Policy and Standards - Magellan Provider

1 FALSE CLAIMS LAWS AND WHISTLEBLOWER PROTECTIONS Page 1 of 23 PROPRIETARY Magellan health policies apply to all subsidiaries and affiliates, including but not limited to Magellan Healthcare, Magellan Complete Care, Magellan Healthcare Provider Group, National Imaging Associates, HealthPeaks MD, Magellan Rx Pharmacy, Magellan Medicaid Administration, AlphaCare of New York, Magellan Method (formerly CDMI), Magellan Rx Management, Magellan Administrative Services and Merit health Insurance Company d/b/a/ Magellan Rx Medicare, as indicated in the Business Division and Entity Applicability section of this Policy . Policy and Standards Product Applicability: (For health Insurance Marketplaces, policies and procedures are the same, unless contractual requirements dictate a more stringent variation in which case customized documents are created.)

2 Commercial Medicaid Medicare Part: C (Medicare Advantage) Medicare Part DFederal(not Medicaid or Medicare) Business Division and Entity Applicability: Magellan Healthcare Magellan Healthcare [Behavioral](B) Magellan Complete Care(C) MCC Florida (CFL) MCC Virginia (CVA) MCC The Management Group (CTMG) Magellan Healthcare Provider Group(G) Alpha Care of New York(L) National Imaging Associates(N) HealthPeaksMD(P) Magellan Rx Management Magellan Rx Pharmacy(I) Magellan Medicaid Magellan Method (formerly CDMI)(D) Magellan Rx Management(R) Magellan Administrative Services(O) Magellan Rx Medicare (K)Corporate Policy : Policy Number: C(FL,VA,TMG) G L N P I A D R O K Policy Name: False Claims Laws and Whistleblower Protections Date of Inception: January 01, 2007 Previous Annual Review Date: July 19, 2016 Current Annual Review Date: August 08, 2017 Review Type: New Policy No Changes Non substantive Substantive (material changes or initial documentation of current Previous Corporate Approval Date: July 28, 2016 Current Corporate Approval Date: August 18, 2017 Unit Effective Date: September 18, 2017 Corporate Policy Approvals: John J.)

3 DiBernardi, Jr., Esq. Approval on file August 17, 2017 Magellan health , Senior Vice President & Corporate ComplianceOfficerDateDan Gregoire, Esq. Approval on file August 18, 2017 Magellan health , Executive Vice President, General CounselDate FALSE CLAIMS LAWS AND WHISTLEBLOWER PROTECTIONS Page 2 of 23 PROPRIETARY Magellan health policies apply to all subsidiaries and affiliates, including but not limited to Magellan Healthcare, Magellan Complete Care, Magellan Healthcare Provider Group, National Imaging Associates, HealthPeaks MD, Magellan Rx Pharmacy, Magellan Medicaid Administration, AlphaCare of New York, Magellan Method (formerly CDMI), Magellan Rx Management, Magellan Administrative Services and Merit health Insurance Company d/b/a/ Magellan Rx Medicare, as indicated in the Business Division and Entity Applicability section of this Policy .

4 Cross Reference(s) Medicaid Compliance Program; Medicare Compliance Program; Magellan Compliance Program for Non-Government Funded Programs Policy Statement Magellan health , its subsidiaries and affiliates, ( Magellan ) is subject to both federal and state laws designed to prevent fraud and abuse in government programs including Medicare and Medicaid and in federally funded contracts. Magellan , in conjunction with the appropriate government agencies, actively pursues all suspected fraud and abuse. As part of Magellan s corporate compliance program for the prevention of fraud, waste and abuse, Magellan complies with all state and federal requirements for government-sponsored programs and federally funded contracts, including the Federal False Claims Act, the Deficit Reduction Act of 2005, the American Recovery and Reinvestment Act of 2009, the Patient Protection and Affordable Care Act (PPACA) of March 2010, applicable Whistleblower Protection laws, and any state false claims statutes.

5 Purpose To identify the requirements of the Federal False Claims Act, the administrative remedies for false claims and statements and any applicable state laws pertaining to civil or criminal penalties for false claims and statements, including the remedies and whistleblower protections under these laws. Scope Account Management Claims (Service Ops)Clinical Operations Compliance Corporate Physical SecurityCredentialing/Re credEAP Federal and State AffairsFinance Human Resources Information Systems SecurityInformation Technology Legal Marketing/Comm/SalesNetwork Operations (Member Services)Quality Improvement Special Investigations UnitKey Terms (as used in this Policy ) None Policy Terms & Definitions are available should the reader need to inquire as to the definition of a term used in this Policy .

6 To access the Policy Terms & Definitions Glossary in MagNet, click on the below link: (internal link(s) available to Magellan health employees only) Policy Terms & Definitions Glossary Standards I. Employees, contractors and providers are notified that they are required to report any suspected cases of fraud, waste, abuse, and overpayments to Magellan . FALSE CLAIMS LAWS AND WHISTLEBLOWER PROTECTIONS Page 3 of 23 PROPRIETARY Magellan health policies apply to all subsidiaries and affiliates, including but not limited to Magellan Healthcare, Magellan Complete Care, Magellan Healthcare Provider Group, National Imaging Associates, HealthPeaks MD, Magellan Rx Pharmacy, Magellan Medicaid Administration, AlphaCare of New York, Magellan Method (formerly CDMI), Magellan Rx Management, Magellan Administrative Services and Merit health Insurance Company d/b/a/ Magellan Rx Medicare, as indicated in the Business Division and Entity Applicability section of this Policy .

7 A. Information about the applicable federal and state laws regarding fraud, waste, abuse, overpayments and whistleblower protections are provided in this Policy . Information about whistleblower protections available under other laws is also available at: B. Information about these laws in terms of the procedures, controls and policies implemented by Magellan to ensure compliance are covered in the Medicaid Compliance Program Policy , Employee Code of Conduct Handbook as well as during the annual Code of Conduct Training, and Fraud, Waste and Abuse Training (Fraud Identification and Recognition Education) which includes information that is consistent with section 6032 of the federal Deficit Reduction Act (DRA) of 2005 such as information about: 1.

8 The False Claims Act; 2. Penalties for submitting false claims & statements; 3. The DRA s role in preventing and detecting fraud, waste and abuse;, 4. Each person s responsibility relating to detection and prevention; 5. The toll-free state telephone numbers for reporting fraud, waste, abuse, overpayments; and 6. Applicable federal and state whistleblower protections. C. For more information about how to report fraud, waste, and/or abuse including overpayments see the Magellan health website for Magellan s DRA Compliance Statement and link to the State False claim Acts for state-by-state information about how to report fraud, waste, and/or abuse including overpayments. II. Federal False Claims Act, 31 USC 3729 A.

9 The Federal False Claims Act is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare and Medicaid programs. B. The act establishes liability for any person who: 1. Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval; 2. Knowingly makes, uses or causes to be made or used a false record or statement material to a false or fraudulent claim ; 3. Conspires to commit a violation of any of the provisions of the False Claims Act as outlined under Standard : 1., 2., 4., 5., 6., or 7. in this Policy . 4. Has possession, custody, or control of property or money used, or to be used, by the Government and knowingly delivers, or causes to be delivered, less than all of that money or property; 5.

10 Is authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and, intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the receipt is true; 6. Knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the Government, or a member of the Armed Forces, who lawfully may not sell or pledge the property; or 7. Knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government, or FALSE CLAIMS LAWS AND WHISTLEBLOWER PROTECTIONS Page 4 of 23 PROPRIETARY Magellan health policies apply to all subsidiaries and affiliates, including but not limited to Magellan Healthcare, Magellan Complete Care, Magellan Healthcare Provider Group, National Imaging Associates, HealthPeaks MD, Magellan Rx Pharmacy, Magellan Medicaid Administration, AlphaCare of New York, Magellan Method (formerly CDMI)