VIII. ENFORCEMENT AND PREVENTION POLICY

The purpose of this policy is to set forth the procedures that will be used by Western New York Independent Living, Inc. (WNYIL Inc.) to respond to reports by employees or others that a business unit or individuals employed by a business unit are engaging in activity which might violate the standards described in the Corporate Compliance Plan and which may be contrary to applicable Medicaid laws or regulations or that such persons or business units may be submitting claims in a manner which does not meet the Medicaid program requirements, as applicable.

A. Investigation

1. Purpose of investigation:

The purpose of the investigation shall be to:

1. Identify those situations, in which the laws, rules and standards of the Medicaid program may not have been followed.


2. To identify individuals who may have knowingly or inadvertently caused claims to be submitted or processed in a manner, which violated Medicaid laws, rules, or standards.


3. To facilitate the correction of any practices not in compliance with the Medicaid laws, rules and standards.


4. To implement those procedures necessary to insure future compliance.


5. To protect WNYIL Inc. in the event of civil or criminal enforcement actions.


6. To preserve and protect WNYIL Inc.'s assets.

2. Control of investigations:

All reports received by Agency management shall be forwarded to WNYIL Inc.'s Compliance Officer. WNYIL Inc.'s Compliance Officer shall prepare a Report of Fraud, Waste and/or Abuse (Exhibit C). WNYIL Inc.'s Compliance Officer will be responsible for directing the investigation of the alleged problem or incident. In undertaking this investigation, WNYIL Inc.'s Compliance Officer may solicit the support of external legal counsel, consultants and auditors, and internal and external resources with knowledge of the applicable laws and regulations and required policies, procedures or standards that relate to the specific problem in question. These persons shall function under the direction of legal counsel and shall be required to submit relevant evidence, notes, findings and conclusions to legal counsel.

3. Investigative process.

Upon receipt of an employee complaint or other information (including audit results), which suggests the existence of a pattern of conduct in violation of compliance policies or applicable laws or regulations, an investigation under the direction and control of legal counsel shall be commenced. Steps to be followed in undertaking the investigation shall include, at a minimum:

1. Notification to WNYIL Inc.'s Executive Director of the nature of the complaint.
2. The investigation shall be commenced as soon as reasonably possible but in no event more than 10 days following the receipt of the complaint or report. The investigation shall include, as applicable, but need not be limited to:

1. An interview of the complainant and other persons who may have knowledge of the alleged problem or process and a review of the applicable laws and regulations which might be relevant to or provide guidance with respect to the appropriateness or inappropriateness of the activity in question, to determine whether a problem actually exists. If the review results in conclusions or findings that the complained of conduct is permitted under applicable laws, regulations or policy or that the complained of act did not occur as alleged or that it does not otherwise appear to be a problem, the investigation shall be closed and a written report filed with WNYIL Inc.'s Compliance Officer. If the initial investigation concludes that there is improper billing occurring, that practices are occurring which are contrary to applicable law, that inaccurate claims are being submitted, or that additional evidence is necessary, the investigation shall proceed to the next step.


2. The identification and review of representative bills or claims submitted to the Medicaid program to determine the nature of the problem, the scope of the problem, the frequency of the problem, the duration of the problem, and the potential financial magnitude of the problem.


3. Interviews of the person or persons in the departments and organizations who appear to play a role in the process in which the problem exists. The purpose of the interview will be to determine the facts related to the complained activity, and may include, but shall not be limited to:

• (a) Individual understanding of the Medicaid laws, rules and regulations;


• (b) The identification of persons with supervisory or managerial responsibility in the process;


• (c) The adequacy of the training of the individuals performing the functions within the process;


• (d) The extent to which any person knowingly or with reckless disregard or intentional indifference acted contrary to the Medicaid laws, rules or regulations;


• (e) The nature and extent of potential civil or criminal liability of individuals or WNYIL Inc.; and


• (f) Preparation of a summary report

• (i) Defines the nature of the problem,


• (ii) Summarizes the investigation process,


• (iii) Identifies any person whom the investigator believes to have either acted deliberately or with reckless disregard or intentional indifference toward the Medicaid laws, rules and policies, and


• (iv) If possible estimates the nature and extent of the resulting overpayment by the government, if any.

B. WNYIL Inc. Response

Possible Criminal Activity. In the event WNYIL Inc. uncovers what appears to be criminal activity on the part of any employee or business unit, it shall undertake the following steps:

In the event Medicaid is involved, the following office will be contacted:

New York State Office of the Medicaid Inspector General
584 Delaware Avenue, Second Floor
Buffalo, NY 14202
Telephone: (716) 847-5090

If the event that Erie County Department of Mental Health is involved:

Bill Fremgen, Contract Coordinator
Erie County Office of Mental Health
95 Franklin St.
Buffalo NY 14202
Telephone: (716) 858-8530

If in the event that the Office of Mental Health and Developmental Disabilities is involved:

WNY DDSO
1200 East & West Road.
West Seneca, NY 14224
Phone: (716) 517-2000

If in the event that the Office for People with Developmental Disabilities is involved:

OPWDD
1200 East & West Road
West Seneca, NY 14224
Phone: (716) 517-2000

If in the event that the Commission on Quality of Care and Advocacy for Persons with Disabilities is involved:

Lisa Rosano-Kaczkowski, CAP Program Director
State of New York
Commission on Quality of Care and Advocacy for Persons with Disabilities
401 State Street
Schenectady NY 12305
Telephone: (800) 624-4143 voice/TTY.

In the event that the New York State Department of Education is involved:

Robert Gumson
Manager of Independent Living Services
VESID, Room 1605
One Commerce Plaza
99 Washington Ave.
Albany NY 12234
Telephone: (518) 474-2925

In the event that Title VII Independent Living funds are involved:

Timothy Beatty, Chief of Independent Living Unit, Rehabilitation Services Administration
400 Maryland Ave, S.W.
Washington, DC 20202-2800
Telephone: (202) 245-7488

Other contacts may be made as the legal counsel for WNYIL Inc. deems appropriate. WNYIL Inc., through its counsel, shall attempt to negotiate a voluntary disclosure agreement prior to the disclosure.

Initiate appropriate disciplinary action against the person or persons whose conduct appears to have been intentional, willfully indifferent or undertaken with reckless disregard for the Medicaid and other programmatic laws and regulations. Appropriate disciplinary action shall include, at a minimum, the removal of the person from any position with oversight for or impact upon the claims submission or billing process and may include, in addition, suspension, demotion, and discharge.

1. Other Non-Compliance. In the event the investigation reveals billing or other problems which do not appear to be the result of conduct which is intentional, willfully indifferent, or with reckless disregard for the appropriate program's laws and regulations, WNYIL Inc. shall nevertheless undertake the following steps:
   
   
   1. Improper Payments. In the event the problem results in duplicate payments by the funding source, or payments for services not rendered or provided other than as claimed, it shall:
      1. Correct the defective practice or procedure immediately,
      2. Calculate and repay to the appropriate governmental entity duplicate payments or improper payments resulting from the act or omission,
      3. Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances. Appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge, and
      4. Promptly undertake a program of education at the appropriate business unit to prevent future similar problems.
      
      
   2. No Improper Payment. In the event the problem has or does not result in an overpayment by the program, WNYIL Inc. shall:
   1. Correct the defective practice or procedure immediately.
   2. Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances. Appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge.
   3. Promptly undertake a program of education at the appropriate business unit to prevent future similar problems.

   C. Discipline

   Employees may be subject to discipline for failing to participate in WNYIL Inc.'s compliance efforts, including, but not limited to:

   1. The failure of an employee to perform any obligation required of the employee relating to compliance with the program or applicable laws or regulations;
   2. The failure to report suspected violations of Compliance Plan laws or applicable laws or regulations to an appropriate person; and
   3. The failure on the part of a supervisory or managerial employee to implement and maintain policies and procedures reasonably necessary to ensure compliance with the terms of the program or applicable laws and regulations.

   Discipline will follow WNYIL Inc.'s existing employee discipline policies and procedures.

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