CMS Monitoring and Oversight Activities.
A. CMS shall conduct monitoring activities to evaluate compliance by the ACO, its Participant Providers, and its Preferred Providers with the terms of the Agreement. Such monitoring activities may include, without limitation:
1. Claims analyses to identify fraudulent behavior or program integrity risks, such as inappropriate reductions in care (e.g., through claims-based utilization, inappropriate changes in case-mix or quality measures), efforts to manipulate risk scores or aligned populations, overutilization, and cost- shifting to other payers or populations;
2. Documentation requests sent to the ACO, its Participant Providers, and/or its Preferred Providers, including surveys and questionnaires;
3. Interviews with any individual or entity participating in ACO Activities or Marketing Activities, including but not limited to members of the ACO leadership and management, Participant Providers, and Preferred Providers;
4. Interviews with Beneficiaries and their caregivers;
5. Audits of charts, medical records, Implementation Plans, and other data from the ACO, its Participant Providers, and its Preferred Providers;
6. Site visits to the ACO, Participant Providers, and Preferred Providers; and
7. Documentation requests sent to the ACO, Participant Providers, and/or Preferred Providers, including surveys and questionnaires.
B. In conducting monitoring and oversight activities, CMS or its designees may use any relevant data or information including, without limitation, all Medicare claims submitted for items or services furnished to Beneficiaries.
CMS Monitoring and Oversight Activities.
1. CMS shall conduct monitoring activities to evaluate compliance by the ACO, its Next Generation Participants, and its Preferred Providers with the terms of this Agreement. Such monitoring activities may include, without limitation:
(a) Interviews with any individual or entity participating in ACO Activities, including members of the ACO leadership and management, Next Generation Participants, and Preferred Providers;
(b) Interviews with Next Generation Beneficiaries and their caregivers;
(c) Audits of charts, medical records, Implementation Plans, and other data from the ACO, its Next Generation Participants, and its Preferred Providers;
(d) Site visits to the ACO and its Next Generation Participants and Preferred Providers; and
(e) Documentation requests sent to the ACO, its Next Generation Participants, and/or its Preferred Providers, including surveys and questionnaires.
2. In conducting monitoring and oversight activities, CMS or its designees may use any relevant data or information including, without limitation, all Medicare claims submitted for items or services furnished to Next Generation Beneficiaries.
CMS Monitoring and Oversight Activities. (a) CMS will conduct monitoring activities to assess the MDPCP Practice’s compliance with the terms of this Agreement, to promote the safety of MDPCP Beneficiaries, and to ensure the integrity of the MDPCP.
(b) The monitoring activities will include comprehensive review of all MDPCP Practice data reported in accordance with Article V.
(c) The monitoring activities may additionally include, without limitation:
(i) Review of any and all data submitted to CMS by the MDPCP Practice and, if applicable, the MDPCP Practice Site at the direction of the MDPCP Practice, and, if applicable, the MDPCP Partner CTO via the MDPCP Portal;
(ii) Review of utilization, efficiency, and quality data collected by CMS or reported to CMS by the MDPCP Practice and, if applicable, the MDPCP Practice Site at the direction of the MDPCP Practice, and, if applicable, the MDPCP Partner CTO;
(iii) Review of any documentation necessary to confirm the MDPCP Practice’s eligibility based on the eligibility requirements described in Article 3.1;
(iv) Review of any documentation related to the MDPCP Practice’s compliance with laws submitted in accordance with Article 12.3;
(v) Review of any documentation related to a Change in Control or to a change in the MDPCP Practice’s name or TIN;
(vi) If applicable, review of the MDPCP Practice’s CTO Arrangement;
(vii) Review of arrangements with MDPCP Practitioners;
(viii) Interviews with MDPCP Practitioners and, if applicable, individuals identified on the Staff Roster;
(ix) Interviews with MDPCP Practice Site’s patients and their caregivers;
(x) If applicable, interviews with the MDPCP Practice’s MDPCP Partner CTO;
(xi) Review of any of the MDPCP Practice’s records and documentation relating to its participation in the MDPCP, including but not limited to charts, medical records, health IT reports, employment contracts, and other data from the MDPCP Practice;
(xii) Site visits to the MDPCP Practice Site; and
(xiii) Documentation sent to the MDPCP Practice for the MDPCP Practice to complete and return to CMS, including surveys and questionnaires.
(d) In conducting monitoring activities, CMS may use any relevant data or information including, without limitation, all Medicare claims submitted for items or services furnished to beneficiaries.
(e) Nothing in this Agreement shall be construed to limit or otherwise prevent CMS from monitoring as permitted by applicable law or regulations.
(f) CMS may monitor the MDPCP Practice pursuant to this Article XII fo...
CMS Monitoring and Oversight Activities. CMS shall conduct monitoring activities to evaluate compliance by the ACO, its Next Generation Participants, and Preferred Providers with the terms of this Agreement. Such monitoring activities may include, without limitation:
