2016-698 Emergency Svc - North State Medical Transport - Application for Services Franchise by Ordinance

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Under the Program Fraud Civil Remedies Act, federal law also provides for administrative remedies against providers for false claims and statements, in the amount of$5,000 for each false claim or statement, and an assessment of up to twice the amount of such claim. These administrative civil remedies are described further in the Program Fraud Civil Remedies Act, 31 U.S.C. Sections 3801-3812. A "false claim" (for purposes of the administrative remedies) is defined as a claim that the person knows or has reason to know(i) is false or fraudulent, (ii) includes or is supported by any written statement which asserts a material fact which is false, (iii) includes or is supported by any written statement that omits a material fact, is false as a result of such omission, and is a statement in which the person making such statement has a duty to include such material fact, or (iv) is for payment for the provision of property or services which the person has not provided as claimed. A "false statement" is defined as a statement that the person knows or has reason to know asserts a material fact that is false or omits a material fact that makes the statement false. IV. STATE FALSE CLAIMS ACTS North Carolina also has a state false claims act that prohibits anyone from knowingly presenting, or causing to be presented, a false or fraudulent claim in order to secure payment from local and/or state government. North Carolina's false claims act is similar to the federal FCA and provide for lawsuits either by the government or a qui tam plaintiff(or "relator"). This law also includes whistleblower protection similar to the federal FCA. V. HIPAA ACT OF 1996 and HITEC ACT OF 2009 HIPAA includes three provisions pertinent to NSMT's Compliance program. These are summarized below: A. Beneficiary Inducements HIPAA specifically created a new provision which authorizes the imposition of civil money penalties for offering inducements to individuals eligible for Medicare or Medicaid if the offer or knows or should know that it will influence the patient to order or receive items or services from a particular provider, practitioner or supplier. Significantly, the statute defines remuneration as including the waiver of coinsurance and deductibles and transfers of items or services for free or for other than fair market value. However, there are limited exceptions provided in the statute. For instance coinsurance waivers that are based on financial need and meet other requirements are protected. There also are exceptions for incentives given to individuals to promote the delivery of preventive care as determined by HHS in regulations and gifts to beneficiaries of nominal value. B. HIPAA specifically makes it unlawful to "knowingly and willfully" embezzle, steal, intentionally misapply, or "otherwise without authority" convert any of the money, property, premiums, or other assets of a"health care benefit program" to the use of any person other than the rightful owner. HIPAA defines "health care benefit program" as "any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual. , ." HIPAA therefore makes it unlawful to engage in this conduct with respect to private health plans. C. HIPAA established certain requirements regarding the submission of electronic claims and the privacy and security of protected health information. Those requirements are set forth in NSMT's HIPAA policies and procedure 21