting information the employee
reasonably believes is evidence of gross mismanagement of a federal contract; gross waste of federal
funds; abuse of authority relating to a federal contract; substantial or specific danger to public health or
safety; or violation of law, rule, or regulation related to a federal contract.

To be protected, the disclosure must be made to one of the following: member of or representative of a
committee of the U.S. Congress; an inspector general; the Government Accountability Office; a federal
employee responsible for contract oversight or management at the relevant agency; an authorized official
of the Department of Justice or other law enforcement agency; a court or grand jury; or a management
official or other employee of the UWHC or a subcontractor who has the responsibility to investigate,
discovery, or address misconduct. An employee who initiates or provides evidence of misconduct in any
judicial or administrative proceeding related to waste, fraud, or abuse on a federal contract is also deemed
to have made a protected disclosure.

An employee who believes he or she has been discharged, demoted, or otherwise discriminated against
for reporting information as described above may, within three years of the alleged discrimination, submit
a complaint to the Inspector General of the federal agency involved with the contract. The Inspector
General will generally perform an investigation and submit the report to the federal agency, which then
determines whether the alleged discrimination occurred and what, if any, remedies will be available to the
employee (including, but not limited to, reversing the reprisal; reinstating the employee with
compensatory damages, including back-pay and employment benefits; and paying costs incurred by the
employee in bringing the complaint). The employee or employer may challenge the agency’s decision in
court.

VI. MODIFICATIONS

This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made
for the purpose of inducing any person to become or remain an employee of UW Health and should not
be considered "promises" or as granting "property" rights. UW Health may add to, subtract from and/or
modify this Policy at any time. Nothing contained in this Policy impairs the right of an employee or
UW Health to terminate the employment relationship at-will.

VII. COORDINATION

Sr. Management Sponsor: VP Business Integrity, Chief Compliance Officer
Author: Professional Services Compliance Officer

Approval Committee: Professional Services Compliance Support Committee and UW Health
Administrative Policy and Procedure Committee

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer