Fraud and Abuse Program Sample Clauses

Fraud and Abuse Program. The Contractor shall have internal controls, policies and procedures, and a compliance plan to guard against fraud and abuse. Specifically, the Contractor shall have written policies, procedures, and standards of conduct that articulate the Contractor’s commitment to comply with all applicable federal and state standards subject to approval by the Division. At a minimum, the plan shall include the following: a. The designation of a compliance officer and a compliance committee that is accountable to senior management. b. Effective training and education for the compliance officer and the Contractor’s employees. c. Effective lines of communication between the compliance officer and the Contractor’s employees. d. Enforcement of standards through well publicized disciplinary guidelines. e. Provision for internal monitoring and auditing. f. Provision for prompt response to detected offenses and for development of corrective action initiatives relating to this Contract. The Contractor shall report Enrollee or provider fraud or abuse which it had reasonable cause to suspect, or should have had reasonable cause to suspect, immediately to the Division, and shall cooperate with the Division regarding the investigation. Failure to do so could result in criminal and/or civil penalties. a. The information to be reported on providers must include the provider name, address, provider number, phone number; the name, title, address, agency and phone number of the person making the report; and details of the report such as information source, names, and list of attached documentation. b. The information to be reported regarding Enrollees must include the Enrollee's name, address, Medicaid identification number; the name, title, address, agency and phone number of the person making the report; and details of the report. c. Quarterly the Contractor must report the number of complaints of fraud and abuse made to the Division that warrant preliminary investigation and the following is to be reported for each case of suspected fraud and abuse that warrants a full investigation: provider name and number, source of complaint, type of provider, nature of complaint, approximate range of dollars involved, and the legal/administrative disposition of the case.
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Fraud and Abuse Program. In addition to the specific requirements of OAC rule 5101:3-26-06, MCPs must have a program that includes administrative and management arrangements or procedures, including a mandatory compliance plan, to guard against fraud and abuse. The MCP’s compliance plan must designate staff responsibility for administering the plan and include clear goals, milestones or objectives, measurements, key dates for achieving identified outcomes, and explain how the MCP will determine the compliance plan’s effectiveness. In addition to the requirements in OAC rule 5101:3-26-06, the MCP’s compliance program which safeguards against fraud and abuse must, at a minimum, specifically address the following: a. Employee education about false claims recovery: In order to comply with Section 6032 of the Deficit Reduction Act of 2005 MCPs must, as a condition of receiving Medicaid payment, do the following: i. establish and make readily available to all employees, including the MCP’s management, the following written policies regarding false claims recovery: a. detailed information about the federal False Claims Act and other state and federal laws related to the prevention and detection of fraud, waste, and abuse, including administrative remedies for false claims and statements as well as civil or criminal penalties; b. the MCP’s policies and procedures for detecting and preventing fraud, waste, and abuse; and c. the laws governing the rights of employees to be protected as whistleblowers. ii. include in any employee handbook the required written policies regarding false claims recovery; iii. establish written policies for any MCP contractors and agents that provide detailed information about the federal False Claims Act and other state and federal laws related to the prevention and detection of fraud, waste, and abuse, including administrative remedies for false claims and statements as well as Appendix I Aged, Blind or Disabled (ABD) population Page 2 civil or criminal penalties; the laws governing the rights of employees to be protected as whistleblowers; and the MCP’s policies and procedures for detecting and preventing fraud, waste, and abuse. MCPs must make such information readily available to their subcontractors; and iv. disseminate the required written policies to all contractors and agents, who must abide by those written policies.
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Fraud and Abuse Program. In order to comply with OAC rule 5101:3-26-06, MCPs must have a program that includes administrative and management arrangements or procedures, including a mandatory compliance plan, to guard against fraud and abuse. The MCP's compliance plan must designate staff responsibility for administering the plan and include clear goals, milestones or objectives, measurements, key dates for achieving identified outcomes, and explain how the MCP will determine the compliance plan's effectiveness.
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Fraud and Abuse Program. In addition to the specific requirements of OAC rule 5101:3-26-06, MCPs must have a program that includes administrative and management arrangements or procedures, including a mandatory compliance plan, to guard against fraud and abuse. The MCP’s compliance plan must designate staff responsibility for administering the plan and include clear goals, milestones or objectives, measurements, key dates for achieving identified outcomes, and explain how the MCP will determine the compliance plan’s effectiveness. In addition to the requirements in OAC rule 5101:3-26-06, the MCP’s complianceprogram which safeguards against fraud and abuse must, at a minimum, specificallyaddress the following: a. Employee education about false claims recovery: In order to comply with Section 6032 of the Deficit Reduction Act of 2005 MCPs must, as a condition of receiving Medicaid payment, do the following:
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Fraud and Abuse Program. In order to comply with OAC rule 5101:3-26-06, MCPs must have a program that includes administrative and management arrangements or procedures, including a mandatory compliance plan, to guard against fraud and abuse. The MCP’s compliance plan must designate staff responsibility for administering the plan and include a clear goal, milestones or objectives, measurements, key dates for achieving identified outcomes, and explain how the MCP will determine the compliance plan’s effectiveness. a. Monitoring for fraud and abuse: In addition to the requirements in OAC rule 5101:3-26-06, the MCP’s program which safeguards against fraud and abuse must specifically address the MCP’s prevention, detection, investigation, and reporting strategies in at least the following areas: i. Embezzlement and theft – MCPs must monitor activities on an ongoing basis to prevent and detect activities involving embezzlement and theft (e.g., by staff, providers, contractors, etc.) and respond promptly to such violations.
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Fraud and Abuse Program. In addition to the specific requirements of OAC rules, 5160- 58-01.1 and 5160-26-06, and in accordance with Ohio Department of Medicaid’s (ODM’s) 1915(c) and 1915(b) CMS-approved waiver, the MCOP must have a program that includes administrative and management arrangements or procedures to guard against fraud and abuse. The MCOP’s compliance program must address the following:
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Fraud and Abuse Program. The Contractor shall have internal controls, policies and procedures, and a compliance plan to guard against fraud and abuse. Specifically, the Contractor shall have written policies, procedures, and standards of conduct that articulate the Contractor’s commitment to comply with all applicable federal and state standards subject to approval by the Division. At a minimum, the plan shall include the following: a. The designation of a compliance officer and a compliance committee that is accountable to senior management. b. Effective training and education for the compliance officer and the Contractor’s employees. c. Effective lines of communication between the compliance officer and the Contractor’s employees. d. Enforcement of standards through well publicized disciplinary guidelines. e. Provision for internal monitoring and auditing.
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Related to Fraud and Abuse Program

  • Fraud and Abuse The Company, the Owners, the Physician Employees and all other persons and entities providing professional services for or on behalf of the Company, to their actual knowledge, have not engaged in any activities that are prohibited under 42 U.S.C. ss.ss. 1320a-7, 7a or 7b or 42 U.S.C. ss. 1395nn (subject to the exce▇▇▇▇▇s set forth in such legislation) or the regulations promulgated thereunder or pursuant to similar state or local statutes or regulations or that are prohibited by rules of professional conduct, including, but not limited to, the following: (a) knowingly and willfully making or causing to be made a false statement or representation of a material fact in any application for any benefit or payment; (b) knowingly and willfully making or causing to be made a false statement or representation of a material fact for use in determining rights to any benefit or payment; (c) failure to disclose knowledge by a Medicare or Medicaid claimant of the occurrence of any event affecting the initial or continued right to any benefit or payment on their own behalf or on behalf of another with intent to fraudulently secure such benefit or payment; (d) knowingly and willfully offering, paying or soliciting or receiving any remuneration (including any kickback, bribe or rebate), directly or indirectly, overtly or covertly, in cash or in kind (i) in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part by Medicare or Medicaid or (ii) in return for purchasing, leasing or ordering or arranging or recommending purchasing, leasing or ordering any good, facility, service or item for which payment may be made in whole or in part by Medicare or Medicaid; or (e) referring a patient for designated health services (as defined in 42 U.S.C. ss. 1395nn) to or providing designated health services to a patient upon a referral from an entity or person with which the physician or an immediate family member has a financial relationship and to which no exception under 42 U.S.C. ss. 1395nn applies. SECTION 3.32. PAYORS. Schedule 3.32 sets forth a true, correct and complete list of the names and addresses of each Payor, including any private pay patient as a single payor, of the Company's services that accounted for more than 5% of the aggregate revenues of the Company in the five previous fiscal years. Except as set forth in Section 3.32, the Company has good relations with such Payors, and none of such Payors has notified the Company that it intends to discontinue its relationship with the Company or to deny any claims submitted to such Payor for payment.

  • Fraud, ▇▇▇▇▇ and Abuse If you have concerns about being billed for services you never received, or that your insurance information has been stolen or used by someone else, you may report potential health care fraud, waste or abuse to our Special Investigations Unit by using our confidential anti-fraud hotline at ▇-▇▇▇-▇▇▇-▇▇▇▇ or by email at ▇▇▇@▇▇▇▇▇▇.▇▇▇. You may also send an anonymous letter to us at: Blue Cross & Blue Shield of Rhode Island Special Investigations Unit ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Providence RI, 02903

  • Substance Abuse Program The SFMTA General Manager or designee will manage all aspects of the FTA-mandated Substance Abuse Program. He/she shall have appointing and removal authority over all personnel working for the Substance Abuse Program personnel, and shall be responsible for the supervision of the SAP.

  • Fraud, Waste, and Abuse Contractor understands that HHS does not tolerate any type of fraud, waste, or abuse. Violations of law, agency policies, or standards of ethical conduct will be investigated, and appropriate actions will be taken. Pursuant to Texas Government Code, Section 321.022, if the administrative head of a department or entity that is subject to audit by the state auditor has reasonable cause to believe that money received from the state by the department or entity or by a client or contractor of the department or entity may have been lost, misappropriated, or misused, or that other fraudulent or unlawful conduct has occurred in relation to the operation of the department or entity, the administrative head shall report the reason and basis for the belief to the Texas State Auditor’s Office (SAO). All employees or contractors who have reasonable cause to believe that fraud, waste, or abuse has occurred (including misconduct by any HHS employee, Grantee officer, agent, employee, or subcontractor that would constitute fraud, waste, or abuse) are required to immediately report the questioned activity to the Health and Human Services Commission's Office of Inspector General. Contractor agrees to comply with all applicable laws, rules, regulations, and System Agency policies regarding fraud, waste, and abuse including, but not limited to, HHS Circular C-027. A report to the SAO must be made through one of the following avenues: ● SAO Toll Free Hotline: 1-800-TX-AUDIT ● SAO website: ▇▇▇▇://▇▇▇.▇▇▇▇▇.▇▇▇▇▇.▇▇.▇▇/ All reports made to the OIG must be made through one of the following avenues: ● OIG Toll Free Hotline ▇-▇▇▇-▇▇▇-▇▇▇▇ ● OIG Website: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ ● Internal Affairs Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇ ● OIG Hotline Email: ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇. ● OIG Mailing Address: Office of Inspector General Attn: Fraud Hotline MC 1300 P.O. Box 85200 Austin, Texas 78708-5200

  • CHILD ABUSE REPORTING CONTRACTOR hereby agrees to annually train all staff members, including volunteers, so that they are familiar with and agree to adhere to its own child and dependent adult abuse reporting obligations and procedures as specified in California Penal Code section 11164 et seq. and Education Code 44691. To protect the privacy rights of all parties involved (i.e., reporter, child and alleged abuser), reports will remain confidential as required by law and professional ethical mandates. A written statement acknowledging the legal requirements of such reporting and verification of staff adherence to such reporting shall be submitted to the LEA.