Provider Fraud, Waste, and Abuse Audit Appeal - Community Care ...

POLICIES AND PROCEDURESPROVIDER FRAUD WASTE AND ABUSE AUDIT APPEALPOLICYDate Issued:9-22-10Date Revised:12-20-10 4-1-11COMMUNITY CAREPolicy # FWA 011Page 1 of 2Date OMHSASApproved: 5/31/11POLICYIt is the policy of Community Care Behavioral Health to provide a transparent reviewprocess that enables HealthChoices providers to appeal Fraud, Waste, and Abuse (FWA)audit results. The Special Investigations Unit (SIU) relies on the Department of PublicWelfare (DPW) regulations, Medical Assistance Bulletins, and Community Careperformance standards and fee schedules, as tools when conducting audits. Although auditresults are based on clear and objective data that are derived from the above sources, theremay be instances when the provider disagrees with audit findings. This policy serves toallow an impartial and timely review of such disagreements.PROCEDUREOral and written instructions regarding the appeal process are reviewed with providers atthe conclusion of each provider audit.A. Oral instructions for the appeal process are reviewed with the providerimmediately following their program audit.1. During the exit interview that is conducted after the completion ofthe audit, all audit findings are reviewed with the provider.2. The provider is informed during this discussion that they will bereceiving a formal letter and an itemization, if applicable, outliningthe results of the audit within two weeks from the date that the exitinterview occurred.3. The appeal process, which is outlined in section B below, is alsoexplained at this time.B. Written appeal instructions are included in the audit results letters to allproviders.1. Providers must submit written notification via certified mail to theFWA auditor, postmarked within 10 business days from the date oftheir audit results letter, of their intent to appeal the audit findings.2. If the Provider does not submit their appeal to the Fraud Waste andAbuse Department within 30 business days any subsequent requestfor an appeal will be denied.ALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OFCOMMUNITY CARE AND ARE SUBJECT TO CHANGE, REVISION, 1 MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIMEWITHOUT NOTICE AND SUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESPROVIDER FRAUD WASTE AND ABUSE AUDIT APPEALPOLICYDate Issued:9-22-10Date Revised:12-20-10 4-1-11COMMUNITY CAREPolicy # FWA 011Page 2 of 2Date OMHSASApproved: 5/31/113. The Provider must submit, via certified mail, their detailed appealin its entirety to the FWA auditor, postmarked within 30 businessdays, of the date of the original audit results letter.4. The appeal must include documentation supporting each claim lineincluding the claim number, member name, date that the serviceoccurred, service code, number of units involved, monetary amount,and the rationale for the appeal for each item in question. Onlyspecific documentation supporting provider disagreement with auditexceptions will be reviewed by the Provider Appeal Committee forconsideration during this appeal process.5. The auditor will forward the formal Provider appeal along with allsupporting documentation to the Director or the Manager of theFWA Department within 1 business day of receipt of the appeal.6. Documentation will then be submitted to the Provider AppealCommittee for review and a decision will be rendered within 30days of receiving all of the appeal information.7. The Provider Appeal Committee is comprised of two RegionalDirectors, the Chief Operations Officer or the Chief GovernmentContracts Officer, where applicable, a professional with the samecredentials as the provider appealing the audit, and the VicePresident of Quality Audit, Fraud, and Abuse , UPMC InsuranceDivision, who will conduct an impartial review of the appeal.8. This Committee is scheduled to meet monthly in order to ensuretimely reviews of any outstanding Provider appeals.9. The decision of the Committee will be considered final.10. The Provider Appeal Committee will notify the Provider in writingof the appeal decision.11. A copy of the appeal decision will be forwarded to the FWADepartment for the audit file.12. Community Care will forward a copy of the provider appeal letteras well as the appeal decision letter to the appropriate state andcounty HealthChoices contract administrators as needed.13. This appeals policy in no way interferes with or limits CommunityCare’s obligation to report all cases of suspected fraud, waste, and orabuse to CMS, DPW/ Bureau of Program Integrity, and the state orCounty Administrator representing the county/counties involved,under Appendix F, within 30 days of the discovery of any suspectedfraud, waste, and/or abuse.ALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OFCOMMUNITY CARE AND ARE SUBJECT TO CHANGE, REVISION, 2 MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIMEWITHOUT NOTICE AND SUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.