Program Integrity. The state must have processes in place to ensure that there is no duplication of federal funding for any aspect of the demonstration.
Program Integrity. 1. The MA Organization agrees to provide notice based on best knowledge, information, and belief to CMS of any integrity items related to payments from governmental entities, both federal and state, for healthcare or prescription drug services. These items include any investigations, legal actions or matters subject to arbitration brought involving the MA Organization (or MA Organization's firm if applicable) and its subcontractors (excluding contracted network providers), including any key management or executive staff, or any major shareholders (5% or more), by a government agency (state or federal) on matters relating to payments from governmental entities, both federal and state, for healthcare and/or prescription drug services. In providing the notice, the sponsor shall keep the government informed of when the integrity item is initiated and when it is closed. Notice should be provided of the details concerning any resolution and monetary payments as well as any settlement agreements or corporate integrity agreements.
2. The MA Organization agrees to provide notice based on best knowledge, information, and belief to CMS in the event the MA Organization or any of its subcontractors is criminally convicted or has a civil judgment entered against it for fraudulent activities or is sanctioned under any Federal program involving the provision of health care or prescription drug services.
Program Integrity. 4.13.1.1 The Contractor shall have a Program Integrity Program, including a mandatory compliance plan, designed to guard against Fraud and Abuse. This Program Integrity Program shall include policies, procedures, and standards of conduct for the prevention, detection, reporting, and corrective action for suspected cases of Fraud and Abuse in the administration and delivery of services under this Contract.
4.13.1.2 The Contractor shall submit its Program Integrity Policies and Procedures, which include the compliance plan and pharmacy lock-in program described below, to DCH for approval as updated.
Program Integrity. The ICDS Plan agrees that it will develop and implement an effective compliance program that applies to its operations, and to prevent, detect, and correct Fraud, waste and abuse consistent with 42 C.F.R. §§ 420, et seq § 422.503, and 42 C.F.R. §§ 438.600-610, 42 C.F.R. § 455 and the contents of this Contract. The compliance program must, at a minimum, include written policies, procedures, and standards of conduct that:
2.1.6.1. Demonstrate the ICDS Plan’s compliance with all applicable federal and state standards, including but not limited to:
2.1.6.1.1. Fraud detection and investigation;
2.1.6.1.2. Procedures to guard against Fraud and abuse;
Program Integrity. 1. To implement and require its responsible subcontractors to implement procedures that are designed to detect and prevent fraud, waste, and abuse set forth in 42 CFR 438.608 and COMAR 10.67.07 (Appendix M).
2. To designate a compliance officer, who reports directly to the chief executive officer and the board of directors and is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract, and at minimum the following staff members:
a. An investigator who is responsible for fraud, waste, and abuse investigations;
b. An auditor who is responsible for identifying potential fraud, waste, and abuse through analysis of claims and related information; and
c. An analyst capable of reviewing data and codes who is responsible for reviewing and researching evidence of potential fraud, waste, and abuse.
3. To maintain staffing and resources located in Maryland to identify and investigate potential fraud, waste, and abuse, which shall be based on criteria determined by the Department that may include but are not limited to:
a. Number of enrollees;
b. Number of claims received on an annual basis;
c. Volume of suspected fraudulent and abusive claims currently being detected;
d. Other factors relating to the vulnerability of the MCO to fraud and abuse; and
e. An assessment of optimal caseload which can be handled by an investigator on an annual basis.
4. To permit the Department, the Maryland Insurance Administration, and/or DHHS, or any of their respective designees, with respect to the MCO and any of its subcontractors, as required by 42 CFR 438.6(h), to:
a. Evaluate the quality, appropriateness, and timeliness of services performed through inspection, or other means, including accessing the MCO and its subcontractors’ facilities using enrollment cards and identities established in the manner specified by the Department; and
b. Inspect and audit any financial records, including but not limited to reimbursement rates.
5. To inform its subcontractors of the provisions of the Social Security Act §1128 B (Criminal Penalties for Acts Involving Federal Health Care Programs).
6. In accordance with Section 1903(m)(4)(B) of the Social Security Act, to report to the State and, upon request, to the Secretary or the Inspector General of the Department of Health and Human Services, the Comptroller General and Enrollees, a description of transactions between the MCO and a party in interest (as de...
Program Integrity. The Contractor shall adopt and implement an effective compliance program to prevent, detect and correct Fraud, Waste, and Abuse consistent with 42 C.F.R. Part 420, et seq, 42 C.F.R. § 422.503, and 42 C.F.R. §§ 438.600-610, 42 C.F.R. Part 455. The compliance program must, at a minimum, include written policies, procedures, and standards of conduct that:
Program Integrity. The PIHP must have administrative and management arrangements or procedures for compliance with 42 CFR 438.608. Such arrangements or procedures must identify any activities that will be delegated to affiliates and how the PIHP will monitor those activities.
Program Integrity. The State must have processes in place to ensure that there is no duplication of Federal funding for any aspect of the Demonstration. Specifically, the State must ensure that there is no duplication of Federal funding between the State’s Maternal, Infant, and Early Childhood Home Visiting Program and the Demonstration. In addition, the State must ensure that there is no duplication of Federal funding between the State’s VFC Program and the Demonstration. The State must confirm in each quarterly and annual report that there is no duplication of funding.
Program Integrity. 2.9.3.1. The Contractor shall have a compliance plan and administrative and management arrangements or procedures designed to prevent and detect fraud, abuse and misuse of Medicaid funds and resources.
2.9.3.1.1. The Contractor shall create a compliance program plan documenting the Contractor’s written policies and procedures, standards and practices. The compliance program plan shall be approved by Contractor’s Chief Executive Officer and Compliance Officer. The compliance program plan shall be submitted to the Department for review and approval and shall include, but not be limited to:
2.9.3.1.1.1. Provisions for internal monitoring and auditing.
2.9.3.1.1.2. Provisions for response to detected offenses and for development of corrective action initiatives.
2.9.3.1.1.3. Processes to screen all Provider claims, collectively and individually, for potential fraud, waste or abuse.
2.9.3.1.1.4. Mechanisms to identify and report suspected instances of Medicaid fraud, waste and abuse.
2.9.3.1.1.5. Mechanisms to identify and report suspected instances of upcoding and unbundling of services, identifying services never rendered and identifying inflated bills for services and/or goods provided.
Program Integrity. Pursuant to Title 42, CFR, section 455.1(a)(2), Contractor shall have a way to verify with beneficiaries that services reimbursed by Medi-Cal were actually furnished to the beneficiaries. Contractor shall have an established method to conduct service verification. Upon request, Contractor shall make this method and sample work available to the Director.
