Billing Manual for Community Care Network Providers

APPENDICESAPPENDIX A.1. Fraud, Waste, and Abuse Compliance and Auditing Policies andProceduresPOLICYCommunity Care has established a fraud, waste, and abuse (FWA) complianceprogram that complies with regulations set forth by the Office of Inspector General(OIG) of the Department of Health and Human Services and with the requirements ofthe Bureau of Program Integrity (BPI) of the Department of Public Welfare (DPW). TheOIG encourages health care organizations to establish programs to educate andattempt to control fraud, waste, and abuse in health care. Documents have beenpublished by the OIG that identify the minimum elements that should be included in acompliance program, as well as specific areas of concern to the OIG. The BPI has alsoissued guidance on the reporting of suspected fraud, waste, and abuse.Toward that end, billing compliance audits of our provider panel are routinely conductedto determine potential areas of fraud and abuse, as defined below, that may beoccurring. These audits are conducted on an ongoing basis by specially trained staff.Community Care will continuously monitor instances of potential or actual fraud andabuse in billing by using recognized standards acceptable to the Medicaid Program.Suspected or substantiated fraud and abuse under the HealthChoices contract will bereported by the Fraud, Waste, and Abuse Department to the Bureau of ProgramIntegrity, to the appropriate county designee, and to appropriate oversight entities.Community Care follows all Medicaid Program regulations and BPI directives whenconducting and reporting audit information. No claims or documentation regulations arecreated by Community Care. In addition, the Department of Public Welfare’s Medichecklist and the OIG’s LEIE list are used to verify that no providers sanctioned by the stateor federal regulatory authorities are participating in HealthChoices.DefinitionsFraud is defined by the BPI as “any type of intentional deception or misrepresentationmade by an entity or person with the knowledge that the deception could result in someunauthorized benefit to the entity or him/herself or some other person in a managedcare setting.” It includes any act that constitutes fraud under applicable federal or statelaw. Fraud may be found under the following conditions (the following list is intended asan example and not as a limitation):When a provider submits a bill for a service that was not provided.When a provider bills for a time period greater than the time actually spent withthe client.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 126