Understanding Fraud, Waste, and Abuse
Summit Home Health Care is committed to preventing, detecting, and correcting fraud, waste, and abuse in connection with all health care programs, including Medicaid and Medicare. We expect every person associated with our organization to understand what these terms mean and how to report concerns.
What Are Fraud, Waste, and Abuse?
Fraud is the intentional misrepresentation or deception made by a person or entity with the knowledge that it could result in an unauthorized benefit to themselves, to the organization, or to another person. Examples include billing for services not provided, misrepresenting diagnoses to justify payment, and falsifying records or credentials.
Waste involves the overuse or misuse of resources that results in unnecessary costs to health care programs. Waste may not involve intentional misconduct, but reflects careless or inefficient practices, such as ordering excessive tests, providing services beyond what is medically necessary, or failing to follow cost-effective procedures.
Abuse describes practices that are inconsistent with sound medical, business, or fiscal standards and that result in unnecessary costs, improper payment, or services that do not meet professionally recognized standards of care. Unlike fraud, abuse may not involve intentional misrepresentation, but it still causes harm to the health care system and the people it serves.
The Federal False Claims Act (31 USC §§ 3729–3733)
The Federal False Claims Act is a federal law that imposes liability on any person or entity that knowingly submits, or causes the submission of, a false or fraudulent claim to the federal government for payment. The law covers claims submitted to programs such as Medicare and Medicaid.
Under the False Claims Act:
- Violations can result in significant civil penalties per false claim (adjusted annually for inflation), plus up to three times the amount of damages sustained by the government.
- “Knowing” includes actual knowledge, deliberate ignorance, and reckless disregard of the truth.
- Persons or entities found in violation may also be excluded from participation in Medicare and Medicaid programs.
Whistleblower (Qui Tam) Protections: The False Claims Act allows private citizens to file lawsuits on behalf of the government against entities that have defrauded federal programs. These individuals, known as “whistleblowers” or “relators,” are protected against retaliation by their employers and may be entitled to a share of any recovery.
New York State False Claims Act (State Finance Law §§ 187–194)
New York State has its own False Claims Act that mirrors the federal law and applies to claims submitted to state-funded programs, including Medicaid. Under the NYS False Claims Act:
- Violations can result in civil penalties of up to three times the amount of the false claim, or $6,000 to $12,000 per claim, whichever is greater.
- The law also includes qui tam provisions allowing private individuals to bring actions on behalf of the state.
- Retaliation against employees who report violations or participate in investigations is prohibited.
New York Social Services Law § 145-b and § 366-b
New York State law makes it unlawful to knowingly make a false statement or representation to obtain or attempt to obtain payment from the Medicaid program. Violations may result in civil penalties and criminal prosecution.
How to Report Suspected Fraud, Waste, or Abuse
If you are aware of or suspect any activity involving fraud, waste, or abuse, you are encouraged, and in many cases required, to report it. You may report concerns through any of the following channels:
Internal Reporting:
- Compliance Officer: Arthur Hagler
- Phone: 917-398-0529
- Email: [email protected]
- Hotline: 917-444-7701
External Reporting:
- NYS OMIG: 1-877-87-FRAUD (1-877-873-7283) or online at omig.ny.gov
- HHS Office of Inspector General: 1-800-HHS-TIPS (1-800-447-8477) or online at oig.hhs.gov
- NYS Medicaid Fraud Control Unit (MFCU): 212-417-5397
Protections for Those Who Report
Summit Home Health Care prohibits intimidation, retaliation, or any adverse action against anyone who reports a compliance concern in good faith, whether through internal channels or to a government agency. Both federal and New York State law provide additional whistleblower protections for individuals who report suspected fraud.
Reporting a concern, even if the concern turns out to be unfounded, is the right thing to do, and we will always support those who come forward in good faith.
Learn More
For more information about Summit Home Health Care’s compliance program, please visit our [Corporate Compliance page](/corporate-compliance) or contact Arthur Hagler at [email protected] or 917-398-0529.