Program Integrity Reporting Clause Samples

Program Integrity Reporting. The Contractor shall cooperate with all appropriate state and federal agencies, including the Indiana MFCU and the FSSA PI Unit, in investigating fraud and abuse. The Contractor shall have methods for identification, investigation, and referral of suspected fraud cases (42 CFR 455.13, 455.14, 455.21). Contractor shall provide an Audit Report to OMPP and the FSSA PI Unit. The Audit Report documents all provider and member-specific program integrity activities of Contractor (i.e., the specific application of Program Integrity Plan provisions to identify specific provider and member waste, fraud and abuse), as documented below. The Contractor shall immediately report all suspected or confirmed instances of waste, fraud and abuse to the OMPP and the FSSA PI Unit. The Contractor shall use the Reporting Forms provided by the OMPP for all such reporting or such other form as may be deemed satisfactory. The Contractor shall be subject to non-compliance remedies under this Contract identified in Exhibit 4 for willful failure to report fraud and abuse by providers, Medicaid beneficiaries/members, or applicants to the FSSA PI Unit as appropriate. All confirmed or suspected cases of waste, fraud and abuse shall be discussed at the Managed Care-Program Integrity coordination meeting following the FSSA PI Unit’s receipt of the report unless otherwise directed by the FSSA PI Unit. The Contractor shall promptly perform a preliminary investigation of all incidents of suspected and/or confirmed fraud and abuse. Unless prior written approval is obtained from the agency to whom the incident was reported, or to another agency designated by the agency that received the report, after reporting fraud or suspected fraud and/or suspected abuse and/or confirmed abuse, the Contractor shall not take any of the following actions as they specifically relate to Indiana claims:  Contact the subject of the investigation about any matters related to the investigation;  Enter into or attempt to negotiate any settlement or agreement regarding the incident; or  Accept any monetary or other thing of valuable consideration offered by the subject of the investigation in connection with the incident.  The Contractor shall promptly provide the results of its preliminary investigation to the FSSA PI Unit or to another agency designated by the FSSA PI Unit.  The Contractor shall cooperate fully in any further investigation or prosecution by any duly authorized government agency, whether administ...