Program Integrity Operations. The Contractor shall have surveillance and utilization control programs and procedures (42 CFR 456.3, 456.4, 456.23) to safeguard Medicaid funds against improper payments and unnecessary or inappropriate use of Medicaid. The Contractor shall have internal controls and policies and procedures in place that are designed to prevent, detect, and report known or suspected waste, fraud and abuse activities. Contractor shall have operations sufficient to enable the efficient identification, investigation, and resolution of waste, fraud and abuse issues of Contractor’s providers, vendors, and subcontractors (including Pharmacy Benefits Managers) and Contractor itself). Contractor is required to conduct and maintain at a minimum the following operations and capabilities. Contractor shall conduct all operations and deploy all capabilities described below on a routine basis and as necessary for the effective reduction of Medicaid waste, fraud and abuse. The Special Investigation Unit within the Contractor’s structure shall have the ability to make referrals to the FSSA PI Unit, and accept referrals from a variety of sources including: directly from providers (either provider self-referrals or from other providers), members, law enforcement, government agencies, etc. The Contractor shall also have effective procedures for timely reviewing, investigating, and processing such referrals. Data mining, analytics, and predictive modeling for the identification of potential overpayments and aberrant payments/providers warranting further review/investigation. Provider profiling and peer comparisons of all of Contractor’s provider types and specialties – at a minimum annually - to identify aberrant service and billing patterns warranting further review/audit. Onsite Audit capability and protocols identifying how and when the Special Investigation Unit shall conduct such onsite audits of providers. Medical claim audit capabilities sufficient to enable the Special Investigation Unit to audit any payment issued to any provider. This includes utilizing medical record reviewers, clinicians, coding specialists, accountants, and investigators needed for review of payments to any provider/provider type. Member service utilization analytics to identify members that may be abusing services. Contractor shall submit to FSSA for approval the criteria utilized for its review of its members and the referral of members to the Right Choices Program.
Program Integrity Operations. The Broker shall have surveillance and utilization control programs and procedures (42 CFR §§ 456.3, 456.4, 456.23) to safeguard Medicaid funds against improper payments and unnecessary or inappropriate use. The Broker shall have internal controls and policies and procedures in place that are designed to prevent, detect, and report known or suspected waste, fraud and abuse activities. Broker shall have operations sufficient to enable the efficient identification, investigation, and resolution of waste, fraud and abuse issues of Broker’s Transportation Providers. Broker shall conduct all operations and deploy all capabilities described below on a routine basis and as necessary for the effective reduction of Medicaid waste, fraud and abuse. The Broker shall have the ability to make referrals of suspected malfeasance to the FSSA PI Unit, and accept referrals from a variety of sources including: directly from Transportation Providers (either provider self-referrals or from other providers), members, law enforcement, government agencies, etc. The Broker shall also have effective procedures for timely reviewing, investigating, and processing such referrals. Broker is required to conduct and maintain at a minimum the following operations and capabilities:
