Fraud, Waste, and Abuse Policy

Each of SUD Specialty Group – CA, Mental Health Specialty Group, P.A., Mental Health Specialty Group NJ, PC, and Mental Health Specialty Group KS, P.A. (collectively, the “Group”) contracts with Path, CCM, Inc. (“Path CCM”) for management and administrative support services. The Group and Path CCM are collectively referred to as “Rula” herein. This policy applies to all Rula entities.

I. APPLICABILITY

This policy applies to all workforce members of the Companies, collectively referred to as “Team Members.” This includes employees, independent contractors, business partners, board members, and any other individuals whose work performance falls under the direct purview of Rula or the Group’s business practices.

II. PURPOSE

The purpose of this policy is to provide Team Members with the necessary information to prevent, detect, investigate, correct, and report fraud, waste, and abuse (FWA), and to outline the core federal and state laws governing healthcare fraud and abuse.

III. POLICY STATEMENT

The Companies are strictly committed to complying with all applicable federal and state laws concerning FWA. Engaging in any activity that violates these laws or contradicts Company policies—including offering or accepting illegal remuneration for patient referrals—is strictly prohibited.

All Team Members are responsible for ensuring full compliance with these standards. The Companies encourage open communication and require the reporting of any potential or suspected violations. The Companies strictly prohibit retaliation of any kind against any individual who reports a compliance concern in good faith. 

IV. DEFINITIONS

To ensure clarity across the Companies, the components of "FWA" are defined as follows:

Fraud: Any intentional deception or misrepresentation made by an individual or entity with the knowledge that the deception could result in an unauthorized benefit or payment to themselves or another party.

Example: Intentionally billing for a telehealth therapy session that never occurred.

Waste: The overutilization, misuse, or inefficient practice of healthcare resources that results in unnecessary costs to payers, government programs, or the healthcare system. Waste is generally not considered to be caused by criminally intentional deception, but rather by poor management, systemic inefficiencies, or operational errors.

Example: Routinely ordering redundant psychological or diagnostic assessments that are not clinically indicated.

Abuse: Practices that are inconsistent with sound fiscal, business, or medical practices, resulting in unnecessary costs or reimbursement for services that fail to meet professionally recognized standards of care or contractual obligations. Abuse can occur without a specific intent to deceive.

Example: "Upcoding" a session by routinely billing for a 60-minute CPT code (e.g., 90837) when the provider only spent 35 or 45 minutes with the patient.

V. RELEVANT FRAUD AND ABUSE LAWS

A. Anti-Kickback Statute (AKS)

The federal Anti-Kickback Statute (AKS) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any "remuneration" (directly or indirectly, in cash or in kind) to induce or reward patient referrals, or to generate business reimbursable by any federal or state healthcare program (e.g., Medicare, Medicaid, Medicare Advantage, TRICARE).

Definition of Remuneration: Remuneration includes anything of value, such as cash, gifts, discounts, rebates, free services, trips, or business opportunities. An arrangement may violate the AKS if even one purpose of the remuneration is to induce referrals.

Safe Harbors: Specific statutory "safe harbors" protect certain legitimate business arrangements from prosecution if they meet strict regulatory criteria. Transactions that do not fit perfectly within a safe harbor are evaluated by the government based on the totality of the facts and circumstances.

Penalties: Violation of the AKS is a felony punishable by criminal fines, imprisonment, and exclusion from federal healthcare programs. Claims resulting from an AKS violation also trigger liability under the federal False Claims Act.

B. Federal Beneficiary Inducements Civil Monetary Penalty (CMP)

This law prohibits offering or transferring remuneration to a Medicare or state healthcare program beneficiary if the provider knows (or should know) it is likely to influence the beneficiary’s choice of a specific provider or service.

Exceptions: Exceptions include nominal gifts (defined by the OIG limits), structured co-insurance/deductible waivers under specific financial hardship conditions, and incentives that promote access to care while posing a low risk to federal programs.

Penalties: Violations carry substantial civil monetary penalties per infraction. 

C. Federal Stark Law

The federal Stark Law prohibits: (i) a physician from making referrals of certain “designated health services” (“DHS”)(e.g., clinical laboratory services; outpatient prescription drugs) payable by Medicare to an entity with which the physician (or immediate family) has a financial relationship (e.g., compensation arrangement or ownership interest) unless an exception applies (Note: While the federal Stark Law applies strictly to physicians, state-level laws may expand similar restrictions to all licensed healthcare professionals); and (ii) the entity from billing Medicare for such DHS based on a prohibited referral.

The Stark Law is a strict liability statute so unlike the AKS, each element of an applicable exception must be met in order to be permissible.

Common Violations: Paying a physician above a fair market value rate based on the number of outpatient prescriptions the physician issues.

Exceptions: Statutory exceptions exist but the financial relationship must squarely meet each element of the exception to be permissible (e.g., personal services and management exception).

Penalties: Violations of the Stark Law may result in denial of payment, refunds of amounts collected, civil monetary penalties, and potential exclusion from Federal healthcare programs. Violations of the Stark law may trigger liability under the False Claims Act.

D. Federal False Claims Act (FCA)

The federal False Claims Act imposes civil liability on any person or entity that knowingly presents, or causes to be presented, a false or fraudulent claim for payment to the government.

A “reverse false claim” includes the failure to refund any overpayments based on a false claim within sixty-60 days of identification.

Common Violations: Billing for services not provided ("ghost billing"), billing for services not medically necessary, duplicate billing, and falsifying medical records or treatment plans.

Knowledge Standard: The FCA defines "knowingly" to include actual knowledge, reckless disregard, or deliberate ignorance of the truth. Simple negligence or clerical errors do not constitute an FCA violation.

Whistleblower (Qui Tam) Provisions: The FCA allows private individuals (known as whistleblowers or qui tam relators) to file lawsuits on behalf of the government and share in any financial recovery.  The Companies’ non-retaliation practices are detailed further in Policy 204: Non-Retaliation.

Penalties: Violators face treble (triple) damages sustained by the government, plus mandatory statutory penalties for each false claim submitted. 

E. State Fraud and Abuse Laws

Many states have enacted healthcare fraud and abuse statutes that mirror or expand upon federal laws. Notably, many state laws apply to all payers, meaning commercial insurance plans and self-pay patients are covered under state fraud rules, not just government programs.

VI. PROCEDURES

A. Compliance and Training 

All Team Members must comply with federal and state fraud and abuse laws and complete mandatory compliance training. Training is required upon hire/onboarding and annually thereafter for all individuals directly or indirectly involved with government-funded healthcare programs.

B. Sanctions and Exclusion Monitoring

The Companies verify that no employees, independent contractors, board members, or providers are excluded, debarred, or otherwise sanctioned from participating in federal or state healthcare programs. Screenings are conducted against databases including, but not limited to, the OIG List of Excluded Individuals/Entities (LEIE), the System for Award Management (SAM), and State Medicaid exclusion lists.

C. Internal Auditing and Monitoring

In collaboration with its business partners, the Compliance Team shall conduct routine, prospective, and retrospective audits of billing data, clinical documentation, and coding patterns.

D. Reporting Potential or Suspected Violations 

Mandatory Reporting: All Team Members are required to promptly report any violations, suspected violations, or questionable practices of which they become aware.

Reporting Channels: Team Members may raise concerns or report violations through any of the following methods:

Compliance Hotlines: Reports can be made online at https://rula.ethicspoint.com/ or by calling (833) 613-2443. Both options are available 24/7 with anonymous reporting options.

Immediate Supervisor: Your manager will respond promptly and escalate the matter to the Compliance Team if necessary.

Upper Management / Compliance Officer: Direct escalation to the compliance leadership team is welcome at any time.

Confidentiality & Non-Retaliation: To the maximum extent permitted by law, the Companies will maintain the confidentiality of anyone who reports a concern or participates in an investigation. Good-faith reporters are entirely protected from retaliation. However, reporting one's own misconduct or intentionally filing a false report to harm a colleague will result in appropriate disciplinary action.

E. Response to Reported Violations

Upon receiving a report of potential FWA, the Director of Fraud, Waste & Abuse (or designee) will promptly initiate an internal investigation. Investigations will be conducted discreetly, objectively, and confidentially to the maximum extent permitted by law. The investigator may review billing data, audit clinical documentation, and interview relevant Team Members. The Director of Fraud, Waste & Abuse, in consultation with the Compliance Officer as needed, will review the investigation findings to determine if systemic errors or intentional misconduct occurred.

All Team Members have a duty to fully cooperate with internal investigations, audits, and inquiries conducted by the Compliance Team, Legal Department, or external regulatory authorities.

If an investigation confirms an FWA violation, the Company will implement swift corrective actions. This includes disciplining responsible parties, implementing process improvements to prevent recurrence, refunding overpayments, and notifying the appropriate government agency or payer, as required.

VII. QUESTIONS

General Compliance Questions: Contact your immediate manager or email the Compliance Department at compliance@rula.com.

Commercial/Business Activities: For questions regarding proposed commercial activities or contracts, contact the Legal Department at legal@rula.com.

The Companies reserve the right to amend, alter, or terminate this policy at any time without prior notice.

Updated July 30, 2026 16:07