[PROVIDER] is committed to prompt, complete, and accurate billing of all services provided to residents for payment by residents, government agencies, or other third-party payors. Billing shall be made only for services actually provided, directly or under contract, pursuant to all terms and conditions specified by the government or third-party payor and consistent with industry practice.
[Provider] and its employees shall not make or submit any false or misleading entries on any bills or claim forms, and no employee shall engage in any arrangement, or participate in such an arrangement at the direction of another employee (including any officer of [Provider] or a supervisor), that results in such prohibited acts. Any false statement on any bill or claim form shall subject the employee to disciplinary action by [Provider], including possible termination of employment.
Providers may wish to include the following suggested elements in their corporate compliance policy:
Prohibited Billing Practices: False claims and billing fraud may take a variety of different forms, including, but not limited to, false statements supporting claims for payment, misrepresentation of material facts, concealment of material facts, or theft of benefits of payments from the party entitled to receive them. [Provider] and employees shall specifically refrain from engaging in the following billing practices:
Make claims for items or services not rendered or not provided as claimed (such as billing for three hours of therapy when only a few minutes were provided);
Submit claims to Medicare Part A for residents who are not eligible for Part A coverage, in other words, who do not require services that are so complex that they can only be effectively and efficiently provided by; or under the supervision of, professional or technical personnel;
Submit claims to any payor, including Medicare, for services or supplies that are not medically necessary or that were not ordered by the resident’s physician or other authorized caregiver;
Submit claims for items or services that are not provided as claimed, such as billing Medicare for expensive prosthetic devices when only non-covered adult diapers were provided;
Submit claims to any payor, including Medicare and Medicaid, for individual items or services when such items or services either are included in the health facility’s per diem rate for a resident or are of the type that may be billed only as a unit and not unbundled;
Double bill (billing for the same time or service more than once);
Provide inaccurate or misleading information for use in determining the Resource Utilization Groups, version III (RUG-III) or other resident, payment or acuity classification scale score or ranking assigned to the resident, including but not limited to misrepresenting a resident’s medical condition on the minimum data set (MDS);
Pay or receive anything of financial benefit in exchange for Medicare or Medicaid referrals (such as receiving non-covered medical products at no charge in exchange for ordering Medicare-reimbursed products); or
Bill residents for services or supplies that are included in the per-diem payment from Medicare, Medicaid, a managed care plan, or other payor.
Reporting False Billing Practices: If an employee has any reason to believe that anyone (including the employee himself or herself) is engaging in false billing practices, that employee shall immediately report the practice to his or her immediate supervisor, the [COMPLIANCE HOTLINE, ANONYMOUS DROP BOX, POST OFFICE BOX, ETC.], or the compliance officer or any of the officers designated to receive such report verbally or in writing.
Failure to act when an employee has knowledge that someone is engaged in false billing practices shall be considered a breach of that employee’s responsibilities and shall subject the employee to disciplinary action by [PROVIDER], including possible termination of employment.