False Claims Acts
Purpose
ABAS delivers Applied Behavior Analysis services across public, commercial, and private payers. The portion funded by Medicaid programs, including MassHealth, is paid with federal and state money. The federal False Claims Act and applicable state false claims acts, including the Massachusetts False Claims Act, impose liability, including treble damages and per-claim civil penalties, on providers that knowingly submit false or fraudulent claims or knowingly retain payments they are not entitled to keep. This policy explains those laws, the standard of knowledge they apply, the protections they give to people who report violations, and what ABAS requires so that every claim it submits is truthful and every identified overpayment is returned on time.
Scope
This policy applies to all ABAS employees. It applies most directly to employees whose work creates or supports claims: the Behavior Technician Team and BCBA Team, who deliver and document services; the Billing & Recovery Specialist, who prepares and submits claims and processes payer remittances; and the Director of Operations, Executive Director, and Compliance Officer, who oversee billing and compliance functions. It covers every claim ABAS submits to any government payer, every record or statement that supports such a claim, and the handling of any overpayment ABAS receives.
Definitions
| Term | Definition |
|---|---|
| Claim | A request or demand for money or property presented to a government payer, directly or through a contractor or intermediary. Every bill ABAS submits to a government payer is a claim. |
| False Claim | A claim for a service that was not rendered, was not rendered as described, was not medically necessary, was not supported by required documentation, or was otherwise not payable under the payer's rules. |
| Knowing / Knowingly | Acting with actual knowledge that information is false, in deliberate ignorance of its truth or falsity, or in reckless disregard of its truth or falsity. Specific intent to defraud is not required. |
| Reverse False Claim | Knowingly concealing, or knowingly and improperly avoiding or decreasing, an obligation to pay money to the government, including keeping an identified overpayment past the deadline for returning it. |
| Overpayment | As defined in POL-004 (Fraud, Waste, and Abuse Prevention): any payment ABAS receives to which it is not entitled, whether through error or otherwise, that must be reported and returned to the payer. The 60-day return deadline in Section 5 applies specifically to overpayments from government payers. |
| Identified | The point at which ABAS knowingly, with actual knowledge, in deliberate ignorance, or in reckless disregard, has received or retained an overpayment. The 60-day repayment period runs from this point. |
| Qui Tam Action | A lawsuit filed by a private person, called a relator, on behalf of the government against a party alleged to have violated a false claims act. The relator may receive a share of any recovery. |
Policy Statement
5.1 Commitment and Legal Framework
ABAS prohibits the submission of false or fraudulent claims and the knowing retention of overpayments. Two layers of law set the framework for this policy. The federal False Claims Act (31 U.S.C. §§ 3729-3733) imposes civil liability on any person who knowingly presents a false or fraudulent claim for payment to the federal government or knowingly avoids an obligation to repay it. ABAS is also subject to the false claims act of each state in which it operates, including the Massachusetts False Claims Act (M.G.L. c. 12, §§ 5A-5O), which imposes parallel liability under state law and applies to claims paid by MassHealth. These laws provide for three times the government's damages plus a civil penalty for each false claim, and they reach conduct well short of deliberate fraud.
5.2 Accurate Claims and Certification of Services Rendered
Every claim ABAS submits is a certification that the service was actually delivered, by the identified rendering provider, as documented, and in compliance with the provider requirements of the program billed (for MassHealth, 130 CMR 450.000). Employees must not submit, or cause ABAS to submit, a claim they know or should know is false, and must not create or approve records that make a false claim appear supported. The conduct standards for accurate documentation and billing are set in POL-004 (Fraud, Waste, and Abuse Prevention), Sections 5.2 and 5.3. This policy states the legal consequence: a claim that violates those standards can be a false claim under federal and state law.
5.3 The Knowing Standard
The False Claims Acts do not punish honest mistakes that are promptly corrected. They punish knowing conduct, and "knowing" is broader than intent to defraud. A claim submitted with actual knowledge that it is false, in deliberate ignorance of whether it is accurate, or in reckless disregard of its accuracy can create liability. For ABAS this means that ignoring billing errors, skipping documentation review before submission, or continuing a billing practice after learning it may be improper can turn ordinary errors into false claims. An employee who becomes aware of a possible error in a submitted claim must report it under Section 8 so ABAS can correct it.
5.4 Overpayments and the 60-Day Rule
Federal law (42 U.S.C. § 1320a-7k(d)) requires a provider to report and return an overpayment within 60 days after the date the overpayment is identified, with a written explanation of the reason for the overpayment. An overpayment knowingly retained past that deadline becomes an obligation under the federal False Claims Act and exposes ABAS to reverse false claims liability. When a potential overpayment is reported, the Compliance Officer oversees its investigation and quantification, and ABAS returns any confirmed overpayment within the 60-day period following the procedures in Section 6. This obligation applies regardless of how the overpayment occurred.
5.5 Qui Tam Actions and Whistleblower Protections
The federal False Claims Act and applicable state false claims acts allow a private person to file a qui tam lawsuit on the government's behalf and to share in any recovery (31 U.S.C. § 3730; in Massachusetts, M.G.L. c. 12, §§ 5A-5O). These laws also protect whistleblowers. An employee or contractor who is discharged, demoted, suspended, harassed, or otherwise discriminated against for lawful acts in furtherance of a false claims action, or for efforts to stop a violation, is entitled to relief that can include reinstatement, double back pay, and damages (31 U.S.C. § 3730(h) and the corresponding provisions of applicable state false claims acts). ABAS prohibits retaliation against anyone who raises a false claims concern in good faith, whether internally or to a government authority. Nothing in this policy, and no ABAS agreement or practice, limits any person's right to report suspected violations to the government or to file a qui tam action.
5.6 Relationship to Other ABAS Policies
This policy defines the legal framework for false claims liability. The day-to-day conduct standards that keep claims accurate live in POL-004 (Fraud, Waste, and Abuse Prevention). Reporting channels, investigation, and non-retaliation protections live in POL-003 (Compliance Reporting, Investigation, and Resolution). Employees do not need to determine which policy applies before reporting a concern; any report made under one is handled under all that apply.
Procedures
Responsibilities
| Role | Responsibility |
|---|---|
| All ABAS Employees | Provide only truthful, accurate information in records that support claims. Report suspected false claims, billing errors, and potential overpayments promptly. Complete required training. |
| Behavior Technician Team | Document each session accurately and at the time of service, so that every billed service is supported by a contemporaneous record. |
| BCBA Team | Verify that services billed under their oversight were authorized, medically necessary, and documented to clinical and payer standards. |
| Billing & Recovery Specialist | Submit claims only when supported by documentation. Identify, log, and escalate credit balances, payer takebacks, and suspected overpayments to the Compliance Officer. |
| Compliance Officer | Investigate reports under this policy, quantify confirmed overpayments, ensure report and return within 60 days of identification, maintain the supporting record, and report outcomes to the Compliance Committee. |
| Executive Director | Approve engagement of outside counsel when needed and ensure resources for repayment and corrective action. |
Steps
- An employee who becomes aware of a possible false claim, billing error, or overpayment reports it to the Compliance Officer through the channels in POL-003, including the anonymous web form if preferred.
- The Compliance Officer opens a ticket and investigates under POL-003 and the Compliance Ticket Management SOP, working with the Billing & Recovery Specialist to determine whether an overpayment exists and to quantify it.
- If an overpayment is confirmed, the Compliance Officer records the date it was identified, and the Billing & Recovery Specialist returns it to the payer with a written explanation within 60 days of that date.
- If the facts suggest a knowing violation, a government inquiry, or a qui tam action, the Compliance Officer escalates to the Executive Director, who decides whether to engage outside counsel under POL-003, Section 5.5.
- The Compliance Officer documents the resolution, implements corrective action to prevent recurrence, and reports the matter and its outcome to the Compliance Committee.
Training Requirements
All ABAS employees must complete training on this policy during onboarding and at least annually as part of compliance refresher training. Training covers what the federal False Claims Act and applicable state false claims acts prohibit, the knowing standard, the 60-day overpayment rule, how to report a concern, and the whistleblower protections in Section 5.5. The Billing & Recovery Specialist and BCBA Team receive role-specific training on claim accuracy and overpayment identification, delivered together with the training required under POL-004. The Compliance Officer tracks completion and reports completion rates to the Compliance Committee.
Reporting and Enforcement
Employees who suspect a false claim, a billing error, or a retained overpayment must report it through the channels in POL-003 (Compliance Reporting, Investigation, and Resolution), including the anonymous web form. Reports are investigated under POL-003 and the Compliance Ticket Management SOP. A confirmed violation may result in disciplinary action up to and including termination, repayment of any improper amounts, and referral to the relevant payer or program, the applicable state attorney general, or federal authorities where required by law. ABAS will not retaliate against anyone who reports a concern in good faith; the protections in POL-003, Section 5.1 apply, in addition to the statutory whistleblower protections described in Section 5.5 of this policy. Reporting internally is encouraged but does not limit any person's legal right to report directly to the government.