Detection of Fraud and ▇▇▇▇▇. The Carrier shall conduct a program to assess its vulnerability to fraud and abuse and shall operate a system designed to detect and eliminate fraud and abuse internally by Carrier employees and subcontractors, by providers providing goods or services to FEHB Members, and by individual FEHB Members. The program must specify provisions in place for cost avoidance not just fraud detection, along with criteria for follow-up actions. The Carrier must submit to OPM an annual analysis of the costs and benefits of its fraud and abuse program. The Carrier must submit annual reports to OPM by March 31 addressing the following: Cases opened; Dollars identified as lost and recovered on active cases Actual savings and prevented loss on active cases; Active cases referred to law enforcement (other than the OPM-OIG) Active cases referred to OPM – OIG; Active cases resolved administratively; Percentage of active cases where the FEHB Program is the only or primary line of business affected Number of FEHB providers who are on prepayment review; and Number of arrests and criminal convictions resulting from active cases The report will also include the industry standards checklist.
Appears in 2 contracts