Monitoring and Auditing Fraud, Waste and Abuse
Customize your policy alerts
Sign up for network_health Policy n03676 alerts
Get alerted when Policy n03676 changes without checking for updates manually.
Monitor payer policy activity
Governs Network Health's proactive audit, monitoring, and investigative activities to prevent, detect, and deter fraud, waste, and abuse across Medicare Parts C and D and Commercial products; applies to Network Health Plan/Network Health Insurance Corporation/Network Health Administrative Services, LLC staff, managers, Payment Integrity SIU, Compliance, and contracted entities (e.g., PBM).
Compliance Intake Form (CIF) reference was changed to new name from CSI (Compliance Safety Investigation) form.
06/07/2024 - Minor changes, approved via eVote.
FWA Monitoring and Audit Procedures
FWA Monitoring and Audit Procedures
Operational responsibilities and procedures for detecting and responding to suspected fraud, waste, and abuse (FWA) include:
Regulatory Citations
| 42 CFR §422.503 | Regulatory citation related to Medicare Part C compliance requirements. |
| 42 CFR §423.504 | Regulatory citation related to Medicare Part D compliance requirements. |
Audit Notification and Scheduling
Audit notification and PBM scheduling requirements
All managers and subcontractors/vendors will be notified in advance of any audit and informed which specific audit tools will be used. For the contracted PBM that administers Medicare Part D benefits, the PBM will be notified of upcoming annual Part D audits and provided an audit schedule with auditing/reporting frequencies and due dates; audit results will be reported to the Compliance Officer for escalation to senior management or the Board as appropriate.
- Managers/subcontractors/vendors will be notified prior to any audit of the specific audit tools that will be utilized (e.g., policies, procedures, department/subcontractor documentation).
- Contracted PBM for Medicare Part D will receive notice of the upcoming annual audit and a schedule specifying auditing/reporting frequency with due dates; results reported to the Compliance Officer for senior management/Board reporting.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.