Xxxxx and Abuse. 6.5.17.1 If the Qualified Vendor discovers, or is made aware, that an act of suspected fraud or abuse has occurred or been alleged, the Qualified Vendor shall immediately report the incident or allegation to the Division as well as to the AHCCCS, Office of the Inspector General. The Qualified Vendor shall refer to the Division’s Provider Manual for guidance.
Xxxxx and Abuse. Neither party shall engage in any activities which are prohibited by or are in violation of the rules, regulations, policies, contracts or laws pertaining to any third party and/or governmental payer program, or which are prohibited by rules of professional conduct ("Governmental Rules and Regulations"), including but not limited to the following:
Xxxxx and Abuse. Fraud and Abuse Referral Immediately upon notification or knowledge of suspected Fraud and Abuse N/A Contractor shall report all suspected Fraud and Abuse to the Department as required in Article V and Article IX of this Contract. Contractor shall provide a preliminary investigation report as each occurrence is identified.
Xxxxx and Abuse. Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person and includes any act that constitutes fraud under applicable Federal or State law. Abuse means provider actions that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for health care. The Contractor shall do the following to guard against Fraud and Abuse:
Xxxxx 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 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 prev...
Xxxxx 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 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 Federal and State standards related to MA MCOs. • The designation of a compliance officer and a compliance committee that is accountable to CHC-MCO senior management. • Effective training and education for the compliance officer and CHC-MCO employees. • Effective lines of communication between the compliance officer and CHC- MCO employees. • Enforcement of standards through well publicized disciplinary guidelines. • Provisions for internal monitoring and auditing. • Provisions for prompt response to detected offenses and the development of corrective action initiatives. • Procedures for systematic confirmation of services actually provided. • Policies and procedures for reporting all Fraud, waste and Abuse to the Department. • Policies and procedures for Fraud, waste, 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 data bases identified by the Department.
Xxxxx and Abuse. Provider recognizes that payments made by ACDE pursuant to this Agreement are derived from federal and State funds, and acknowledges that it may be held civilly and/or criminally liable to ACDE and/or the Agency, in the event of non-performance, misrepresentation, fraud or abuse for services rendered to Members, including but not limited to, the submission of false claims/statements for payment by Provider, its employees or agents. Provider shall be required to comply with all policies and procedures as developed by ACDE and the Agency, including but not limited to the requirements set forth in the Provider Manual and the Agency Contract, for the detection and prevention of fraud and abuse. Such compliance may include, but not be limited to, referral of suspected or confirmed fraud or abuse to ACDE.
Xxxxx and Abuse. Fraud increases the cost of health care for everyone. If you suspect that a Physician, pharmacy or Hospital has charged you for services you did not receive, billed you twice for the same service or misrepresented any information, please do the following:
Xxxxx and Abuse. The PH-MCO must develop a written compliance plan that contains the following elements described in CMS publication “Guidelines for Constructing a Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans” found at xxx.xxx.xxx.xxx/xxxxxx/xxxxx and that includes the following: • Written policies, procedures, and standards of conduct that articulate the PH-MCO’s commitment to comply with all Federal and State standards related to MA MCOs. • The designation of a compliance officer and a compliance committee that are accountable to PH-MCO senior management. • Effective training and education for the compliance officer and PH-MCO employees. • Effective lines of communication between the compliance officer and PH-MCO employees. • Enforcement of standards through well publicized disciplinary guidelines. • Provisions for internal monitoring and auditing. • Provisions for prompt response to detected offenses and the development of corrective action initiatives.
Xxxxx and Abuse. The provisions of the federal Social Security Act addressing illegal remuneration (the "Anti-Kickback Statute") prohibit providers and others from soliciting, receiving, offering or paying, directly or indirectly, any remuneration in return for either making a referral for a Medicare, Medicaid or CHAMPUS covered service or ordering, arranging for or recommending any such covered service. Violations of the Anti-Kickback Statute may be punished by a fine of up to $25,000 or imprisonment for up to five (5) years, or both. In addition, violations may be punished by substantial civil penalties and/or exclusion from the Medicare and Medicaid programs. Regarding exclusion, the Office of Inspector General ("OIG") of the Department of Health and Human Services may exclude a provider from participation in the Medicare program for a 5-year period upon a finding that the Anti-Kickback Statute has been violated. After OIG establishes a factual basis for excluding a provider from the program, the burden of proof shifts to the provider to prove the Anti-Kickback Statute has not been violated.
