| Fraud, Waste & Abuse |
Comprehensive Systems, Inc.
Detecting & Preventing Medicaid Waste, Fraud, and Abuse
Federal and state laws prohibit waste, abuse, and fraud of Medicaid funds that
Comprehensive Systems, Inc. receives for services provision. These laws include the
2005 Deficit Reduction Act and False Claims Act (amended 1986). At Comprehensive
Systems, Inc. Medicaid funds are received for Intermediate Care Facility for the Mentally
Retarded (ICF/MR), Adult Rehabilitation Option or Remedial Services, and Home and
Community Based Waiver Services (HCBS).
Comprehensive Systems, Inc.(CSI) prohibits Medicaid waste, abuse, and fraudulent
practices. The leadership of CSI is aware of and fully committed to the organization
clearly establishing expectations regarding employee behavior, i.e. to act in a way that
always respects laws and regulations and in a manner that will protect the organizations’s
assets from fraud, waste, and abuse. The development and implementation of policies and
procedures and other corporate compliance measures will help ensure regular monitoring
and conformance with all legal and regulatory requirements.
Medicaid waste, abuse or fraud may include, but are not limited to, the following:
1. Billing for services that were never provided
2. False cost reports whereby inappropriate expenses not related to services provision
are intentionally included in cost reports
3. Illegal kickbacks, where a provider may conspire with another provider to share of
part of monetary reimbursement the provider receives in exchange for services referrals.
Such kickbacks cold include cash, vacation trips, automobiles or other items of value.
Any employee who suspects Medicaid waste, abuse or fraud should immediately report the
allegation to his/her supervisor or the Corporate Compliance Officer or a member of the
Compliance Committee. Or, a report can be made to the President of the Board of
Directors of Comprehensive Systems, Inc. For those not comfortable with reporting in
person, a written and anonymous Confidential Report of Concern may be completed. The
form can be found on the company website at www.comprehensivesystems.org. Click
on the Corporate Compliance link. Directions on how to proceed are on the website. An
internal investigation will be initiated immediately after a report is received. Appropriate
corrective actions will be taken as a result of the investigative findings, including self-
reporting to the Department of Human Services (DHS). Suitable disciplinary actions will
be implemented as a result of the internal investigation. All founded allegations related to
the investigation will be maintained in the corporate compliance officer’s confidential
records
Employees may report suspected Medicaid waste, abuse or fraud to:
1. Iowa Medicaid Director, Division of Medical Services, Department of Human
Services (DHS), 100 Army Post Road, Des Moines, Iowa 50315, phone number
515/725/1121, FAX number 515/725/1010 or
2. Iowa Medicaid Fraud Control Unit with the Department of Inspections an Appeals
(DIA), Lucas State Office Building, 3rd Floor, Des Moines, Iowa, 50319, phone number
515/281/6377, or FAX number 515/242/6507 or
3. Health and Human Services Office of Inspector General, phone number
1/800/hhs/tips, FAX number 1/800/223/8164, E-Mail hhstips@oig.hhs.gov, mailing
address: Office of Inspector General, Department of Health and Human Services, ATTN.:
hotline, 330 Independence Ave., SW, Washington, C 20201.
False Claims Act — “Whistleblower” protection – Non Retaliation
The False Claims Act contains language protecting “whistleblower employees,” who report
suspected Medicaid waste, abuse and fraud, from retaliation by their employer. Employers
that are discharged, demoted, suspended, threatened, harassed or in any way discriminated
against in the terms and conditions of employment by the employer for “blowing the
whistle” are entitled to recover all relief necessary to make the employee whole. Damages
available to the employee that proves retaliation include: reinstatement, two times back pay,
interest, emotional distress damages, costs, and attorney’s fees. Additionally, the
successful whistleblower may be eligible to recover 15% to 30% of the government’s
recovery from the fraudulent practice. The False Claims Act allows a private person to
file a lawsuit on behalf of the United State government against a person or business that
has committed the fraud.
Any employee who feels they are being retaliated against for reporting Medicaid waste,
abuse or fraud should immediately report this concern to the Corporate Compliance
Officer. Comprehensive Systems, Inc. will implement appropriate protective actions for
the employee. An internal investigation will be initiated immediately with suitable
corrective actions taken as a result of the investigative findings. Documentation related to
founded allegations will be maintained in the Corporate Compliance Officer’s confidential
records. (See Comprehensive Systems, Inc. Corporate Compliance Policy)
Comprehensive Systems, Inc. also monitors Medicaid documentation in order to detect
and prevent improper payments for Medicaid services.
Improper payments may include the following:
1. Payment for services when the service provision is not adequately documented. A
service that is not adequately documented should not be billed to Medicaid.
Comprehensive Systems, Inc. has implemented an audit process to monitor
documentation..
2. Medically unnecessary services due to lack of documentation in medical records to
support eligibility and need for services. Comprehensive Systems, Inc. Nursing, Accounts
Payable, and Admissions verify any medical procedures.
3. Incorrect coding when billing for services and/or using the wrong code for a
particular service. Comprehensive Systems, Inc. has implemented an audit process to
verify billing.
4. Non-covered costs or services that do not meet the state of Iowa’s reimbursement
rules and regulations. These are services that are not medically necessary.
5. Third party liability is where a private insurance company or another payer, was
the primary payer and Medicaid was billed instead. Comprehensive Systems, Inc.
Accounts Payable and Unit/Home Administrators are responsible for making sure the
appropriate entity is billed..
Any employee, who suspects improper Medicaid documentation, should immediately
report the allegations to the Corporate Compliance Officer. An internal investigation will
be initiated immediately with appropriate corrective actions taken as a result of the
investigative findings. All documentation for founded allegations will be maintained in the
Corporate Compliance Officer’s confidential records.
Any employee, who feels retaliation from having reported improper Medicaid
documentation, should immediately report this concern to his/her Supervisor, Program
Managers, Chief Operating Officer, or Chief Executive Officer. Comprehensive Systems,
Inc. will implement protective procedures as stated in the Corporate Compliance Program.
An internal investigation will be initiated immediately upon receipt with appropriate
corrective actions taken as a result of the investigative findings. All documentation for
founded allegations will be maintained in the Corporate Compliance Officer’s confidential
records.
Comprehensive Systems, Inc. has key mechanisms and procedures in place to detect and
prevent Medicaid waste, abuse, fraud, and improper documentation including:
1. Annual External Audit completed by an outside Certified Public Accountant (CPA)
for all Medicaid funded services.
2. An outside Certified Public Accountant completes all Medicaid prospective and
annual cost reports submitted to the Department of Human Services (DHS).
3. Medicaid service logs are reviewed each month by the Internal Auditor prior to
billing for services, ensuring documentation meets rules and regulations prior to billing for
services. Corrective actions are implemented as needed to improve the quality of Medicaid
documentation.
4. Initial and Annual Training is provided to all employees on detecting and preventing
Medicaid abuse, waste, and fraud including reporting procedures. A training video is in
the works and in-service calendars have been updated to include this training.
5. Each month, Quality Assurance staff completes random reviews of Medicaid
service logs from the CSI service areas. Reports are generated which include any
corrective actions needed to improve the quality of documentation.
It is well to note that filing a false report is a serious offense. Reporting is not intended for
petty gripes or to get another employee “in trouble.” Any employee, filing an intentionally
false or misleading report, would be subject to disciplinary action up to and including
termination.
Detecting & Preventing Medicaid Waste, Fraud, and Abuse
Federal and state laws prohibit waste, abuse, and fraud of Medicaid funds that
Comprehensive Systems, Inc. receives for services provision. These laws include the
2005 Deficit Reduction Act and False Claims Act (amended 1986). At Comprehensive
Systems, Inc. Medicaid funds are received for Intermediate Care Facility for the Mentally
Retarded (ICF/MR), Adult Rehabilitation Option or Remedial Services, and Home and
Community Based Waiver Services (HCBS).
Comprehensive Systems, Inc.(CSI) prohibits Medicaid waste, abuse, and fraudulent
practices. The leadership of CSI is aware of and fully committed to the organization
clearly establishing expectations regarding employee behavior, i.e. to act in a way that
always respects laws and regulations and in a manner that will protect the organizations’s
assets from fraud, waste, and abuse. The development and implementation of policies and
procedures and other corporate compliance measures will help ensure regular monitoring
and conformance with all legal and regulatory requirements.
Medicaid waste, abuse or fraud may include, but are not limited to, the following:
1. Billing for services that were never provided
2. False cost reports whereby inappropriate expenses not related to services provision
are intentionally included in cost reports
3. Illegal kickbacks, where a provider may conspire with another provider to share of
part of monetary reimbursement the provider receives in exchange for services referrals.
Such kickbacks cold include cash, vacation trips, automobiles or other items of value.
Any employee who suspects Medicaid waste, abuse or fraud should immediately report the
allegation to his/her supervisor or the Corporate Compliance Officer or a member of the
Compliance Committee. Or, a report can be made to the President of the Board of
Directors of Comprehensive Systems, Inc. For those not comfortable with reporting in
person, a written and anonymous Confidential Report of Concern may be completed. The
form can be found on the company website at www.comprehensivesystems.org. Click
on the Corporate Compliance link. Directions on how to proceed are on the website. An
internal investigation will be initiated immediately after a report is received. Appropriate
corrective actions will be taken as a result of the investigative findings, including self-
reporting to the Department of Human Services (DHS). Suitable disciplinary actions will
be implemented as a result of the internal investigation. All founded allegations related to
the investigation will be maintained in the corporate compliance officer’s confidential
records
Employees may report suspected Medicaid waste, abuse or fraud to:
1. Iowa Medicaid Director, Division of Medical Services, Department of Human
Services (DHS), 100 Army Post Road, Des Moines, Iowa 50315, phone number
515/725/1121, FAX number 515/725/1010 or
2. Iowa Medicaid Fraud Control Unit with the Department of Inspections an Appeals
(DIA), Lucas State Office Building, 3rd Floor, Des Moines, Iowa, 50319, phone number
515/281/6377, or FAX number 515/242/6507 or
3. Health and Human Services Office of Inspector General, phone number
1/800/hhs/tips, FAX number 1/800/223/8164, E-Mail hhstips@oig.hhs.gov, mailing
address: Office of Inspector General, Department of Health and Human Services, ATTN.:
hotline, 330 Independence Ave., SW, Washington, C 20201.
False Claims Act — “Whistleblower” protection – Non Retaliation
The False Claims Act contains language protecting “whistleblower employees,” who report
suspected Medicaid waste, abuse and fraud, from retaliation by their employer. Employers
that are discharged, demoted, suspended, threatened, harassed or in any way discriminated
against in the terms and conditions of employment by the employer for “blowing the
whistle” are entitled to recover all relief necessary to make the employee whole. Damages
available to the employee that proves retaliation include: reinstatement, two times back pay,
interest, emotional distress damages, costs, and attorney’s fees. Additionally, the
successful whistleblower may be eligible to recover 15% to 30% of the government’s
recovery from the fraudulent practice. The False Claims Act allows a private person to
file a lawsuit on behalf of the United State government against a person or business that
has committed the fraud.
Any employee who feels they are being retaliated against for reporting Medicaid waste,
abuse or fraud should immediately report this concern to the Corporate Compliance
Officer. Comprehensive Systems, Inc. will implement appropriate protective actions for
the employee. An internal investigation will be initiated immediately with suitable
corrective actions taken as a result of the investigative findings. Documentation related to
founded allegations will be maintained in the Corporate Compliance Officer’s confidential
records. (See Comprehensive Systems, Inc. Corporate Compliance Policy)
Comprehensive Systems, Inc. also monitors Medicaid documentation in order to detect
and prevent improper payments for Medicaid services.
Improper payments may include the following:
1. Payment for services when the service provision is not adequately documented. A
service that is not adequately documented should not be billed to Medicaid.
Comprehensive Systems, Inc. has implemented an audit process to monitor
documentation..
2. Medically unnecessary services due to lack of documentation in medical records to
support eligibility and need for services. Comprehensive Systems, Inc. Nursing, Accounts
Payable, and Admissions verify any medical procedures.
3. Incorrect coding when billing for services and/or using the wrong code for a
particular service. Comprehensive Systems, Inc. has implemented an audit process to
verify billing.
4. Non-covered costs or services that do not meet the state of Iowa’s reimbursement
rules and regulations. These are services that are not medically necessary.
5. Third party liability is where a private insurance company or another payer, was
the primary payer and Medicaid was billed instead. Comprehensive Systems, Inc.
Accounts Payable and Unit/Home Administrators are responsible for making sure the
appropriate entity is billed..
Any employee, who suspects improper Medicaid documentation, should immediately
report the allegations to the Corporate Compliance Officer. An internal investigation will
be initiated immediately with appropriate corrective actions taken as a result of the
investigative findings. All documentation for founded allegations will be maintained in the
Corporate Compliance Officer’s confidential records.
Any employee, who feels retaliation from having reported improper Medicaid
documentation, should immediately report this concern to his/her Supervisor, Program
Managers, Chief Operating Officer, or Chief Executive Officer. Comprehensive Systems,
Inc. will implement protective procedures as stated in the Corporate Compliance Program.
An internal investigation will be initiated immediately upon receipt with appropriate
corrective actions taken as a result of the investigative findings. All documentation for
founded allegations will be maintained in the Corporate Compliance Officer’s confidential
records.
Comprehensive Systems, Inc. has key mechanisms and procedures in place to detect and
prevent Medicaid waste, abuse, fraud, and improper documentation including:
1. Annual External Audit completed by an outside Certified Public Accountant (CPA)
for all Medicaid funded services.
2. An outside Certified Public Accountant completes all Medicaid prospective and
annual cost reports submitted to the Department of Human Services (DHS).
3. Medicaid service logs are reviewed each month by the Internal Auditor prior to
billing for services, ensuring documentation meets rules and regulations prior to billing for
services. Corrective actions are implemented as needed to improve the quality of Medicaid
documentation.
4. Initial and Annual Training is provided to all employees on detecting and preventing
Medicaid abuse, waste, and fraud including reporting procedures. A training video is in
the works and in-service calendars have been updated to include this training.
5. Each month, Quality Assurance staff completes random reviews of Medicaid
service logs from the CSI service areas. Reports are generated which include any
corrective actions needed to improve the quality of documentation.
It is well to note that filing a false report is a serious offense. Reporting is not intended for
petty gripes or to get another employee “in trouble.” Any employee, filing an intentionally
false or misleading report, would be subject to disciplinary action up to and including
termination.
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