Common use of Program Integrity Reporting Clause in Contracts

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 administrative, civil, or criminal. Such cooperation shall include providing, upon request, information, access to records, and access to interview Contractor employees and consultants, including but not limited to those with expertise in the administration of the program and/or in medical or pharmaceutical questions or in any matter related to an investigation. On a quarterly basis, and as otherwise directed by the FSSA PI Unit, the Contractor shall submit a detailed Audit Report to OMPP which outlines the Contractor’s program integrity-related activities, as well as identifies the Contractor’s progress in meeting program integrity-related goals and objectives. The Audit Report shall specify current audits, reviews, claim denials, and investigation activity of the unit, a summary of the reason for the audit/investigative activity, the disposition of any such completed activity (including detailed overpayment amounts identified or recouped), and projected upcoming activity for the following quarter. The Audit Report should also specify individual provider recoupment, repayment schedules, and actions taken for each audit or investigation. The quarterly progress report must identify recoupment totals for the reporting period. The Audit Report shall also identify projected upcoming activity, including the top 20 providers on Contractor’s list for audit, and the type(s) of audit(s) envisioned. The FSSA PI Unit shall review and approve, approve with modifications, or reject the Audit Report and specify the grounds for rejection. Recoupment totals and summaries for each reporting period (quarterly unless otherwise specified by the FSSA PI Unit) must also be submitted in the Audit Report. The Contractor shall notify OMPP within one (1) business day upon discovery of a HIPAA or other security breach.

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 3 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 administrative, civil, or criminal. Such cooperation shall include providing, upon request, information, access to records, and access to interview Contractor employees and consultants, including but not limited to those with expertise in the administration of the program and/or in medical or pharmaceutical questions or in any matter related to an investigation. On a quarterly basis, and as otherwise directed by the FSSA PI Unit, the Contractor shall submit a detailed Audit Report to OMPP which outlines the Contractor’s program integrity-related activities, as well as identifies the Contractor’s progress in meeting program integrity-related goals and objectives. The Audit Report shall specify current audits, reviews, claim denials, and investigation activity of the unit, a summary of the reason for the audit/investigative activity, the disposition of any such completed activity (including detailed overpayment amounts identified or recouped), and projected upcoming activity for the following quarter. The Audit Report should also specify individual provider recoupment, repayment schedules, and actions taken for each audit or investigation. The quarterly progress report must identify recoupment totals for the reporting period. The Audit Report shall also identify projected upcoming activity, including the top 20 providers on Contractor’s list for audit, and the type(s) of audit(s) envisioned. The FSSA PI Unit shall review and approve, approve with modifications, or reject the Audit Report and specify the grounds for rejection. Recoupment totals and summaries for each reporting period (quarterly unless otherwise specified by the FSSA PI Unit) must also be submitted in the Audit Report. The Contractor shall notify OMPP within one (1) business day upon discovery of a HIPAA or other security breach.