Regional Generic Provider Agreement - Ohio Department of Job and ...

Appendix I
Covered Families and Children (CFC) population
Page 2
and abuse, including administrative remedies for false claims and
statements as well as 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.
b. Monitoring for fraud and abuse 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.
ii. Underutilization of services – MCPs must monitor for the potential
underutilization of services by their members in order to assure that all
Medicaid-covered services are being provided, as required. If any
underutilized services are identified, the MCP must immediately
investigate and, if indicated, correct the problem(s) which resulted in such
underutilization of services.
The MCP’s monitoring efforts must, at a minimum, include the following
activities: a) an annual review of their prior authorization procedures to
determine that they do not unreasonably limit a member’s access to
Medicaid-covered services; b) an annual review of the procedures
providers are to follow in appealing the MCP’s denial of a prior
authorization request to determine that the process does not unreasonably
limit a member’s access to Medicaid-covered services; and c) ongoing
monitoring of MCP service denials and utilization in order to identify
services which may be underutilized.
iii. Claims submission and billing – On an ongoing basis, MCPs must identify
and correct claims submission and billing activities which are potentially
fraudulent including, at a minimum, double-billing and improper coding,
such as upcoding and bundling.
c. Reporting MCP fraud and abuse activities: Pursuant to OAC rule 5101:3-26-06,
MCPs are required to submit annually to ODJFS a report which summarizes the
MCP’s fraud and abuse activities for the previous year in each of the areas
specified above. The MCP’s report must also identify any proposed changes to
the MCP’s compliance plan for the coming year.