Fidelis SecureCare of North Carolina Provider Manual

Fraud, Waste and Abuse
Provider and Fidelis have an obligation to comply with all federal and state laws and
Medicare requirements related to fraud, waste, and abuse.
Provider Responsibilities:
By December 31, 2009, and annually thereafter, affected providers and entities should:
1. Complete training as defined in 42 CFR 422.503 and 42 CFR 423.504
2. Submit an attestation to Fidelis verifying completion of training
The topics that providers must be trained on:
• Laws and regulations related to Medicare Advantage and Part D fraud, waste
and abuse (i.e., False Claims Act, Anti-Kickback statute, HIPAA, etc.)
• Your obligation to make sure that your downstream contractors and related
entities have appropriate policies and procedures in place to address fraud,
waste, and abuse
• The need to have a process in place for reporting suspected fraud, waste and
abuse in first tier, downstream, and related entities to Fidelis along with
protections for employees of downstream contractors and related entities who
report suspected fraud, waste and abuse
• An understanding of the types of fraud, waste and abuse that can occur
with downstream contractors and related entities
Provider is also responsible for cooperating with Fidelis during any investigation of
suspected fraud, waste or abuse on the part of the provider or any of its downstream
contractors.
Fidelis Responsibility:
Fidelis is responsible for monitoring the activities of its providers, vendors, and other
downstream contractors to ensure that claim submission / billing practices, utilization
practices, and business practices meet federal, state and Medicare requirements.
Fidelis will notify any provider or vendor that it suspects is not complying with these
requirements and request a review of its records and/or activities. In certain cases, this
could include suspension of payment until corrective action plans are in place.
Effective January 1, 2009, The Centers for Medicare and Medicaid Services (CMS) is
requiring that all Medicare Advantage Organizations and Prescription Drug Plan
Sponsors must apply Fraud, Waste and Abuse (FWA) training to all entities that they
are partnering with to provide benefits or services in the Part C or the Part D programs
Fidelis is offering this service in accordance with the requirement of the “Revisions to
the Medicare Advantage and Part D Prescription Drug Contract Determinations,
Fraud, Waste and Abuse Training