Fraud and Abuse Prevention Sample Clauses

Fraud and Abuse Prevention. 1. The Health Plan shall establish functions and activities governing program integrity in order to reduce the incidence of fraud and abuse and shall comply with all state and federal program integrity requirements, including but not limited to the applicable provisions of the Social Security Act, ss. 1128, 1902, 1903, and 1932; 00 XXX 000, 000, 434, 435, 438, 441, 447, 455; 45 CFR Part 74; Chapters 409, 414, 458, 459, 460, 461, 626, 641 and 932, F.S., and 59A-12.0073, 59G and 69D-2, FAC. HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract 2. The Health Plan shall have adequate staffing and resources to enable the compliance officer to investigate unusual incidents and develop and implement corrective action plans relating to fraud and abuse. The compliance officer shall have unrestricted access to the Health Plan’s governing body for compliance reporting, including fraud and abuse. 3. The Health Plan’s written fraud and abuse prevention program shall have internal controls and policies and procedures in place that are designed to prevent, reduce, detect, correct and report known or suspected fraud and abuse activities. 4. The Health Plan shall submit its compliance plan and its fraud and abuse policies and procedures to the Bureau of Medicaid Program Integrity (MPI) for written approval before those procedures are implemented. a. At a minimum the compliance plan must include: (1) Written policies, procedures and standards of conduct that articulate the Health Plan’s commitment to comply with all applicable federal and state standards; (2) The designation of a compliance officer and a compliance committee accountable to senior management; (3) Effective training and education of the compliance officer and the Health Plan’s employees; (4) Effective lines of communication between the compliance officer and the Health Plan’s employees; (5) Enforcement of standards through well-publicized disciplinary guidelines; (6) Provision for internal monitoring and auditing; and (7) Provisions for prompt response to detected offenses and for development of corrective action initiatives. b. At a minimum, the Health Plan’s fraud and abuse policies and procedures shall: (1) Ensure that all officers, directors, managers and employees know and understand the provisions of the Health Plan’s fraud and abuse policies and procedures; (2) Include procedures designed to prevent and detect potential or suspected fraud and abuse in the administration and delivery of services ...
Sample 1
AutoNDA by SimpleDocs
Fraud and Abuse Prevention. 1. The Health Plan shall establish functions and activities governing program integrity in order to reduce the incidence of fraud and abuse and shall comply with all state and federal program integrity requirements, including but not limited to the applicable provisions of the Social Security Act, ss. 1128, 1902, 1903, and 1932; 00 XXX 000, 000, 434, 435, 438, 441, 447, 455; 45 CFR Part 74; Chapters 409, 414, 458, 459, 460, 461, 626, 641 and 932, F.S., and 59A-12.0073, 59G and 69D-2, FAC. 2. The Health Plan’s compliance officer as described in Attachment II, Section X, Administration and Management, Item B., Staffing, sub-item 2.j., shall have unrestricted access to the Health Plan’s governing body for compliance reporting, including fraud and abuse and overpayment. 3. The Health Plan shall have adequate staffing and resources to enable the compliance officer to investigate unusual incidents and develop and implement corrective action plans relating to fraud and abuse and overpayment. a. The Health Plan shall establish and maintain a fraud investigative unit to investigate possible acts of fraud, abuse or overpayment, or may subcontract such functions. b. If a Health Plan subcontracts for the investigation of fraudulent claims and other types of program abuse by enrollees or service providers, the Health Plan shall file the following with the Bureau of Medicaid Program Integrity (MPI) for approval at least sixty (60) calendar days before subcontract execution: (1) The names, addresses, telephone numbers, e-mail addresses, and fax numbers of the principals of the entity with which the Health Plan wishes to subcontract; (2) A description of the qualifications of the principals of the entity with which the Health Plan wishes to subcontract; and (3) The proposed subcontract. c. The Health Plan shall submit to MPI such executed subcontracts, attachments, exhibits, addendums or amendments thereto, within thirty (30) calendar days after execution. d. The Health plan shall notify MPI and provide a copy of any corporate integrity or corporate compliance agreements within thirty (30) calendar days after execution of such agreements. e. The Health Plan shall notify MPI and provide a copy of any corrective action plans required by the Department of Financial Services (DFS) and/or federal governmental entities, excluding AHCA, within thirty (30) calendar days after execution of such plans. 4. The Health Plan’s written fraud and abuse prevention program shall have inter...
Sample 1
Fraud and Abuse Prevention. 19.1. Contractor shall establish, diligently maintain and utilize internal program management and monitoring procedures sufficient to provide for the proper, effective management of all activities funded under this Contract. 19.2. Failure on the part of Contractor or a subcontractor of Contractor to comply with the provisions of this Contract when such failure involves fraud or misappropriation of funds, may result in immediate withholding of funds or payment under this Contract until such time such fraud and/or misappropriation has been rectified and the funds involved paid back to ATCOG or a written plan for pay back has been accepted by ATCOG.
Sample 1
Fraud and Abuse Prevention. The Vendor shall establish functions and activities governing program integrity in order to reduce the incidence of fraud and abuse and shall comply with all state and federal program integrity requirements, including but not limited to the applicable provisions of the Social Security Act, ss. 1128, 1902, 1903 and 1932; 40 XXX 000, 000, 434, 435, 438, 441, 447 and 455; 45 CFR part 74; Chapters 409, 414, 458, 459, 460, 461, 626, 636, 641, 812 and 817, F.S., and 59A-12.0073, 59G and 69D-2, FAC.
Sample 1
Fraud and Abuse Prevention. 10.2.1 The DMO must have a written Program Integrity Plan (Integrity Plan) designed to reduce the incidence of fraud, waste, and abuse and must comply with all state and federal program integrity requirements, including but not limited to the applicable provisions of the Social Security Act, §§ 1128, 1902, 1903, and 1932; 42 CFR §§ 431, 433, 434, 435, 438, 441, 447, 455; 45 CFR Part 74, chapters 409, 414, 458, 459, 460, 461, 626, 641, the Agreement and all applicable state laws. a. The Integrity Plan must have internal controls, policies, and procedures in place to prevent, reduce, detect, investigate, correct and report known or suspected fraud, waste, and abuse activities. b. The Integrity Plan must have a clear procedure and policy to report instances of fraud, waste, and abuse. c. In accordance with Section 6032 of the federal Deficit Reduction Act of 2005, the DMO must make available to all DMO employees a copy of the written fraud, waste, and abuse policies. If the DMO has an employee handbook, the DMO must include specific information about Section 6032, the DMO's policies, and the rights of employees to be protected as whistleblowers. 10.2.2 The DMO must have a written compliance and antifraud plan (compliance plan), including its fraud, waste, and abuse policies and procedures. The compliance plan must comply with 42 CFR § 438.608 and include an organizational chart listing DMO's personnel who are responsible for the investigation and reporting of possible overpayment, abuse, waste, or fraud. The compliance plan must have a description of the DMO's procedures for: a. Mandatory reporting of possible overpayment, abuse, waste, or fraud to DHS and OMIG; b. A summary of the results of the investigations of fraud, waste, abuse, or overpayment which were conducted during the previous fiscal year by the DMO's fraud investigative unit; c. Enforcement of standards through well-publicized statutory requirements, the Agreement requirements, and related disciplinary guidelines; d. A description of the specific controls in place for prevention and detection of potential or suspected fraud and abuse, including but not limited to: e. Prior authorization; f. Utilization management; g. Subcontract and Provider Agreement provisions; h. Provisions from the provider and the member handbooks; and i. Standards for a code of conduct. 10.2.3 At a minimum, the DMO must ensure that: a. All suspected or confirmed instances of internal and external fraud, waste, and abuse re...
Sample 1
Fraud and Abuse Prevention. Panasonic and the Claims Administrator shall each have the power to implement reasonable procedures designed to detect and prevent fraudulent or abusive claims. The Claims Administrator shall have authority to reduce or altogether deny a claim as to which the Settlement Class Member or any person acting on behalf of the Settlement Class Member has engaged in fraudulent and/or abusive practices, including but not limited to submitting false claims or documentation.
Sample 1
Fraud and Abuse Prevention. 8.1. The Subrecipient shall establish, maintain and utilize internal systems and procedures sufficient to prevent, detect and correct incidents of waste, fraud and abuse in the performance of this Agreement and to provide for the proper and effective management of all Program and fiscal activities by the Agreement. Subrecipient's internal control systems and all transactions and other significant events are to be clearly documented and the documentation shall be readily available for monitoring by HCD. 8.2. The Subrecipient shall give HCD complete access to all of its records, employees and agents for the purpose of monitoring or investigating the performance of the Agreement and shall fully cooperate with HCD’s efforts to detect, investigate, and prevent waste, fraud, and abuse. 8.3. The Subrecipient may not discriminate against any employee or other person who reports a violation of the terms of this Agreement or of any law or regulation to HCD or to any appropriate law enforcement authority, if the report is made in good faith.
Sample 1
AutoNDA by SimpleDocs
Fraud and Abuse Prevention 
Sample 1Sample 2

Related to Fraud and Abuse Prevention

  • Fraud and Abuse The Company, the Owners, the Physician Employees and all other persons and entities providing professional services for or on behalf of the Company, to their actual knowledge, have not engaged in any activities that are prohibited under 42 U.S.C. ss.ss. 1320a-7, 7a or 7b or 42 U.S.C. ss. 1395nn (subject to the excexxxxxs set forth in such legislation) or the regulations promulgated thereunder or pursuant to similar state or local statutes or regulations or that are prohibited by rules of professional conduct, including, but not limited to, the following: (a) knowingly and willfully making or causing to be made a false statement or representation of a material fact in any application for any benefit or payment; (b) knowingly and willfully making or causing to be made a false statement or representation of a material fact for use in determining rights to any benefit or payment; (c) failure to disclose knowledge by a Medicare or Medicaid claimant of the occurrence of any event affecting the initial or continued right to any benefit or payment on their own behalf or on behalf of another with intent to fraudulently secure such benefit or payment; (d) knowingly and willfully offering, paying or soliciting or receiving any remuneration (including any kickback, bribe or rebate), directly or indirectly, overtly or covertly, in cash or in kind (i) in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part by Medicare or Medicaid or (ii) in return for purchasing, leasing or ordering or arranging or recommending purchasing, leasing or ordering any good, facility, service or item for which payment may be made in whole or in part by Medicare or Medicaid; or (e) referring a patient for designated health services (as defined in 42 U.S.C. ss. 1395nn) to or providing designated health services to a patient upon a referral from an entity or person with which the physician or an immediate family member has a financial relationship and to which no exception under 42 U.S.C. ss. 1395nn applies. SECTION 3.32. PAYORS. Schedule 3.32 sets forth a true, correct and complete list of the names and addresses of each Payor, including any private pay patient as a single payor, of the Company's services that accounted for more than 5% of the aggregate revenues of the Company in the five previous fiscal years. Except as set forth in Section 3.32, the Company has good relations with such Payors, and none of such Payors has notified the Company that it intends to discontinue its relationship with the Company or to deny any claims submitted to such Payor for payment.

  • Fraud, Waste, and Abuse Contractor understands that HHS does not tolerate any type of fraud, waste, or abuse. Violations of law, agency policies, or standards of ethical conduct will be investigated, and appropriate actions will be taken. Pursuant to Texas Government Code, Section 321.022, if the administrative head of a department or entity that is subject to audit by the state auditor has reasonable cause to believe that money received from the state by the department or entity or by a client or contractor of the department or entity may have been lost, misappropriated, or misused, or that other fraudulent or unlawful conduct has occurred in relation to the operation of the department or entity, the administrative head shall report the reason and basis for the belief to the Texas State Auditor’s Office (SAO). All employees or contractors who have reasonable cause to believe that fraud, waste, or abuse has occurred (including misconduct by any HHS employee, Grantee officer, agent, employee, or subcontractor that would constitute fraud, waste, or abuse) are required to immediately report the questioned activity to the Health and Human Services Commission's Office of Inspector General. Contractor agrees to comply with all applicable laws, rules, regulations, and System Agency policies regarding fraud, waste, and abuse including, but not limited to, HHS Circular C-027. A report to the SAO must be made through one of the following avenues: ● SAO Toll Free Hotline: 1-800-TX-AUDIT ● SAO website: xxxx://xxx.xxxxx.xxxxx.xx.xx/ All reports made to the OIG must be made through one of the following avenues: ● OIG Toll Free Hotline 0-000-000-0000 ● OIG Website: XxxxxxXxxxxXxxxx.xxx ● Internal Affairs Email: XxxxxxxxXxxxxxxXxxxxxxx@xxxx.xxxxx.xx.xx ● OIG Hotline Email: XXXXxxxxXxxxxxx@xxxx.xxxxx.xx.xx. ● OIG Mailing Address: Office of Inspector General Attn: Fraud Hotline MC 1300 P.O. Box 85200 Austin, Texas 78708-5200

  • Fraud Prevention A. To screen its employees and contractors to determine if they have been excluded from Medicare, Medicaid or any federal or state health care program. The Contractor agrees to search monthly the HHS-Office of Inspector General ("OIG") and Texas Health and Human Services Commission Office of Inspector General ("HHSC-OIG") List of Excluded Individuals/Entities ("LEIE") websites to capture exclusions and reinstatements that have occurred since the last search and to immediately report to HHSC-OIG any exclusion information the Contractor discovers. Exclusionary searches for prospective employees and contractors shall be performed prior to employment or contracting. B. That no Medicaid payments can be made for any items or services directed or prescribed by a physician or other authorized person who is excluded from Medicare, Medicaid or any federal or state health care program when the individual or entity furnishing the items or services either knew or should have known of the exclusion. This prohibition applies even when the Medicaid payment itself is made to another contractor, practitioner or supplier who is not excluded. C. That this contract is subject to all state and federal laws and regulations relating to fraud and abuse in health care and the Medicaid program. As required by 42 C.F.R. §431.107, the Contractor agrees to keep all records necessary to disclose the extent of services the Contractor furnishes to people in the Medicaid program and any information relating to payments claimed by the Contractor for furnishing Medicaid services. On request, the Contractor also agrees to furnish HHSC, AG-MFCU, or HHS any information maintained under 42 C.F.

  • Fraud and Corruption We hereby certify that we have taken steps to ensure that no person acting for us or on our behalf engages in any type of Fraud and Corruption.

  • Fire Prevention LESSEE agrees to use every reasonable precaution against fire and agrees to provide and maintain approved, labeled fire extinguishers, emergency lighting equipment, and exit signs and complete any other modifications within the leased premises as required or recommended by the Insurance Services Office (or successor organization), OSHA, the local Fire Department, or any similar body.

  • Workplace Violence Prevention and Crisis Response (applicable to any Party and any subcontractors and sub-grantees whose employees or other service providers deliver social or mental health services directly to individual recipients of such services): Party shall establish a written workplace violence prevention and crisis response policy meeting the requirements of Act 109 (2016), 33 VSA §8201(b), for the benefit of employees delivering direct social or mental health services. Party shall, in preparing its policy, consult with the guidelines promulgated by the U.S. Occupational Safety and Health Administration for Preventing Workplace Violence for Healthcare and Social Services Workers, as those guidelines may from time to time be amended. Party, through its violence protection and crisis response committee, shall evaluate the efficacy of its policy, and update the policy as appropriate, at least annually. The policy and any written evaluations thereof shall be provided to employees delivering direct social or mental health services. Party will ensure that any subcontractor and sub-grantee who hires employees (or contracts with service providers) who deliver social or mental health services directly to individual recipients of such services, complies with all requirements of this Section.

  • HEALTH, SAFETY AND ENVIRONMENT In the performance of this Contract, Contractor and Operator shall conduct Petroleum Operations with due regard to health, safety and the protection of the environment (“HSE”) and the conservation of natural resources, and shall in particular:

  • Health, Safety and Security 14.1 The Employer recognizes a responsibility to provide an environment intended to protect the health, safety and security of Members as they carry out their responsibilities. To that end, the Employer agrees: (a) to maintain a Joint Health and Safety Committee (the JHSC) with broad representation drawn from all sectors of the University, including at least one (1) person appointed by the Association; (b) to cooperate with the Association in making every reasonable provision for the safety, health and security of Members; (c) to take reasonable measures to maintain the security of the buildings and grounds while at the same time maintaining reasonable access for Members who have a need for such access at times other than during regular working hours; (d) to ensure that the Association has the right to appoint at least one (1) person to any representative committee whose terms of reference specifically include the health, safety or security of Members as they carry out their responsibilities; (e) to comply with the Occupational Health and Safety Act, R.S.O. 1990, and relevant regulations thereto, as amended from time to time (the “Act”); (f) that Members may refuse unsafe work pursuant to and in accordance with the relevant provisions of the Act for so doing; (g) that Members report any known or potential dangers to their Xxxx; (h) In addition, the Employer agrees: i) to provide Members with health and safety training, personal protective equipment, and access to health and safety programs, policies and procedures; ii) to provide resources for the JHSC; iii) to compensate a CASBU Member who is eligible to be, and serves as, the person appointed by the Association to the JHSC when that service is outside the period of the Member’s contract; iv) to provide training for the person appointed by the Association to the JHSC directly related to their duties and responsibilities in connection with the JHSC; v) to recognize a JHSC Member’s right to be present during workplace safety testing and audits and receive written copies of any reports and recommendations from the testing/audits and a copy of a draft report if one is provided to the Employer; vi) to recognize a JHSC Member’s right to have advance notice when advance notice is given by the Ministry of Labour of any Ministry of Labour inspection and to accompany a Ministry of Labour Inspector during an inspection and receive a copy of any report produced by the inspector. 14.2 The parties agree that all personal communications must adhere to the Personal Harassment and Discrimination Policy and the Nipissing University Acceptable Use Policy. Effective June 10, 2006, universities are subject to the Freedom of Information and Protection of Privacy Act (FIPPA). All records in the custody and control of the University will be subject to FIPPA with exceptions as defined by the Act. Persons may request and have a right to access University information or records. A record is defined under the Act as any record of information however recorded, whether in printed or electronic form, film, or otherwise and includes drafts, post-it notes, margin notes, hard drive files, emails, voice mails, electronic agendas, address books, and recording devices. 14.3 Unless required under FIPPA, and for the purposes of this Article, files are documents under a Member’s control and stored on University property, either in paper or electronic form. Such files do not include the Member’s official file in the Xxxx’x office nor the Personnel File of the Member in the Human Resources office. 14.4 On termination of a Member’s employment for any reason other than cause, the Employer will permit, by appointment only, accompanied access for a period of fifteen (15) working days (or longer with the agreement of the Xxxx) by the former Member or the Member’s executors to the Member’s files, whether in paper or electronic format. The purpose of the allowed access is for transferring required documents to other faculty, the Chair, or the Xxxx. Where files are not required to support continued student academic needs or ongoing operational requirements, the former Member or designate may remove or destroy their personal files. Items that are clearly of a personal nature or are owned by the former Member such as furniture, pictures, books, etc., may be removed at this time.

  • CHILD ABUSE REPORTING CONTRACTOR hereby agrees to annually train all staff members, including volunteers, so that they are familiar with and agree to adhere to its own child and dependent adult abuse reporting obligations and procedures as specified in California Penal Code section 11164 et seq. and Education Code 44691. To protect the privacy rights of all parties involved (i.e., reporter, child and alleged abuser), reports will remain confidential as required by law and professional ethical mandates. A written statement acknowledging the legal requirements of such reporting and verification of staff adherence to such reporting shall be submitted to the LEA.

  • COMPLIANCE WITH HEALTH, SAFETY, AND ENVIRONMENTAL REGULATIONS The Contractor, it’s Subcontractors, and their respective employees, shall comply fully with all applicable federal, state, and local health, safety, and environmental laws, ordinances, rules and regulations in the performance of the services, including but not limited to those promulgated by the City and by the Occupational Safety and Health Administration (OSHA). In case of conflict, the most stringent safety requirement shall govern. The Contractor shall indemnify and hold the City harmless from and against all claims, demands, suits, actions, judgments, fines, penalties and liability of every kind arising from the breach of the Contractor’s obligations under this paragraph.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!