The Deficit Reduction Act (DRA) of 2005, effective January 1, 2007, Section 6032 amended and codified at 42 USC § 1396(a)(68) requires any entities that receive or make annual payments under the Medicaid State plan of at least $5 million to have detailed, specific written policies established regarding the Federal and State False Claims Acts for their employees, agents and contractors. The Federal False Claims Act is found at 31 USC §§ 3729–3733 while the North Carolina False Claims Act can be found at General States (NCGS) §§ 1-695 through 1-609, provides for treble damages, costs and civil penalties for certain fraudulent acts.

For any provider that receives annual Medicaid payments of $5 million or more shall:

1. Written policies, procedures, and standards of conduct that articulate the organization’s commitment to comply with all applicable Federal and State standards. [42CFR§438.608]
2. The designation of a compliance officer and a compliance committee that are accountable to senior management. [42CFR§438.608]
3. Effective training and education for the compliance officer and the organization’s employees. [42CFR§438.608]
4. Effective lines of communication between the compliance officer and the organization’s employees. [42CFR§438.608]
5. Enforcement of standards through well-publicized disciplinary guidelines. [42CFR§438.608]
6. Provision for internal monitoring and auditing. [42CFR§438.608]
7. Provision for prompt response to detected offenses, and for development of corrective action initiatives. [42CFR§438.608]
8. Establish written policies for all employees (including management) that provide detailed information about the False Claims Act established under 31 USC Sections 3729 through 3733, administrative remedies for false claims and statements established under 31 USC Section 3801 through 3812, any State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs (as defined in 42 USC Section 1320a–7b(f));[ 42 USC Sec 1396(a)(68)]
9. include as part of such written policies, detailed provisions regarding the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse;); [ 42 USC Sec 1396(a)(68)]
10. include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph (A), the rights of employees to be protected as whistleblowers, and the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse); [ 42 USC Sec 1396(a)(68)]

On an annual basis, Providers that receives annual Medicaid payments of $5 million or more shall certify in writing that it meets the requirements outlined above. [Sec 1396(a)(68)]

Please click here for a copy of the annual certification/attestation statement. A copy of the completed annual certifications/attestation should be maintained by the compliance officer for inspection by Partners, other payers, NC DHHS and/or U.S. DHHS.

Partners will be including as part of its periodic provider monitoring checks to ensure that providers are meeting the requirements outlined above.