General Compliance and Fraud, Waste, and Abuse Requirements

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Providers are responsible for complying with all applicable laws, regulations and BHN’s Administrative Guidelines. BHN 's general compliance and Fraud, Waste and Abuse ("FWA") requirements apply to all Providers, regardless of their participation in Medicare or Medicaid.

Provider Requirements

  • Provide FWA and General Compliance training for the required employees and contractors of the working on MA and Part D programs. You can access the materials available on the CMS Medicare Learning Network® at the CMS website. Additionally, Providers must check for mandatory training materials related to Fraud Waste and Abuse issued by the respective state's Medicaid control unit and comply with any required training.
  • Maintain a record of completion (i.e., method, training materials, dated employee sign-in sheet(s), attestations or electronic certifications that include the date of the training) for ten (10) years. BHN and/or CMS may request documentation from you to verify compliance with this requirement.
  • Assist BHN in identifying, investigating and taking appropriate corrective action against fraud, waste, and/or abuse (as defined in 42 CFR 455.2) in the provision of health care services.
  • Providers, and any subcontractors, engaged by a Provider, whether or not they are enrolled as Medicare or Medicaid providers, shall cooperate fully with State and federal oversight and prosecutorial agencies, including but not limited to, DMAHS, MFD, DHSS, MFCU, HHS-OIG, FBI, DEA, FDA, and the U.S. Attorney’s Office. Failure to cooperate shall be grounds for termination of the Provider agreement. Such cooperation shall include providing access to all necessary recipient information, medical and clinical information, correspondence, documents, computer files, and appropriate staff.

Immediate Notification by Provider of Certain Occurrences

Provider shall notify BHN in writing immediately upon, but in no event more than thirty (30) days after, the occurrence of any of the following:

  • Arrest, indictment or conviction for any felony or criminal charge related to the practice of Provider's profession;
  • Any charges of professional or ethical misconduct brought against Provider and/or any clinician employed by Provider;
  • Any investigation of Provider for alleged fraud and abuse or false claims conducted by a Payor or government agency;
  • The exclusion, debarment, suspension or any other limitation of Provider's right to participate in Medicare, any Medicaid program or any other federal or state health care program;
  • Provider contracts with an individual or entity that Provider or its affiliates knew or should have known is excluded from participation in any federal health care program.

Exclusion Checks

Prior to hiring or contracting with employees, Providers must screen against state and federal government exclusion lists, including the Office of Inspector General (“OIG”) list of Excluded Individuals and Entities and the General Services Administration (“GSA”) Excluded Parties Lists System. Anyone listed on one or both of these lists is excluded and therefore not eligible to support any federal or state programs. The individual or entity must be removed immediately from providing services or support to BHN, and BHN must be notified upon such identification. The exclusion lists should be reviewed on a regular basis and any exclusion or any other event that makes an individual ineligible to perform work directly or indirectly on state or federal health care programs must be disclosed to BHN within ten (10) days of such exclusion.

Records Access

Pursuant to appropriate consent/authorization by a patient, the Provider will make the patient's medical records and other personally identifiable information (including encounter data for government-sponsored programs) available for purposes including preauthorization, concurrent review, quality assurance, (including Quality Assurance Reporting Requirements (“QARR”)), payment processing, and qualification for government programs, including but not limited to newborn eligibility for Supplemental Security Income (SSI) and for analysis and recovery of overpayments due to fraud and abuse. The Provider shall provide copies of such records at no cost. The Provider expressly acknowledges that he/she/it shall also provide BHN, on request, all financial data and reports, and information concerning the appropriateness and quality of services provided, as required by law.

Reporting Potential Fraud, Waste or Abuse to BHN

If you identify potential FWA and/or compliance issues, immediately report the information to BHN so that BHN can investigate and respond appropriately. BHN prohibits any form of retaliation against you if you make a report in good faith.

Report potential Fraud, Waste, or Abuse to BHN by calling 888-624-6218