Common use of Fraud Reporting Clause in Contracts

Fraud Reporting. Contractor shall report to GCHP’s compliance officer all cases of suspected fraud, waste, and/or abuse, as defined in Title 42, of the Code of Federal Regulations, Section 455.2, where there is reason to believe that an incident of fraud and/or abuse has occurred, by subcontractors, Members, providers, or employees within forty-eight (48) hours of the time when Contractor first becomes aware of, or is on notice of, such activity. Contractor shall immediately report to GCHP any notices of investigations of Contractor relating to fraud, waste, or abuse. Upon the request of GCHP and/or the State, Contractor shall consult with the appropriate State agency prior to and during the course of any such investigations. Contractor shall comply with GCHP’s antifraud plan, including its policies and procedures relating to the investigation, detection, and prevention of and corrective actions relating to fraud, waste and abuse. Contractor shall submit quarterly fraud reports to GCHP which must, at a minimum, include: Number of complaints of fraud and abuse submitted that warranted preliminary investigation. For each complaint which warranted a preliminary investigations, supply: Name and/or SSN or CIN; Source of complaint; Type of provider (if applicable); Nature of complaint; Approximate dollars involved; and Legal and administrative disposition of the case. Contractor shall submit the following components with the report or explain why the components are not submitted with the report: police report, health plan’s documentation (background information, investigation report, interviews, and any additional investigative information), Member information (patient history chart, Patient profile, Claims detail report), provider enrollment data, Confirmation of services, list items or services furnished by the provider, Pharmaceutical data from manufacturers, wholesalers and retailers and any other pertinent information. b. Suspended, Excluded, or Ineligible Employees or Contractors. Contractor shall comply with 42 C.F.R. 438.608(a)(8) and 438.610. Additionally, Contractor is prohibited from employing, contracting or maintaining a contract with persons or entities for the provision of services related to this Agreement that are excluded, suspended or terminated from participation in the Medicare or Medi-Cal/Medicaid programs. Contractor shall notify GCHP immediately upon discovery of employment or contract with a person or entity that is excluded, suspended, or terminated. A list of suspended and ineligible providers is updated monthly and available on line and in print at the DHCS Medi-Cal Web site (▇▇▇▇://▇▇▇▇-▇▇▇.▇▇.▇▇▇), by the DHHS, Office of Inspector General, List of Excluded Individuals and Entities (▇▇▇▇://▇▇▇.▇▇▇.▇▇▇), and the Federal System of Award Management (▇▇▇▇://▇▇▇.▇▇▇.gov). Contractor is deemed to have knowledge of any persons or entities on these lists.