Мошенничество, расточительство и злоупотребления

Compliance Policies and Processes | Reporting Procedures | Laws & Regulations | Training | Provider Fraud | Member Fraud | Program Integrity Links compliance

Program Integrity Department

Compliance Policies and Processes

• Fraud, Waste and Abuse Policy
• Audit Process
• Audit Appeals Process
• Minimum Provider Documentation Standards for Payment
  • Treatment and Psychotherapy Services
  • Therapeutic and Rehabilitation Services
• Program Integrity Audit Findings List

Compliance Plan Requirements

• Program Integrity Tips
• Контрольный список программы соответствия поставщикам
• Обзор системы внутреннего контроля
• DHS BH-MCO Regional Training
• Physician Roadmap: Avoiding Medicare and Medicaid Fraud and Abuse

reporting

Reporting Procedures

• Institutionalized or Incarcerated Referral Form
• Potential Fraud, Waste and Abuse Referral Form
• Provider Self-Audit and Referral Form
  • Provider Self-Audit Protocol Updated 06/20/2016
  • Attachment #1 – Beacon Claims Spreadsheet
  • Attachment #2 – Beacon Provider Self-Audit Referral Form
  • Attachment #3 – Beacon Provider Audit Response
  • Attachment #4 – Beacon Provider Self-Audit Work Plan Form
• Call 1-888-293-3027 and speak with a representative
• Online: https://beaconsafetosay.ethix360.com/
• Via mail:
  • InTouch Attn: Beacon Health Options 3100 West Lake Street Suite 325 Minneapolis, MN 55416

Beacon Compliance Department Contact Information laws

Laws and Regulations

• Balanced Budget Act
• Закон о сокращении дефицита
• Federal False Claims Act (2008 correction)
• Federal False Claims Act (original)
• Federal Regulation 42 Title VI (included Medicaid Managed Care ?438)
• Fraud Enforcement and Recovery Act
• Patient Protection and Affordable Care Act
• Health Information Portability and Accountability Act (HIPAA)
• Health Information Technology for Economic and Clinical Health Act (HITECH)
• Pennsylvania Code – Fraud and Abuse Sanctions (1101.77)
• Pennsylvania Code – Provider (1101.75) and Recipient (1101.92) Prohibited Acts
• Pennsylvania Code – Medicaid Provisions (Medical Assistance Provisions)

обучение

Тренинги

• 2020 Trainings
  • 2020 Annual Fraud, Waste and Abuse Training
  • Annual Training with Audio
• 2019 Trainings
  • 2019 Annual Fraud, Waste and Abuse Training
    • Annual Training with Audio
• 2018 Trainings
  • 2018 Annual Fraud, Waste and Abuse Training
    • Annual Training with Audio
  • Обучение ведению дел
  • Психиатрические службы частичной госпитализации

• 2017 Trainings

  • 2017 Annual Fraud, Waste and Abuse Training
    • Annual Training with Audio
  • BHRS Compliance
  • Alternative Treatment Services Monitoring Training
    • Training with Audio
  • Услуги психиатрической реабилитации: основные положения главы 5230
    • Тренинг по службам психиатрической реабилитации, вопросы и ответы
    • Оценка готовности
  • Интенсивные амбулаторные услуги: основные положения главы 5200
    • Обучение интенсивным амбулаторным услугам, вопросы и ответы
  • Одноранговые службы поддержки
    • Тренинг по службам поддержки сверстников, вопросы и ответы

• 2016 Trainings

  • Annual FWA for All Providers
  • Provider Self-Audit Protocol
    • Вопросы и ответы по самоаудиту

• 2015 Trainings

  • 2015 BHRS Summit – Compliance Topics for BHRS
  • Clinician/Staffing Requirements Training – 2015 Updates
  • Compliance Considerations: School Based Services
  • Methadone Compliance Training Part I – Psychotherapy Requirements
  • Methadone Compliance Training Part II – Documentation Requirements
  • Family Based Mental Health Services Training 05/15/2015 – Clinical Practice Standards
  • Family Based Mental Health Services Training 05/15/2015 – Search for Compliance
  • Documentations Requirements – Part 1: Consent and Treatment Plans
  • Documentations Requirements – Part 2: Progress Notes and Encounter Forms

• 2014 Trainings

  • 2014 Annual Fraud and Abuse Training for All Providers
  • BHRS Summit Fraud and Abuse Training
  • RTF Summit Fraud and Abuse Training
  • Амбулаторные психиатрические службы

• 2013 Trainings

  • 2013 Compliance Webinar Series: The Search for Compliance (May 2013)
    • Part I – Provider Responsibilities
    • Part II – Outpatient Psychiatric Services
    • Part III – Recipient Verification Requirements
      • Вопросы и ответы
    • Part IV – Provider Self-Audits
    • Part V – Compliance Topics for Certified Peer Support
    • Part VI – Compliance Audits & Record Requests
    • Part VII – Compliance Topics for BHRS
    • Part VIII – Compliance Topics to Staffing Requirements
    • Part IX – Compliance Topics for RTF
    • Part X – Compliance Audits

• Archived Trainings

  • 2011 Provider Compliance Training Make-Up
    • Instructions
    • Questionnaire Page
  • DPW BH-MCO Regional Training
  • Program Integrity Presentation PowerPoint (January 2011)
  • Program Integrity Tips
  • OIG — A Roadmap to Avoid Fraud and Abuse

prv-fraud

Provider Fraud

• http://www.modernhealthcare.com/article/20150905/NEWS/150909922
• http://www.cchrint.org/2015/06/29/psychiatrists-over-represented-in-commission-of-fraud/
• http://www.bizjournals.com/philadelphia/blog/health-care/2015/07/martinez-chlebowski-allentown-fraud-mental-health.html
• http://www.smartbrief.com/s/2016/01/nc-woman-receives-over-2-years-role-medicaid-fraud-ring

mbr-fraud

Member Fraud

• http://www.nydailynews.com/new-york/nyc-crime/woman-avoids-jail-huge-benefits-fraud-case-bronx-article-1.2404897

integrity

Program Integrity Links

• Audits – Medicaid RAC
• HHS Fraud, Waste, and Abuse Report – December 2011
• Department of Health and Human Services (DHS)
• Code of Federal Regulation (TITLE 42-Public Health, Chapter IV-CMS, DHHS, SUBCHAPTER C-Medical Assistance Programs, Part 455- Program Integrity: Medicaid)
• Office of Inspector General (OIG)
• Center for Medicare and Medicaid Services (CMS)
• National Association of Medicaid Fraud Control Units (NAMFCU)
• Pennsylvania Attorney General
• Pennsylvania Bureau of Program Integrity