TennCare requires its providers and affiliates to abide by federal and state law and regulations governing the administration/operations of managed care organizations (MCOs) within the health care program.
This includes compliance with the federal False Claims Act (Deficit Reduction Act 6032) that establishes liability for the following activities:
If there is a violation of the False Claims Act, the federal government may impose penalties of not less than $10,781 and not more than $21,563 plus three times the amount of damages sustained by the government. The government may reduce the damages if the person committing the violation reports it within 30 days of discovering the violation; the person cooperates fully with the federal government’s investigation; and there are no criminal prosecutions, civil actions or administrative actions commenced at the time of the report – The person reporting cannot have any knowledge of such investigations.
The federal government via the Department of Health and Human Services Office of the Inspector General (OIG) may also utilize administrative remedies for the submission of false statements and/or claims, which include administrative penalties of not more than $5,000 per false claim – The government may determine whether suspension or debarment from the health care program is warranted.
The government or an individual may bring a civil action for a violation of the applicable False Claims Act. If a person brings an action on behalf of the government, then that person may be entitled to a portion of any recovery under the applicable False Claims Act. The recovery is governed by the person’s involvement in the claim and/or litigation as well as whether the government intervened in the litigation.
Protections against retaliation exist under federal and state law for anyone providing a good faith report:
Tennessee Medicaid False Claims Act
In addition, TennCare also requires its providers and affiliates to abide by state law and regulation governing the administration/operation of MCOs within the health care program. This includes compliance with the Tennessee Medicaid False Claims Act (TCA § 71-5-181 and what follows} establishing liability for the following activities:
The state may impose three times the amount of damages sustained by the government if there is a violation of the Medicaid False Claims Act. In Tennessee, the state may impose a civil penalty between $5,000-$25,000. Any suspected fraud and/or abuse may be reported to the following: