Fraud, Waste and Abuse Policy

SUD Specialty Group – CA, Mental Health Specialty Group, P.A., Mental Health Specialty Group NJ, PC, and Mental Health Specialty Group KS, P.A. (collectively, “Group”) contracts with Path, CCM, Inc. d/b/a Rula (“Rula”) for management and administrative support services. Each entity within the Group and Rula may be referenced herein collectively as Company.

I. APPLICABILITY

This policy applies to all team members. For purposes of this policy, the Group’s and Rula’s team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula or the Group’s business practices.

II. PURPOSE

The purpose of this policy is to provide team members with information regarding the prevention, detection, and reporting of fraud and abuse, and general information regarding applicable laws related to fraud and abuse.  

III. POLICY STATEMENT

Company is committed to complying with all applicable federal and state laws concerning fraud, waste, and abuse. Company may not engage in any activity that violates applicable federal or state laws or is otherwise non-compliant with Company’s policies, including without limitation providing or accepting illegal remuneration in exchange for referrals of patients. All team members are responsible for helping ensure full compliance with federal and state laws regarding the prevention, detection, and reporting of fraud and abuse. Team members are encouraged to report or raise questions regarding any potential or suspected violations of the applicable fraud and abuse laws or Company policy. Company prohibits any retaliatory action against an individual who reports, in good faith, potential or suspected violations relating to fraud and abuse. 

IV. RELEVANT FRAUD AND ABUSE LAWS

1. Anti-Kickback Statute

The Anti-Kickback Statute (“AKS”) is a federal law that makes it a criminal offense for anyone to knowingly and willfully offer, pay, solicit, or receive any remuneration, directly or indirectly, overtly or covertly, in cash or in kind, in return for or to induce (1) patient referrals, or (2) the purchasing, leasing, or ordering of, or arranging for or recommending purchasing, leasing, or ordering of, items or services, for which payment may be made in whole or in part by any federal or state healthcare program (e.g., Medicare, Medicaid, TRICARE). 

“Remuneration” is anything of value and can include discounts, rebates, grants, vouchers, cash, gifts, services, coupons, lottery tickets, trips, or the opportunity to generate business. Remuneration may be considered unlawful under the AKS if even one purpose of the remuneration is to induce referrals for federally reimbursable items or services.

There are a number of “safe harbors” under the AKS, which specify certain arrangements that will not be subject to prosecution. The fact that an arrangement does not fit within a safe harbor does not necessarily mean that the AKS has been violated or that the government will undertake an enforcement action. If an arrangement does not satisfy a safe harbor, the government will evaluate the totality of the facts and circumstances surrounding the arrangement to determine if it creates risk under the AKS. 

Violation of the AKS constitutes a felony and may be punishable by fines, imprisonment, or both, and violators are subject to exclusion from the federal healthcare programs. A claim that includes items or services resulting from a violation of the AKS can also constitute a false claim under the federal False Claims Act.

2. Federal Beneficiary Inducements CMP

Federal law provides for the imposition of civil monetary penalties against any person who offers or transfers remuneration to a Medicare or state healthcare program beneficiary that the person knows or should know is likely to influence the beneficiary’s selection of a particular provider for the order or receipt of any item or service for which payment may be made, in whole or in part, by Medicare or a state healthcare program. Violations may result in substantial civil penalties.  

This law, referred to as the Beneficiary Inducements CMP, defines “remuneration” broadly but includes certain exceptions, including for the waiver or coinsurance and deductible amounts under certain circumstances, incentives given to individuals to promote the delivery of preventive care, remuneration that promotes access to care and poses a low risk of harm to patients and federal healthcare programs, and items or services of nominal value. 

3. Federal False Claims Act 

The federal False Claims Act imposes liability on a person or entity that, among other things, knowingly presents, or causes to be presented, a false or fraudulent claim for payment by the government. The government may use the False Claims Act to prosecute fraud in areas such as billing for services not provided, billing for services not medically necessary, duplicate billing, and falsifying treatment plans or medical records to maximize payment.   

When an entity is determined to have violated the False Claims Act, it may be required to pay up to three times the actual damages sustained by the government, plus substantial civil penalties for each false claim submitted. The False Claims Act also allows private parties to bring an action on behalf of the government. These individuals are known as whistleblowers or qui tam relators, and they may be entitled to a share of any damages awarded to the government. 

The False Claims Act defines the term “knowingly” broadly. Although simple negligence will not give rise to liability under the False Claims Act, the statute may be implicated if a person or entity has actual knowledge that the claim is false, or if they act in reckless disregard or deliberate ignorance of the truth or falsity of information. 

4. State Fraud and Abuse Laws

Many states have adopted statutes that address similar conduct as the federal fraud and abuse laws. These state laws vary considerably. They are often broad in scope, and they may apply regardless of the payor for the healthcare services provided (i.e., in some cases, these laws may be applicable to commercial insurance plans and self-pay patients, not just governmental payors). 

V. PROCEDURES

A. Compliance and Training 

All individuals are required to comply with applicable federal and state fraud and abuse laws and must complete required Company training on these laws. Training must be completed upon hire and annually for all individuals who are working with, directly or indirectly, government programs.

B. Sanctions and Exclusion Monitoring

Company monitors all employees, board members, and providers to ensure they are not present on exclusions and sanctions lists (OIG, SAM, State Medicaid Lists). Company initiates these checks upon starting and monthly thereafter.

C. Reporting Potential or Suspected Violations 

1. Team members who report a known or suspected violation of law or Company policy in good faith are not at risk for retribution or retaliation. Anyone who deliberately makes a false report with the intention of harming or retaliating against a colleague, however, will be subject to disciplinary action.  Notwithstanding the foregoing, individuals who report their own misconduct may be subject to disciplinary action for such misconduct. Such self-reporting, and subsequent cooperation, will be taken into account in determining appropriate disciplinary action.  

2. All individuals are required to report violations, suspected violations, questionable conduct, or questionable practices of which they become aware. Personnel may ask questions or make reports in the following ways:

1. Report to a Supervisor. Team members may contact their immediate supervisor to raise any compliance question or concern or to report any suspected or known violations of the applicable fraud and abuse law(s) or related policies and procedures. The supervisor will respond promptly and, if appropriate, refer the question or concern to upper management, including the Compliance Officer. 

2. Report to Upper Management. Team members may contact higher levels of management, including the Compliance Officer, to raise any compliance question or concern or to report any suspected or known violations of the applicable fraud and abuse law(s), or related policies and procedures. 

Report to the Compliance Hotline. Team members may report compliance concerns or suspected or known violations of applicable fraud and abuse laws or related policies and procedures to the compliance hotline at rulaFWA.ethicspoint.com. To the maximum extent possible, Company will maintain the confidentiality of individuals making reports to the compliance hotline and/or participating in the investigation of alleged violations. 

D. Response to Reported Violations

If Company determines that a reported violation did, in fact, occur, Company will take appropriate corrective action. When appropriate, any monies associated with confirmed overpayments will be returned and the appropriate governmental agency notified. Prompt corrective action will be taken to help prevent similar occurrences.

VI. QUESTIONS

Should you have any questions, comments, or concerns about this policy, we encourage you to raise them with your manager or with our compliance team. If you have questions regarding a proposed commercial activity, please contact the legal department at legal@rula.com. 

The Company reserves the right to change this policy without notice.