Program Integrity Overpayment Recovery Clause Samples
The Program Integrity Overpayment Recovery clause establishes the right and process for recovering funds that were overpaid under a program or agreement. Typically, this clause outlines the circumstances under which overpayments are identified, the methods for notifying the affected party, and the procedures for repayment or offsetting future payments. For example, if an audit reveals that a participant received more funds than they were entitled to, the clause would dictate how and when those excess funds must be returned. Its core function is to ensure financial accuracy and accountability by providing a clear mechanism for correcting payment errors and protecting the program from financial losses due to overpayments.
Program Integrity Overpayment Recovery. Where the excluded individual is the provider of services or an owner of the provider, all amounts paid to the provider for services rendered following their exclusion shall be refunded. The Contractor shall be responsible for checking the lists of providers currently excluded by the State and the Federal Government every thirty (30) calendar days. The Contractor shall capture ownership and control information from its providers required under ▇▇ ▇▇▇ ▇▇▇, including 42 CFR 455.104. In addition, Contractor shall also maintain a list of all rendering providers of providers enrolled, even if rendering providers are not required to enroll with IHCP. Rendering providers are defined as those providers that are performing the services for which a provider bills the Contractor or IHCP. The Contractor shall also verify that all rendering providers are not currently excluded by the State and the Federal Government every thirty (30) calendar days. The federal list is available at: ▇▇▇▇://▇▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇.▇▇▇. FSSA reserves the right to immediately disenroll any provider if the provider becomes ineligible to participate in the IHCP. The Contractor shall immediately inform the OMPP Program Integrity Unit via a written communication should it disenroll, terminate or deny provider enrollment or credentialing for “program integrity” reasons (i.e., the detection and investigation of fraud and abuse). The Contractor shall follow established procedures to enroll and disenroll providers, including PMPs. The Hoosier Healthwise MCE Policies and Procedures Manual provides detailed information on PMP and provider enrollment and disenrollment procedures. To process provider enrollments and disenrollments with the Contractor, the Contractor shall submit the required information to the State fiscal agent through the Portal. The Contractor shall report PMP disenrollments to the State fiscal agent’s Provider Enrollment unit by mail, fax, e-mail or Portal. The Contractor shall first notify the State fiscal agent of the intent to disenroll a PMP within five (5) business days of the receipt/issuance of the PMP’s disenrollment. The fiscal agent shall receive enrollment/disenrollment requests at least five (5) business days prior to the 24th day of the month before the date the Contractor desires the enrollment or disenrollment to become effective. As noted above, the OMPP PI Unit should also receive disenrollment notices when they are program integrity related. When advanced notice is no...
Program Integrity Overpayment Recovery. The Contractor’s policies on non-payment of certain hospital-acquired conditions must comply with 405 IAC 1-10.5-5 and the IHCP Provider Bulletin regarding Present on Admission Indicator for Hospital Acquired Conditions dated August 25, 2009 (BT200928), as well as any updates or amendments thereto. In accordance with 42 CFR 447.26(d), the Contractor shall require that as a condition of payment, all providers agree to comply with the reporting requirements in 42 CFR 447.26(d). The Contractor’s policy on non-payment of certain never events shall be developed in accordance with current Medicare National Coverage Determinations (NCDs), as well as any Indiana Medicaid FFS rules or other guidance adopted or issued by OMPP at a future date.
Program Integrity Overpayment Recovery. The Contractor has primary responsibility for the identification of all potential waste, fraud and abuse associated with services and ▇▇▇▇▇▇▇▇ generated as a result of this Contract. In cases involving wasteful or abusive provider billing or service practices (including overpayments) identified and recovered by Contractor. In cases involving wasteful or abusive provider billing or service practices (including overpayments) identified by the FSSA PI Unit, FSSA may recover any identified overpayment directly from the provider or may require Contractor to recover the identified overpayment and repatriate the funds to the State Medicaid program as directed by the FSSA PI Unit. The FSSA PI Unit may also take disciplinary action against any provider identified by Contractor or the FSSA PI Unit as engaging in inappropriate or abusive billing or service provision practices. If a fraud referral from Contractor generates an investigation and/or corresponding legal action results in a monetary recovery to IHCP, the reporting Contractor will be entitled to share in such recovery following final resolution of the matter (settlement agreement/final court judgment) and following payment of recovered funds to the State of Indiana. The Contractor's share of recovery will be as follows: From the recovery, the State (including the IMFCU) shall retain its costs of pursuing the action, including any costs associated with FSSA PI Unit operations associated with the investigation, and its actual documented loss (if any). The State will pay to the Contractor the remainder of the recovery, not to exceed the Contractor's actual documented loss. Actual documented loss of the parties will be determined by paid false or fraudulent claims, canceled checks or other similar documentation which objectively verifies the dollar amount of loss. If the State determines it is in its best interest to resolve the matter under a settlement agreement, the State has final authority concerning the offer, or acceptance, and terms of a settlement. The State will exercise its best efforts to consult with the Contractor about potential settlement. The State may consider the Contractor's preferences or opinions about acceptance, rejection or the terms of a settlement, but they are not binding on the State. If final resolution of a matter does not occur until after the Contract has expired, the preceding terms concerning disposition of any recovery and consultation with the Contractor shall survive ...
Program Integrity Overpayment Recovery. Where the excluded individual is the provider of services or an owner of the provider, all amounts paid to the provider shall be refunded. The Contractor shall have adequate staffing and resources to investigate unusual incidents and develop and implement corrective action plans to assist the Contractor in preventing and detecting potential fraud and abuse activities. Staffing levels, at a minimum, will be equal to one full-time staff member for every 100,000 members in addition to the Special Investigation Unit Manager and the Compliance Director. The Contractor shall comply with all federal and state requirements regarding fraud and abuse, including but not limited to Sections 1128, 1156, and 1902(a)(68) of the Social Security Act. The Contractor shall also provide all documentation and information requested by FSSA PI Unit or required under this section and its subsections in the form and manner mandated by the FSSA PI Unit.
Program Integrity Overpayment Recovery. Where the excluded individual is the provider of services or an owner of the provider, all amounts paid to the provider shall be refunded to the State. Any Transportation Provider listed on any of these excluded or disbarred entity databases shall not be included in the Broker’s Network.
Program Integrity Overpayment Recovery. 10.5.1 The DMO shall check with OMIG before initiating repayment of any program integrity-related funds to ensure that repayment is permissible.
10.5.2 DHS or OMIG shall have the right to take disciplinary action against any Provider identified by the DMO, DHS, or OMIG as engaging in inappropriate or abusive billing or service provision practice.
10.5.3 If a fraud referral from the DMO generates an investigation, and corresponding legal action results in a monetary recovery to DHS, the reporting DMO will be entitled to share in such recovery following final resolution (settlement agreement/final court judgment). The State shall retain its costs of pursuing the action, including any costs associated with DHS, OMIG, or MFCU operations associated with the investigation and its actual documented loss (if any). The State shall pay to the DMO the remainder of the recovery, not to exceed the DMO’s actual documented loss. Actual documented loss of the DMO may be determined by paid false or fraudulent claims, canceled checks, or other similar documentation which objectively verifies the dollar amount of loss.
10.5.4 If the State makes a recovery from a fraud investigation in which the DMO has sustained a documented loss but the case did not result from a referral made by the DMO, the State shall not be obligated to repay any monies recovered to the DMO but may do so at its discretion.