Common use of Fraud, Waste, and Abuse Clause in Contracts

Fraud, Waste, 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 42 CFR §438.608(a)(1)(i-vii) and 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 applicable requirements and standards under the Agreement, and all applicable Federal and State requirements. • 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 on the applicable Federal and State requirements and applicable standards and requirements under the Agreement. • 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, for prompt response to compliance issues as they are raised, for investigation of potential compliance problems as identified in the course of self-evaluation and audits, for correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and for 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 and applicable law enforcement agencies. • 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, conducting self-evaluations, audits and remedial actions, and reporting to appropriate officials. • A policy and procedure for monitoring provider preclusion through databases identified by the Department.

Fraud, Waste, 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 42 CFR §438.608(a)(1)(i-vii) and 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 applicable requirements and standards under the Agreement, and all applicable Federal and State requirements. • 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 on the applicable Federal and State requirements and applicable standards and requirements under the Agreement. • 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, for prompt response to compliance issues as they are raised, for investigation of potential compliance problems as identified in the course of self-evaluation and audits, for correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and for 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 and applicable law enforcement agencies. • Policies and procedures for Fraud, XxxxxWaste, 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 databases identified by the Department.

Fraud, Waste, and Abuse. The CHCPH-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 following elements described in 42 CFR C.F.R. §438.608(a)(1)(i-vii) and 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 on the CMS website and that includes the following: • Written policies, procedures, and standards of conduct that articulate the CHC-MCO’s organization's commitment to comply with all applicable requirements and standards under the Agreement, and all applicable Federal and State requirements. • The designation of a compliance officer and a compliance committee that reports directly to the Chief Executive Compliance Officer and the board of directors and who is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of this Agreementthe Agreement and who reports directly to the Chief Executive Officer and the board of directors. • The establishment of a Regulatory Compliance Committee on the Board of Directors and at the senior management level charged with overseeing the organization’s 's compliance program and its compliance with the requirements under this the Agreement. • Effective A system for training and education for the compliance officerCompliance Officer, the organization's senior management management, and CHC-MCO the organization's employees on the applicable Federal and State requirements and applicable standards and requirements under the Agreement. • Effective lines of communication between the compliance officer and CHC- PH-MCO employees. • Enforcement of standards through well publicized disciplinary guidelines. • The establishment Establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, for prompt response to compliance issues as they are raised, for investigation of potential compliance problems as identified in the course of self-evaluation and audits, for correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and for ensure 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 and applicable law enforcement agenciesagency . • Policies and procedures for Fraud, XxxxxWaste, 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-self- evaluations, audits and remedial actions, and reporting to appropriate officials. • A policy and procedure for monitoring provider preclusion through databases identified by the Department.

Fraud, Waste, and Abuse. ‌ The CHCPH-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 following elements described in 42 CFR C.F.R. §438.608(a)(1)(i-vii) and 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 on the CMS website and that includes the following: • Written policies, procedures, and standards of conduct that articulate the CHC-MCO’s organization's commitment to comply with all applicable requirements and standards under the Agreement, and all applicable Federal and State requirements. • The designation of a compliance officer and a compliance committee that reports directly to the Chief Executive Compliance Officer and the board of directors and who is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of this Agreementthe Agreement and who reports directly to the Chief Executive Officer and the board of directors. • The establishment of a Regulatory Compliance Committee on the Board of Directors and at the senior management level charged with overseeing the organization’s 's compliance program and its compliance with the requirements under this the Agreement. • Effective A system for training and education for the compliance officerCompliance Officer, the organization's senior management management, and CHC-MCO the organization's employees on the applicable Federal and State requirements and applicable standards and requirements under the Agreement. • Effective lines of communication between the compliance officer and CHC- PH-MCO employees. • Enforcement of standards through well publicized disciplinary guidelines. • The establishment Establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, for prompt response to compliance issues as they are raised, for investigation of potential compliance problems as identified in the course of self-evaluation and audits, for correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and for ensure 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 and applicable law enforcement agenciesagency. • 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, conducting self-self- evaluations, audits and remedial actions, and reporting to appropriate officials. • A policy and procedure for monitoring provider preclusion through databases identified by the Department.

Fraud, Waste, and Abuse. The CHCPH-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 following elements described in 42 CFR C.F.R. §438.608(a)(1)(i-vii) and 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 on the CMS website and that includes the following: • Written policies, procedures, and standards of conduct that articulate the CHC-MCO’s organization's commitment to comply with all applicable requirements and standards under the Agreement, and all applicable Federal and State requirements. • The designation of a compliance officer and a compliance committee that reports directly to the Chief Executive Compliance Officer and the board of directors and who is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of this Agreementthe Agreement and who reports directly to the Chief Executive Officer and the board of directors. • The establishment of a Regulatory Compliance Committee on the Board of Directors and at the senior management level charged with overseeing the organization’s 's compliance program and its compliance with the requirements under this the Agreement. • Effective A system for training and education for the compliance officerCompliance Officer, the organization's senior management management, and CHC-MCO the organization's employees on the applicable Federal and State requirements and applicable standards and requirements under the Agreement. • Effective lines of communication between the compliance officer and CHC- PH-MCO employees. • Enforcement of standards through well publicized disciplinary guidelines. • The establishment Establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, for prompt response to compliance issues as they are raised, for investigation of potential compliance problems as identified in the course of self-evaluation and audits, for correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and for ensure 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 and applicable law enforcement agenciesagency . • 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, conducting self-self- evaluations, audits and remedial actions, and reporting to appropriate officials. • A policy and procedure for monitoring provider preclusion through databases identified by the Department.