Billing Manual for Community Care Network Providers

When a provider bills for the provision of a service that did not meet the servicedefinitions, performance specifications, state or federal regulations, oraccreditation standards customarily recognized in behavioral health care.Inappropriate or frequent referrals that may constitute a conflict of interest.Care authorizations to providers who may have personal or other financialrelationships with care managers.Other related claims or care management issues that may involve intentionaldeception or misrepresentation as referenced above.Abuse is defined by the BPI as “any practices that are inconsistent with sound fiscal,business, or medical practices, and result in unnecessary cost to the Medicaid Program,or in reimbursement for services that are not medically necessary or that fail to meetprofessionally recognized standards or contractual obligations (including the terms ofthe [HealthChoices] RFP, Agreement and the requirements of the state or federalregulations) for health care in a managed care setting.” It also includes recipientpractices that result in unnecessary cost to the Medicaid Program.Community Care works collaboratively and cooperates fully with all oversight entities,counties, and regulatory agencies including, but not limited to, the BPI, the Office of theAttorney General’s Medicaid Fraud Control Section, the U.S. Justice Department, theCenter for Medicare and Medicaid Services, and the Pennsylvania Office of InspectorGeneral.Procedures for Monitoring the Provider Network for Fraud, Waste, or AbuseThe Fraud, Waste, and Abuse Department utilizes a number of methodologies in orderto detect fraud, waste, and abuse. The initiatives include, but are not limited to:Conducting routine provider chart reviews.Data analysis of provider billing information, including comparing historical trends ofpeer and best practice thresholds.Cooperation and collaboration between the Provider Reimbursement and FWADepartments in order to be proactive in detecting or preventing FWA.Review and testing of edits that are in place within the claims system to preventduplicate payments or payments without authorizations.Investigation of all referrals including those submitted through the FWA Hotline andthe FWA e-mail account.Cooperation and collaboration with external investigators including the BPI, CMS,Medi-Medi, or other law enforcement agencies.The auditing process for routine audits is outlined below.a. The provider will receive a notification letter and a telephone call informing him orher that the provider has been selected for an audit. The provider is either given theexact date and start time of the on-site audit, or they receive a request for membercharts to be sent to Community Care for a desk audit.Community Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 127