Xxxxx and Abuse. 6.5.17.1 If the Qualified Vendor discovers, or is made aware, that an act of suspected fraud or abuse has occurred or been alleged, the Qualified Vendor shall immediately report the incident or allegation to the Division as well as to the AHCCCS, Office of the Inspector General. The Qualified Vendor shall refer to the Division’s Provider Manual for guidance.
Xxxxx and Abuse. Neither party shall engage in any activities which are prohibited by or are in violation of the rules, regulations, policies, contracts or laws pertaining to any third party and/or governmental payer program, or which are prohibited by rules of professional conduct ("Governmental Rules and Regulations"), including but not limited to the following:
i. 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;
ii. knowingly and willfully making or causing to be made any false statement or representation of a material fact for use in determining rights to any benefit or payment;
iii. failing to disclose knowledge by a claimant of the occurrence of any event affecting the initial or continued right to any benefit or payment on the Provider's own behalf or on behalf of another, with intent to fraudulently secure such benefit or payment; or
iv. knowingly and willfully soliciting or receiving any remuneration (including any kickback, bribe, or rebate), directly or indirectly, overtly or covertly, in cash or in kind or offering to pay or receive such remuneration
1. 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
2. in return for purchasing, leasing, or ordering or arranging for 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. Each party acknowledges that this list is not an exhaustive or complete list of all governmental requirements and each party represents and warrants to the other that each will endeavor, to the best of their knowledge, to educate, to seek information, and/or to make themselves aware of these governmental requirements.
Xxxxx and Abuse. To the knowledge of the Responsible Officers of the Loan Parties, neither the Borrowers nor any Subsidiary or any of their respective officers or directors have engaged in any activities that are prohibited under Medicare Regulations or Medicaid Regulations that could reasonably be expected to have a Material Adverse Effect.
Xxxxx and Abuse. Fraud and Abuse Referral Immediately upon notification or knowledge of suspected Fraud and Abuse N/A Contractor shall report all suspected Fraud and Abuse to the Department as required in Article V and Article IX of this Contract. Contractor shall provide a preliminary investigation report as each occurrence is identified.
Xxxxx and Abuse. Contractor agrees to submit a quarterly fraud and abuse report that conforms to the State's specifications. This report is due no later than thirty (30) days after the end of the reporting quarter. As indicated in 42 C.F.R. § 455.17 the quarterly fraud and abuse report shall indicate at minimum:
(1) the number of complaints of fraud and abuse that warranted preliminary investigation, and (2) for each case of suspected provider fraud and abuse that warrants a full investigation. For the latter case, the contractor shall report the following: • the provider’s name and number • the source of the compliant • the type of provider • the nature of the complaint • the approximate range of dollars involved • the legal and administrative disposition of the case including actions taken by law enforcement officials to whom the case has been referred.
i. Recovery Reporting In accordance with 42 C.F.R. Part 433, Subpart F, the Contractor and all subcontractors must establish a mechanism for a network provider to report to the Contractor when it has received an overpayment, to return the overpayment to the Contractor within sixty (60) calendar days after the date on which the overpayment was identified, and to notify the Contractor in writing of the reason for the overpayment. The report of total recoveries shall be provided to EOHHS on an annual basis and will separate out recoveries made for these types of overpayments in addition to any recoveries made related to fraud, waste and abuse activities. The Contractor and subcontractors must report to EOHHS within sixty (60) calendar days any capitation payments that has been identified as exceeding the contracted capitation payments.
Xxxxx and Abuse. The CHC-MCO must develop and implement administrative and management arrangements and procedures and a mandatory written compliance plan to prevent, detect, and correct Fraud, Waste, and Abuse that contains the elements described in CMS publication “Guidelines for Constructing a Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans” found at: xxxxx://xxx.xxx.xxx/Medicare-Medicaid-Coordination/Fraud- Prevention/FraudAbuseforProfs/Downloads/mccomplan.pdf and that includes the following: Written policies, procedures, and standards of conduct that articulate the CHC-MCO’s commitment to comply with all Federal and State standards related to MA MCOs. The designation of a compliance officer and a compliance committee that 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 this Agreement. The establishment of a Regulatory Compliance Committee on the Board of Directors and at the senior management level charged with overseeing the organization’s compliance program and its compliance with the requirements under this Agreement. Effective training and education for the compliance officer, senior management and CHC-MCO employees. Effective lines of communication between the compliance officer and CHC- MCO employees. Enforcement of standards through well publicized disciplinary guidelines. The establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, prompt response to compliance issues as they are raised, investigation of potential compliance problems as identified in the course of self-evaluation and audits, correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and ongoing compliance with the requirements under the Agreement. • Procedures for systematic confirmation of services actually provided. • Policies and procedures for reporting all Fraud, Waste, and Abuse to the Department. • Policies and procedures for Fraud, Xxxxx, and Abuse prevention, detection and investigation. • A policy of non-intimidation and non-retaliation for good faith participation in the compliance program, including, but not limited to, reporting potential issues, investigating issues, cond...
Xxxxx and Abuse. The PH-MCO must develop a written compliance plan that contains the following elements described in CMS publication “Guidelines for Constructing a Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans” found at xxx.xxx.xxx.xxx/xxxxxx/xxxxx and that includes the following: • Written policies, procedures, and standards of conduct that articulate the PH-MCO’s commitment to comply with all Federal and State standards related to MA MCOs. • The designation of a compliance officer and a compliance committee that are accountable to PH-MCO senior management. • Effective training and education for the compliance officer and PH-MCO employees. • Effective lines of communication between the compliance officer and PH-MCO employees. • Enforcement of standards through well publicized disciplinary guidelines. • Provisions for internal monitoring and auditing. • Provisions for prompt response to detected offenses and the development of corrective action initiatives.
Xxxxx and Abuse. Fraud increases the cost of health care for everyone. If you suspect that a Physician, pharmacy or Hospital has charged you for services you did not receive, billed you twice for the same service or misrepresented any information, please do the following:
A) Call the Provider and ask for an explanation. There may be an error.
B) If the Provider does not resolve the matter, please notify WHP’s Member Services department at (000) 000-0000 or (000) 000-0000 and explain the situation. For the hearing impaired, please call the toll-free Indiana Relay number at (000) 000-0000.
C) If the issue is not resolved, you may contact the National Insurance Crime Bureau at (000) 000-0000.
Xxxxx and Abuse. The CHC-MCO must develop and implement administrative and management arrangements and procedures and a mandatory written compliance plan to prevent, detect, and correct Fraud, waste, and Abuse that contains the elements described in CMS publication “Guidelines for Constructing a Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans” found at: xxxxx://xxx.xxx.xxx/Medicare-Medicaid-Coordination/Fraud- Prevention/FraudAbuseforProfs/Downloads/mccomplan.pdf and that includes the following: • Written policies, procedures, and standards of conduct that articulate the CHC-MCO’s commitment to comply with all Federal and State standards related to MA MCOs. • The designation of a compliance officer and a compliance committee that is accountable to CHC-MCO senior management. • Effective training and education for the compliance officer and CHC-MCO employees. • Effective lines of communication between the compliance officer and CHC- MCO employees. • Enforcement of standards through well publicized disciplinary guidelines. • Provisions for internal monitoring and auditing. • Provisions for prompt response to detected offenses and the development of corrective action initiatives. • Procedures for systematic confirmation of services actually provided. • Policies and procedures for reporting all Fraud, waste and Abuse to the Department. • Policies and procedures for Fraud, waste, and Abuse prevention, detection and investigation. • A policy of non-intimidation and non-retaliation for good faith participation in the compliance program, including but not limited to reporting potential issues, investigating issues, conducting self-evaluations, audits and remedial actions, and reporting to appropriate officials. • A policy and procedure for monitoring provider preclusion through data bases identified by the Department.
Xxxxx and Abuse. DVHA in collaboration with its IGA partners must have both administrative and management procedures, and a mandatory compliance plan, to guard against fraud and abuse. The procedures and compliance plan must include the following: • Written policies, procedures and standards of conduct that articulate a commitment to comply with all applicable Federal and State standards; • Designation of a compliance officer and a compliance committee that are accountable to senior management; • Effective training and education for the compliance officer and all of DVHA’s employees; • Effective lines of communication between the compliance officer and employees; • Enforcement of standards through well-publicized disciplinary guidelines; • Provision for internal monitoring and auditing; and • Provision for prompt response to detected offenses, and for development of corrective action initiatives. DVHA must further require any employees, contractors, and grantees that provide goods or services for the Global Commitment to Health Demonstration to furnish, upon reasonable request, to DVHA, the Vermont Attorney General, and the United States DHHS, any record, document, or other information necessary for a review, audit, or investigation of program fraud or abuse, and shall establish procedures to report all suspected fraud and abuse to AHS and the Vermont Attorney General. For each case of suspected fraud and abuse reported, DVHA shall supply (as applicable) the name and identification number; source of the complaint or issue; type of provider; nature of the complaint or issue; the approximate dollars involved; and the legal and administrative disposition of the case. DVHA must provide access to both original documents and provide free copies of requested documents on a reasonable basis. Such access may not be limited by confidentiality provisions of the plan or its contractors. DVHA will ensure that its compliance program, includes at a minimum, the following elements: • Written policies, procedures, and standards of conduct that articulate the organization’s commitment to comply with all applicable requirements and standards under the contract, and all applicable Federal and State requirements; • The designation of a Compliance Officer who is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract and who reports directly to the Commissioner; • The establishment of a Regulatory Comp...
