Currentwellsense_health_planPolicy Compliance 10
Fraud, Waste and Abuse Policy
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Governs the Plan's Fraud, Waste and Abuse (FWA) program, training, reporting, investigation, and whistleblower protections for all members of the Plan's Workforce, and describes legal obligations under federal and state false claims and related laws.
Policy Summary
Payerwellsense_health_plan
PolicyFraud, Waste and Abuse Policy
Policy CodePolicy Compliance 10
Change TypeNo material changes
Effective DateFeb 8, 2006
Last ReviewJul 18, 2023
Next Review DateJul 18, 2023
Key ActionWorkforce members must report suspected false, inaccurate, or questionable claims to supervisors, the Fraud and Abuse Prevention Coordinator, Compliance Officer, FraudandAbuse@bmchp-wellsense.org, EthicsPoint, or the confidential hotline.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
1-888-411-4959confidential hotline
annualFWA training
60 daysoverpayment report timeframe
11version
MA, NHstate False Claims Acts
Fraud, Waste & Abuse Program Requirements and Operational Criteria
inv-01: Fraud, Waste and Abuse program requirements
Responsibilities and program elements for preventing, detecting, reporting and investigating FWA
Provide annual FWA training to all employees
Workforce must immediately report suspected FWA to designated contacts (immediate supervisor, Manager of Special Investigations, Vice President of Business Operations, FraudandAbuse@bmchp-wellsense.org, Compliance Department, EthicsPoint, or the confidential Hotline 1-888-411-4959)
Compliance Department oversees the Fraud, Waste and Abuse Program, investigations, and reporting to appropriate authorities
Plan will investigate all reported activity and will not retaliate against good-faith reporters (whistleblower protections)
Make diligent efforts to recover improper payments and monitor utilization and conduct audits as part of overpayment recovery efforts
Program conducted in accordance with federal and state requirements as set forth in Appendices I and II
inv-02: Program integrity and reporting criteria
Contractual program integrity and reporting requirements summarized for specific state programs and plan types.
Comply with federal employee education requirements on false claims when Medicaid payments in the prior Federal fiscal year were at least $5 million; provide written certification to MassHealth/EOHHS as required>= $5,000,000 Medicaid payments
Report complaints or preliminary findings of suspected fraud in writing to MassHealth/EOHHS within five (5) business days (or as specified by contract); when contact with providers is required, notify MassHealth/EOHHS prior to contacting the provider if required by contract
Designate a Fraud & Abuse Coordinator and maintain program integrity staff; submit annual CEO/CFO certifications and required written reports per contract
Notify investigative authorities and fully cooperate (MFCU, BSI, MFCU equivalents); provide timely access to documents and knowledgeable staff at no charge
Maintain overpayment identification, recovery, documentation, retention and reporting processes; report overpayments to DHHS within sixty (60) calendar days and complete DHHS 'Request to Open' and referral timelines as specified<= 60 calendar days to report overpayments to DHHS
For Senior Care Options and other specified plans, submit annual fraud & abuse reports in required formats and ensure non-discrimination against employees who report fraud (whistleblower protections)
Use OIG LEIE to screen employees, contractors and providers upon hiring and monthly thereafter; notify EOHHS of discovered exclusionsmonthly screening
For NH DHHS and similar state programs, maintain DHHS-approved Program Integrity and FWA compliance plans; participate in meetings and provide requested data within three (3) business days3 business days for data requests
Refer large or multiplan schemes to external resources: Refer significant/multi-plan or large financial risk schemes to NBI MEDIC using Qlarant Investigations MEDIC Complaint form
inv-03: FWA detection, reporting, recovery, and enforcement requirements
Requirements the Plan must follow for FWA prevention, detection, reporting, and recovery:
Implement and maintain administrative and management arrangements or procedures designed to detect and prevent fraud, waste and abuse
Document and monitor marketing representative activities; report staff terminations for prohibited marketing conduct or FWA to DHHS within three (3) business days of the termination reportability event3 business days
Maintain written policies for employees, subcontractors, and agents detailing the False Claims Act and employee whistleblower protections
Post and maintain DHHS-approved FWA information on the Plan website, including provider notices, participating provider lists, excluded/sanctioned providers, resources, contacts, and educational sessions
Maintain overpayment identification, recovery and tracking process; perform ongoing analysis of authorizations, utilization, claims, provider billing patterns, and encounter data; perform audits and investigations of subcontractors and providers
Report to DHHS within sixty (60) calendar days when capitation payments or other payment amounts received exceed contract-specified amounts<= 60 calendar days
Complete DHHS 'Request to Open' form for any potential FWA case; DHHS Program Integrity Unit has fifteen (15) business days to respond15 business days response time
If Plan determines a credible allegation of fraud/abuse exists, refer to DHHS Program Integrity Unit and to MFCU within five (5) business days using DHHS template5 business days to refer credible allegation
When allegation is accepted for investigation by DHHS/MFCU/law enforcement, DHHS notifies the Plan's Compliance Officer within two (2) business days and may direct suspension of payments to affected providers2 business days for DHHS notification
Upon DHHS notification, the Plan must send notice of decision to suspend program payments to the provider within five (5) calendar days unless DHHS/MFCU/law enforcement requests delay; if delay requested, Plan may delay up to thirty (30) calendar days and may renew delay in writing no more than twice subject to a maximum 90-day delay5 calendar days (or up to 30/renewable delays to max 90 days)
Provider may file an appeal related to program integrity actions within thirty (30) calendar days of the Plan's notice of adverse action30 calendar days appeal period
Billing, Coding, and Overpayment Management
Billing fraud examplesmixedNot Covered
| Examples of Provider fraud include, but are not limited to: persistent improper coding, billing for services never rendered, inflating bills for services and/or goods provided, and providers who engage in a pattern of providing and/or billing for medically unnecessary services. |
Stark Law DHS listmixed
| Clinical laboratory services | |
| Physical therapy services | |
| Occupational therapy services | |
| Outpatient speech-language pathology services | |
| Radiology and certain other imaging services | |
| Radiation therapy services and supplies | |
| Durable medical equipment and supplies | |
| Parenteral and enteral nutrients, equipment and supplies | |
| Prosthetics, orthotics, and prosthetic devices and supplies | |
| Home health services |
1–10 of 12
1/2
Overpayment managementmixed
| Maintain overpayment identification, recovery and tracking process; perform ongoing analysis of authorizations, utilization, claims, provider billing patterns, and encounter data; perform audits and investigations of subcontractors, providers and provider entities; document, retain, recover and report overpayments as required (report to DHHS within sixty (60) calendar days when capitation or other payments received exceed contract-specified amounts). |
inv-07: Medicaid payment threshold for employee education requirements
ThresholdAt least $5 million in Medicaid payments during the prior Federal fiscal year triggers federal employee education and certification requirements (42 U.S.C. §1396a(a)(68)).
Certification timingWritten certification of compliance provided on or before April 30 annually (or other date specified by EOHHS) in a form acceptable to MassHealth/EOHHS.
Documentation requiredProvide, upon request, copies of written policies, employee handbook, and other information EOHHS may deem necessary to determine compliance.
inv-08: DHHS overpayment report timeframe
Reporting timeframeReport identified overpayments (capitation or other excess payments) to DHHS within sixty (60) calendar days.
DHHS recovery authorityDHHS may recover overpayments not returned by the Plan within sixty (60) calendar days of DHHS notification.
ScopeApplies to Capitation Payments or other payment amounts received in excess of contract-specified amounts (42 CFR 438.608(c)(3)).
Reporting, Corrective Action, Overpayment Recovery, and Appeal Rights
Documentation Required
Reporting and whistleblower protections
Workforce members must immediately report suspected false, inaccurate, or questionable claims to their immediate supervisor, the Fraud and Abuse Prevention Coordinator/Manager of Special Investigations, the Compliance Officer, the FraudandAbuse email box (FraudandAbuse@bmchp-wellsense.org), the Compliance Department, EthicsPoint (wellsense.ethicspoint.com), or the confidential 24/7 hotline (1-888-411-4959). The Plan provides protections against retaliation for good-faith reporters.
- Report immediately any potential false, inaccurate or questionable claims or concerns.
- Anonymous reports are permitted via the confidential hotline.
Documentation Required
Provider corrective action, overpayment reporting, coordinator
Require providers to implement corrective actions or, where appropriate, terminate provider agreements; report provider overpayments and voluntary disclosures per contract and state requirements; and designate a Fraud & Abuse Coordinator to oversee these activities.
- Implement corrective action plans or terminate Agreements as appropriate.
- Submit ad hoc and annual written reports on Fraud & Abuse activities in MassHealth-specified formats.
- Provide annual CEO/CFO certifications and maintain required documentation.
Billing Rule
Overpayment detection and recovery
Maintain an overpayment identification, recovery and tracking process and perform ongoing analysis of authorizations, utilization, claims, provider billing patterns, and encounter data to detect improper payments; conduct audits and investigations of subcontractors and providers and document recovery and retention procedures.
- Report identified capitation or other excess payments to DHHS within sixty (60) calendar days.
- Perform audits and investigations of Providers and Subcontractors and retain documentation supporting recovery efforts.
Denial Risk
Provider appeal rights
Providers have the right to file an appeal related to program integrity actions; the appeal must be filed within thirty (30) calendar days of the Plan's notice of adverse action.
- File an appeal with the Plan within 30 calendar days of the notice of adverse action.
Prior Authorization
Payment suspension and notification
If DHHS, MFCU, or law enforcement accepts an allegation for investigation, DHHS may direct the Plan to suspend payments to affected providers; upon DHHS notification, the Plan must notify providers of the decision to suspend payments within five (5) calendar days unless DHHS/MFCU/law enforcement requests a written delay (up to 30 days per request, renewable no more than twice, not to exceed 90 days).
- Send suspension notice to provider within 5 calendar days unless a written delay is requested.
- If DHHS/MFCU/law enforcement requests delay in writing, the Plan may delay notice up to 30 calendar days per request; delay may be renewed in writing no more than twice (maximum 90 days).
Key Terms and Legal Definitions
inv-14: Key terms (Abuse; Fraud; Waste; Workforce)
AbusePractices inconsistent with sound fiscal, business or medical practices that result in unnecessary cost to state and federally funded programs (e.g., reimbursement for services not medically necessary).
FraudAn intentional deception or misrepresentation made with knowledge that it could result in an unauthorized benefit under a state or federally funded program (examples: persistent improper coding, billing for services not rendered, inflating bills).
WasteOver-utilization of services or other practices that directly or indirectly result in unnecessary costs to federal and state funded programs; generally not criminal but misuse of resources.
WorkforceEmployees, temporary employees, volunteers, trainees, First Tier, Downstream and Related Entities (FDRs), and other contracted vendors.
inv-15: FDR / First Tier / Downstream / Related Entity
First Tier EntityAny party that enters into a written arrangement with a Managed Care Organization or Part D plan sponsor to provide administrative or health care services to Medicare-eligible individuals.
Downstream EntityAny party that enters into a written arrangement, acceptable to CMS, below the level of the arrangement between an MCO or Part D sponsor and a first tier entity; arrangements continue down to the ultimate provider of health and administrative services.
Related EntityAny entity related to an MCO or Part D sponsor by common ownership or control that performs management functions under contract, furnishes services to Medicare enrollees, or leases/sells materials above specified thresholds (see 42 C.F.R. §423.501).
FDR (First Tier/Downstream/Related)Collective term for First Tier, Downstream and Related Entities; parties that enter written arrangements with the MCO or Part D sponsor to provide administrative or healthcare services or are related by ownership/control.
inv-16: DHS (Designated Health Services)
DefinitionDesignated Health Services (DHS) are services identified under the Stark Law (Section 1877) that are subject to physician self-referral prohibitions.
Examples of DHSClinical laboratory services; physical therapy; occupational therapy; outpatient speech-language pathology; radiology and certain imaging; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment and supplies; prosthetics and orthotics; home health services; outpatient prescription drugs; inpatient and outpatient hospital services.
inv-17: Anti-Kickback Statute
ScopeFederal Anti-Kickback Statute prohibits the exchange (or offer) of anything of value to induce or reward referrals of federal health care program business (see 42 U.S.C. §1320a-7b).
PenaltiesConviction may result in fines up to $25,000 and imprisonment up to five years; mandatory exclusion from federal health care programs; civil money penalties and treble damages may also apply (42 U.S.C. §1320a-7a(a)(7)).
Safe harbors and exclusionsCertain payments are statutorily excluded and the HHS OIG may establish regulatory 'safe harbors' (42 C.F.R. §1001.952); transactions not covered by exceptions are evaluated case-by-case by the OIG.
inv-18: False Claims / False Statements
Statutory basisFederal provisions (42 U.S.C. 1320a-7b) criminalize making false statements or representations of material fact in applications for benefits or payments under Federal health care programs and presentment of false claims.
PenaltiesViolations can result in criminal fines up to $25,000, imprisonment up to five years, or both.
ApplicationCovers false statements used to determine rights to benefits or payments and false representations about licensing or conditions of facilities seeking Medicare/Medicaid certification.
inv-19: False Claims Act / whistleblower protections
Statute and related lawsFalse Claims Act (FCA) and other federal and State laws (including those described in Section 1902(a)(68) of the Social Security Act) apply; employees have rights to be protected as whistleblowers.
Whistleblower protectionsEmployees reporting in good faith are protected from retaliation; policies must provide detailed information about the FCA and whistleblower rights.
State-level actionsState False Claims Acts (e.g., Massachusetts, New Hampshire) and related qui tam provisions may provide for relator recoveries under state statutes.
inv-20: Request to Open
PurposeDHHS 'Request to Open' form is used to initiate review of any potential fraud, waste, or abuse case, including those that lead to a credible allegation of fraud.
DHHS response timeDHHS Program Integrity Unit has fifteen (15) business days to respond to the Plan's 'Request to Open' form.
Referral timelineWhen the Plan concludes a credible allegation of fraud or abuse exists, refer to DHHS Program Integrity Unit and to MFCU within five (5) business days using DHHS-provided template.
Policy Summary
Payerwellsense_health_plan
PolicyFraud, Waste and Abuse Policy
Policy CodePolicy Compliance 10
Change TypeNo material changes
Effective DateFeb 8, 2006
Last ReviewJul 18, 2023
Next Review DateJul 18, 2023
Key ActionWorkforce members must report suspected false, inaccurate, or questionable claims to supervisors, the Fraud and Abuse Prevention Coordinator, Compliance Officer, FraudandAbuse@bmchp-wellsense.org, EthicsPoint, or the confidential hotline.
SourceLink
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