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Virginia Administrative Code
Title 12. Health
Agency 30. Department Of Medical Assistance Services
Chapter 10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions
1/24/2022

12VAC30-10-820. Employee education about false claims recoveries.

12VAC30-10-820. Employee education about false claims recoveries.

A. Definitions. The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:

"Contractor" or "agent" includes any contractor, subcontractor, agent, or other person that or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, Medicaid health care items or services, performs billing or coding functions, or is involved in the monitoring of health care provided by the entity.

"Employee" means any officer or employee of the entity.

"Entity" means a governmental agency, organization, unit, corporation, partnership, or other business arrangement (including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists), whether for-profit or not-for-profit, which receives or makes payments, under a state plan approved under title XIX or under any waiver of such plan, totaling at least $5,000,000 annually. A governmental component providing Medicaid health care items or services for which Medicaid payments are made would qualify as an "entity" (e.g., a state mental health facility or school district providing school-based health services). A government agency that merely administers the Medicaid program, in whole or part (e.g., managing the claims processing system or determining beneficiary eligibility), is not, for these purposes, considered to be an entity.

B. The Medicaid agency meets the requirements regarding establishment of policies and procedures for the education of employees of entities covered by § 1902(a)(68) of the Social Security Act (the Act) regarding false claims recoveries and methodologies for oversight of entities' compliance with these requirements.

C. Provider requirements.

1. If an entity furnishes items or services at more than a single location or under more than one contractual or other payment arrangement, the provisions of § 1902(a)(68) of the Act apply if the aggregate payments to that entity meet the $5,000,000 annual threshold. This applies whether the entity submits claims for payments using one or more provider identification or tax identification numbers.

2. An entity will have met the $5,000,000 annual threshold as of January 1, 2007, if it received or made payments in that amount in federal fiscal year 2006. Future determinations regarding an entity's responsibility stemming from the requirements of § 1902(a)(68) of the Act will be made by January 1 of each subsequent year based upon the amount of payments an entity either received or made under the state plan during the preceding federal fiscal year.

3. The entity must establish and disseminate written policies that must also be adopted by its contractors or agents. Written policies may be on paper or in electronic form, but must be readily available to all employees, contractors, or agents. The entity need not create an employee handbook if none already exists.

4. An entity shall establish written policies for all employees (including management), and of any contractor or agent of the entity, that include detailed information about the False Claims Act and the other provisions named in § 1902(a)(68)(A) of the Act, including the Virginia Fraud Against Taxpayers Act (§ 8.01-216.1 et seq. of the Code of Virginia). The entity shall include in those written policies detailed information about the entity's policies and procedures for detecting and preventing waste, fraud, and abuse. The entity shall also include in any employee handbook a specific discussion of the laws described in the written policies, the rights of employees to be protected as whistleblowers and a specific discussion of the entity's policies and procedures for detecting and preventing fraud, waste, and abuse.

D. 12VAC30-20-275 describes, in accordance with § 1902(a)(68) of the Act, the methodology of compliance oversight and the frequency with which the Commonwealth will reassess compliance on an ongoing basis.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. October 31, 2007.

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