2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and Abuse1 false claim = $11,000 penaltyTreble damages = 3 × $100 or $300This now equals $11,300 in fines for the $100claim. Add to that any trial costs and thepotential to be excluded from participating inany government health plan.New Mexico False Claims Act (Dual Eligible)Effective May 2004, the act provides forCivil action against the filing of false claimsunder the New Mexico Medicaid programPenalties for three times the amount ofdamages the state sustains as a result of theactProtection rights to an employee whodiscloses information to the New MexicoHuman Services Department (HSD)The NM Medicaid False Claims Act (NMMFCA)signed into law in 2004 is applicable to Medicarebeneficiaries who are also covered under thestate’s Medicaid program (dual eligible). Thepurpose of NMMFCA is to deter persons fromcausing or assisting to cause the state to payMedicaid claims that are false. It provides remediesfor obtaining treble damages and civil recoveries forthe state.The NMMFCA increases the state’s ability to bringa lawsuit for Medicaid fraud and recoup funds. NewMexico’s Attorney General prosecutes Medicaidfraud.The NMMFCA contains a whistleblower provisionthat provides incentives for people who comeforward with knowledge and evidence of falseclaims submitted to Medicaid. Whistleblowers mayreceive up to 25% of the amount recovered.Employee whistleblowers are entitled to all reliefnecessary, including reinstatement, double theamount of back pay, and compensation for anyspecial damages sustained.New Mexico Fraud Against Taxpayers ActThe New Mexico Fraud Against Taxpayers Act waspassed by the New Mexico legislature effectiveJuly 1, 2007. It provides for private civil action onbehalf of the state against a person who makes afalse claim for payment and provides for civil actionby a state agency and state intervention. It alsoprovides for qui tam (whistleblower awards) andprohibits retaliation by employers.Whistleblower ActsIn whistleblower lawsuits (qui tam)An employee or private citizen sues on behalfof the governmentThe plaintiff receives as much as 30% of thetotal award and the remainder goes to thegovernmentHow Whistleblowers are ProtectedEmployers may not retaliate againstemployees who report or help investigatefalse claims.No negative employment consequences areallowed, such as firing, demoting, suspending,or harassing.Remedies against retaliation include jobreinstatement with double back pay and otherspecial damages.15-82014 Practitioner and Provider Manual - Ver. 3