Fraud, Waste and Abuse

Transcription

1 Fraud, Waste and Abuse Policy Statement: Justification: Departments Involved: All LOBs Involved: All Colorado Access is dedicated to providing quality healthcare services to members while conducting business in an ethical manner. Colorado Access supports the efforts of federal and state authorities in identifying incidents of fraud, waste and abuse. Colorado Access has, and will maintain, mechanisms to prevent, identify, detect, investigate report and correct incidents of fraud, waste and abuse in accordance with contractual, regulatory and statutory requirements. Contractual, Regulatory and Statutory Referenced policies: CMP204 Corporate Compliance Program Education and Training CMP207 Unannounced Visits, Search Warrants and Subpoenas CMP212 False Claims Act Definition of Terms: Abuse: Practices that are inconsistent with sound fiscal, business or medical practices, and that result in an unnecessary cost to government programs, or in seeking reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes member practices that result in unnecessary cost to Medicare and Medicaid programs. 1 Claim: The definition of claim under the FCA includes any request or demand, whether under a contract or otherwise, for money or property which is made to a contractor, provider or other recipient, if the United States Government provides any portion of the money or property which is requested or demanded, or if the government will reimburse such contractor provider, or other recipient for any portion of the money or property which is requested or demanded. 2 False Claims Act: The FCA prohibits the knowing submission of unjustified or false claims to obtain federal funds, including Medicare and Medicaid programs. 3 Fraud: An intentional (willful or purposeful) deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable Medicare and Medicaid, or other federal or state laws. 4 Waste: Incurring unnecessary costs as a result of deficient management, practices, systems or controls; the over-utilization of services (not caused by criminally negligent actions) and the misuse of resources. Procedure: I. Reporting Fraud, Waste and Abuse A. All employees of Colorado Access are responsible for immediately reporting potential or suspected incidents of fraud, waste and abuse involving Colorado Access, its members, providers, contractors, vendors or consultants by using one of the 1 42 CFR USC USC CFR Page 1 of 5

2 II. reporting methods listed in paragraph I.C. below. Colorado Access educates employees about fraud, waste and abuse through its Standards of Business Conduct and mandatory compliance training, as indicated in policy and procedure CMP204 Compliance Program Education and Training. B. All providers, vendors, contractors, consultants, members and others associated with Colorado Access are encouraged to report potential or suspected incidents of fraud, waste and abuse, involving Colorado Access, its members, vendors, contractors, consultants and providers by using the reporting methods listed in paragraph I.C. below. Colorado Access will include information about fraud, waste, abuse and the False Claims Act, in the provider manual, on the company website, in provider bulletins, company policies and procedures, vendor contracts, and in other communications and training materials. C. Potential or suspected incidents of fraud, waste and abuse may be reported by any of the following methods: 1. Contacting your direct supervisor or a member of the Colorado Access Compliance Team. 2. Contacting the Corporate Compliance Officer (CCO) directly either in person, by phone at , in writing at the Colorado Access facility located at East Harvard Boulevard, Suite 600, Denver, CO 80231, by dedicated fax number at , or one of the confidential compliance suggestion boxes located throughout the Colorado Access facility. 3. Using the dedicated compliance address at compliance@coaccess.com. 4. Calling the confidential Compliance Hotline , that provides both confidential and anonymous reporting. D. Colorado Access will not discriminate or retaliate against anyone who reports a perceived problem or concern in good faith and will abide by the whistleblower provisions of the False Claims Act (see policy and procedure CMP212 False Claims Act). Prevention and Detection A. Colorado Access has designated a Corporate Compliance Officer who is responsible for establishing methods for preventing, identifying, detecting, investigating and correcting potential incidents of fraud, waste and abuse and reporting such incidents to the appropriate state and federal agencies. The CCO serves as the Chair of the Executive Compliance Committee that sets direction and monitors overall performance of the compliance program and reports to the Finance Audit and Compliance Committee of the Board of Directors. The CCO is responsible for ensuring the design and development of methods for preventing and identifying fraud, waste and abuse and responding appropriately and immediately to all detected program violations. In addition, employees and individuals who contract with the company are encouraged to report incidents of fraud, waste and abuse under the False Claims Act. If incidents of fraud, waste and abuse are identified, systematic changes and corrective action initiatives will be put into place as appropriate to prevent further offenses. In addition, employees and contractors are free to pursue the Whistleblower provisions of the False Claims Act in accordance with that law (see policy and procedure CMP212 False Claims Act). B. Colorado Access has established and maintains a compliance program designed to detect, and prevent, investigate and report incidents of fraud, waste and abuse 5 6, 5 ABC, Contract Routing Number , II.G.5.c., Page 30 of 93 6 CHP Health Plan, Contract Routing Number , Exhibit A, , Page 63 of 81 Page 2 of 5

3 III. which may include, but are not limited to, a claims quality assurance program that monitors the accuracy of adjudicated claims, internal monitoring and auditing, prompt response to detected offenses and for development of corrective action initiatives, reporting mechanisms, and a process that identifies employees, subcontractors, vendors and providers that are debarred or excluded from participating in federal programs. In addition, Colorado Access has established and maintains a formal accounting system that monitors the funds received from the State of Colorado to fulfill the administration of the contracted State healthcare programs. Colorado Access system of accounting is in accordance with Generally Accepted Accounting Principles (GAAP). Where Statutory Accounting Principles are required by the Colorado Division of Insurance, Colorado Access applies those statutory principles in lieu of GAAP. Both GAAP and Statutory Accounting Principles provide adequate safeguards to ensure the proper monitoring of financial transactions. Notifying State Agencies and Other Entities A. Colorado Access will report potential, suspected and any judgments or settlements involving incidents of fraud, waste and abuse to the appropriate state and/or federal agency in accordance with statutory, regulatory and contractual requirements. For specific reporting requirements by line of business, note the following: 1. Access Behavioral Care (ABC) Immediate notification of known confirmed intentional incidents of Medicaid fraud and abuse is sent to the Contract Manager at HCPF and to the appropriate law enforcement agency, including, but not limited to, the Medicaid Fraud Control Unit (MFCU). 7 Colorado Access will immediately report indications or suspicions of fraud by giving a verbal report to the contract manager. It will then investigate its suspicions and shall submit its written findings and concerns to the contract manager within three (3) business days of the verbal report. If the investigation is not complete in three (3) business days, Colorado Access will continue its investigation. A final report will be delivered within fifteen (15) business days of the verbal report. The contract manager may approve an extension of time in which to complete the final report upon a showing of good cause Child Health Plan Plus (CHP+HMO) Intentional incidents of fraud and abuse shall be reported immediately to HCPF and to the appropriate law enforcement agency, including, but not limited to, MFCU. 9 Colorado Access shall immediately report indications or suspicions of fraud by giving a verbal report to HCPF. Colorado Access shall investigate its suspicions and shall submit its preliminary fraud report containing its findings and concerns to HCPF. Colorado Access shall continue its investigation and shall provide a final fraud report to HCPF detailing the results of the investigation. HCPF may approve an extension of time in which to complete the final fraud report upon a showing of good cause. 10 A verbal fraud report is due within one business day of when Colorado Access becomes aware of the fraud; the preliminary report shall be due within three business days of the verbal fraud report; the final fraud report shall be due within fifteen days of the verbal fraud report ABC, Contract Routing Number , II.G.5.k., Page 30 of 93 8 ABC, Contract Routing Number , II.G.5.l.,Page 30 of 93 9 CHP Health Plan, Contract Routing Number , , Page 65 of CHP Health Plan, Contract Routing Number , , Page 66 of CHP Health Plan, Contract Routing Number , , Page 66 of 81 Page 3 of 5

4 3. Access Advantage (AA) Notification is sent to the Regional Plan Manager at the Centers for Medicare and Medicaid Services Regional Care Collaborative Organization (RCCO) Colorado Access will report to HCPF any suspicion or knowledge of fraud or abuse, including, but not limited to, false or fraudulent filings of claims and the acceptance of or failure to return any monies allowed or paid on claims known to be fraudulent. 13 Colorado Access will report any suspicion or knowledge of fraud or abuse to HCPF immediately upon receipt of the information causing suspicion or knowledge of the fraud or abuse. 14 Colorado Access will prepare a written program integrity report detailing the specific background information of any reported fraud or abuse, the name of the provider and a description of how Colorado Access became aware of the information that led to the report. Colorado Access will deliver this Program Integrity Report to HCPF within ten (10) business days from when it reported the fraud or abuse to HCPF. 15 Colorado Access will report any possible instances of a member's fraud, such as document falsification, to the Department of Human or Social Services in the county in which the member resides, immediately upon gaining information leading to knowledge of the fraud or suspicion of fraud. Colorado Access will deliver a written report of the possible instances of the member's fraud detailing the specific background information of the reported fraud, the name of the member and a description of how Colorado Access became aware of the information that led to the report. Colorado Access will deliver this Member fraud report to the county department to which it made its initial report within ten (10) business days from when it reported the fraud to the county department Member When the incident of fraud and abuse involves a member that has knowingly given incorrect information to Colorado Access, Colorado Access may request an immediate disenrollment of the member. 17 B. Upon receipt or detection of an incident of known or suspected fraud, waste or abuse and prior to the required reporting to any of the entities listed above, the CCO or a designee may consult with the Staff Attorney as needed. C. Employees who identify instances of suspected fraud, waste and abuse may report the issue to the Department of Justice or a private attorney for further investigation. This reporting will not subject the employee to discharge, demotion suspension, threat, harassment, retaliation or discrimination of any kind (see policy and procedure CMP212 False Claims Act). D. Colorado Access will report known or suspected or actual fraudulent claims, judgments or settlements involving fraud, waste and abuse to the Colorado Division of Insurance, in accordance with the requirements of state regulation 18 and within sixty (60) days of the completion of an investigation and/or receipt of the judgment or CFR (h)(1) and (h)(1) 13 RCCO, Contract Routing Number , Exhibit A , Page 32 of RCCO, Contract Routing Number , Exhibit A , Page 32 of RCCO, Contract Routing Number , Exhibit A , Page 32 of RCCO, Contract Routing Number , Exhibit A , Page 32 of CFR (d)(i)(C)(3) 18 CRS Page 4 of 5

5 IV. settlement. Reports to the Division of Insurance will be submitted by using the Claim form available through the Colorado Division of Insurance website at E. The external regulatory agency and/or entity to which Colorado Access reports incidents of fraud waste and abuse under this policy and procedure, including HCPF and MFCU, will determine whether the information provided by Colorado Access substantiates fraud, waste and abuse. If it is determined that a credible allegation of fraud exists, the agency/entity reported to will determine the course of action to be taken including payment suspension 19, recovery, sanction, disenrollment, and civil or criminal prosecution. Colorado Access will cooperate with these agencies if they need additional information or follow-up action. F. Colorado Access, may, on its own initiative, suspend payment to any network provider against whom there is a credible allegation of fraud, but only after consultation with HCPF and the MFCU. Colorado Access shall not suspend payment when law enforcement officials have specifically requested that a payment suspension not be imposed because such a payment suspension may compromise or jeopardize an investigation. 20 Enforcement and Correction A. Colorado Access, and its employees, is expected to fully cooperate with federal and state agencies that conduct healthcare fraud and abuse investigations. This includes releasing to a state agency all relevant nonproprietary or non-private information or evidence which Colorado Access maintains and is relevant to the investigation, in accordance with state and federal laws, rules and regulations (see policy and procedure CMP207 Unannounced Visits, Search Warrants and Subpoenas). B. Colorado Access will take appropriate disciplinary action (e.g. corrective action plans, employment termination or contract termination) against employees, providers, subcontractors, consultants, and agents found to have committed fraud, waste or abuse, in its sole discretion or at the direction of external regulatory agencies and/or entities. 19 ABC, Contract Amendment No. 5, Contract Routing Number , 6.a., Page 2 of 5 20 ABC, Contract Amendment No. 5, Contract Routing Number , 6.a., Page 2 of 5 Page 5 of 5