CCSEMA_2-color.png

Compliance & Legal

Connected Care of Southeastern Massachusetts, an Accountable Care Organization (“ACO”) is committed to behaving and doing business honestly, responsibly and in accordance with laws and regulations. Below is an overview of several of the key laws that govern the relationship between Connected Care, ACO Participants, Vendors, Clinicians and Patients.

 

For more information, please view the Connected Care of Southeastern Massachusetts Code of Ethics.

 

False Claims Act (FCA)

The False Claims Act (FCA) is a federal law that makes it a civil and/or criminal offense to knowingly submit a false claim to the U.S Government for payment.  The FCA requires submission of truthful and complete information to payers, submission of claims that are medically necessary and performed by qualified personnel, and return of any identified government payments received in error.

 

Reverse False Claims is a section of the FCA that makes providers liable when overpayments are knowingly received and concealed to avoid refunding the government. Providers are required to report and make a refund within 60 days of identifying the overpayment.

 

Connected Care maintains a policy related to false claims. The policy explains the federal False Claims Act, the Federal Program Fraud Civil Remedies Act and the Massachusetts False Claims Law; provides general information regarding Connected Care’s efforts to combat fraud, waste, and abuse; and describes the remedies and fines for violations that can result from certain types of fraudulent activities. If you have any questions about FCA or would like a copy of the full policy, please contact the Compliance Office at 781-624-2190.

 

Deficit Reduction Act

The Deficit Reduction Act (“DRA”) is a federal requirement for health care entities receiving or making $5 million or more in Medicaid payments during a year to establish written policies and procedures informing employees about the False Claims Act and whistleblower protections. Whistleblower protections extend to any person who lawfully attempts to stop any FCA violations or reports information about false claims or suspected false claims that are submitted by others.  They may not be retaliated against, demoted, suspended, threatened, or harassed for such actions. The FCA also protects individuals who provide assistance with an investigation, provide testimony, or participate in the government’s handling of a false claim.

 

Other requirements include policies describing prevention of fraud, waste and abuse, training and protection of employees who make good faith reports. Massachusetts Medicaid requires annual attestation of compliance. Failure to comply with the DRA requirements may include exclusion from the federal health program.

 

OIG Exclusions from State/Federal Programs

OIG has the authority to exclude individuals and entities from Federally funded health care programs pursuant to section 1128 of the Social Security Act (Act), and from Medicare and State health care programs under section 1156 of the Act, and maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals/Entities (LEIE). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP).

 

These exclusion checks must be done upon hiring or contracting with an individual for services and monthly thereafter. Exclusion checks must be conducted on: employees, contractors, volunteers, students, medical staff, vendors, board members, researchers and referring/ordering physicians.  

 

Anti‐Kickback Statute (AKS)

The Anti-Kickback Statute (AKS) is a federal regulation that states that no one may offer, give, request or receive money, or anything else of value, in exchange for a patient referral or for other health care business paid for by a federal health care program. The Federal Anti-Kickback Statute prohibits the acceptance of any item of value (remuneration) made directly or indirectly, in cash or kind, that may induce, or appear to induce the purchase or referral of any kind of health care goods, services, or items reimbursed by a federal or state health care program, including Medicare and Medicaid.  Massachusetts also prohibits certain gifts and business courtesies to Health Care Practitioners from pharmaceutical and medical device manufacturer vendors.  Penalties may include fines up to $50,000 for each improper act and damages up to three (3) times the amount of remuneration. A violation may also lead to the entity or individuals exclusion from the Medicare and other Federal health care programs.

 

Connected Care is committed to ensuring that all decisions regarding selection of Vendors are made fairly and in the best interest of the organization, free from actual or perceived personal bias. It is the policy of Connected Care and its entities that interactions with industry should be conducted so as to avoid or minimize conflicts of interest and/or the appearance of conflicts of interest.  Under no circumstances may Connected Care personnel offer or receive a gift from a vendor when the intent is to generate health care business. If you have any questions about AKS please contact the Compliance Office at 781-624-2190.

 

Anti‐Inducement Law

The Anti‐Inducement Law is a federal law that states that no one may give money or anything else or value, to a government payer beneficiary to influence his or her choice of a provider for which services or items are paid for by a federal health care program. There are specific exceptions such as incentives to promote certain preventative care (e.g., prenatal care, blood pressure screenings, etc.) and items of nominal value (defined as under $10, not to exceed $50 annually). If you have any questions about the Anti-Inducement Law and how it might relate to your interactions with Connected Care, please contact the Compliance Office at (781) 624-2190. 

 

The Stark Law is a federal law that limits referrals where physicians have certain financial interests. Specifically, if a physician or his/her immediate family member has a financial relationship with another health care provider, the physician may not refer Medicare patients to that provider for certain services (unless an exception applies).  There are specific exceptions such as written employment or personal services agreements and written rental agreements if they meet certain criteria.

 

Connected Care protects against potential violations of the Stark Law through the Conflict of Interest Process.  This process was developed to provide guidance if there are any potential conflicts of interest.  

 

Connected Care Practitioners, as well as all Connected Care leaders, must take official actions in good faith, in the best interest of the organization, and free from influence by their own or their family’s personal interests.  This becomes particularly important for vendors that may have financial arrangements with physicians who refer or order services to a Connected Care Practitioner.

View List