Fraud, Waste and Abuse Recovery Process

ADMINISTRATIVE POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Date Effective Fraud, Waste and Abuse Recovery Process AD-0825 11/01/2020 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statement s prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment o f disease, illness, or injury and without whi ch the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals , Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorizationor payment of services. Please refer to the plan contract (often re ferred to as the Evidence of Coverage) for the serv ice(s)referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination . Table of C ontents Administrative Policy Statement ………………………….. ………………………….. ………………………….. . 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Fraud, Waste and Abuse Recovery ProcessOHIO MEDICARE ADVANTAGEAD-08 25 Effective Date: 11/01/2020 2 A. SubjectFraud, Waste and Abuse Recove ry Process B. Background The CareSource Program Integrity Department ( PI ) Fraud Waste and Abuse (FWA) recovery process applies only to FWA recoveries resulting from PII FWA investigations and audits. The designation of a FWA case is determined by PI. C. Definitions Fraud, Waste and Abuse Recovery L etter Letter sent by CareSource Program Integrity Department to a Provider/Health Partner when there is su spected fraud, waste or abuse. D. Policy I. FWA Recovery Letter From CareSource PII A. When PI identifies payments subject to recovery as the result of a FWAinvestigation and/or audit , a FWA Recovery Letter will be sent to theProvider/Health Partner. The FWA Re covery Letter may include (among other information) the following : 1. Amount owed to CareSource2. Time period and specific claims to which FWA recovery applies3. Audits and/or investigation results or findings 4. Basis for the action being taken 5. Steps and/or Action items to address any required corrective actions; 6. Options for payment owed to CareSource 7. Due date for payment in full, typically, thirty (30) calendar days unless timeframe required contractually; and 8. Rights for r e-evaluation (if any) . II. Three (3) Options for a ResponseA. Upon receipt of the FWA Recovery Letter, there are 3 options for a response:1. *Option #1: Make immediate payment in full within 30 ca lendar days of the date of the FWA Recovery L etter . To submit payment in full, foll ow the instructions in t he FWA Recovery L etter. 2. *Option #2: Request a payment plan if unable to pay within 30 calend ar days of the date of the FWA Recovery L etter . To request a payment plan, reply to the FWA Recovery Letter with your payment proposal. You may request installment payments or the offset of future claims. Payment plans will be granted at the sole discretion of CareSource. Any recoveries tha t cannot be paid in full within 30 calendar days, may be subject to interest at the prime rate (Wall Street Journal s Market D ata) +2% until fully repaid. Fraud, Waste and Abuse Recovery ProcessOHIO MEDICARE ADVANTAGEAD-08 25 Effective Date: 11/01/2020 3 3. *Option #3: Request a re-evaluation within 30 calendar days of the date onthe FWA Recovery L etter if you disagree with the findings . To do this, you must submit a written request with the reason (s) for the dispute and include any pertinent information that may not have been previously considered by CareSource. *Timeframes are as indicated unless otherwise required contractually or by law for a different timeframe .B. Your written request, reasons f or the dispute , and any supporting documentation must be sent t o the address shown in the FWA Recovery L etter. Once received, CareSource PI will review the request for re-evaluation information and may (as applicable) consult with medical directors, indep endent clinical consultants, and any other resources to determine the outcome of the written request for re – evaluation. If needed, PII may contact you to arrange an informal telephone c all or an in-person conference to review the request for re-evaluation. C. If an informal telephone call or an in-person meeting is scheduled, all appropriate and necessary administrative, operational , and clinical staff of the Provider /Health Partner must be available . Failure for these individual s to attend will not extend the timeframes in the re-evaluation process. D. CareSource will respond with a Final Determination Letter within sixty (60)calendar days (unless otherwise required contractually or by law for a different timeframe) of receiving t he timely written request for re-evaluation and supporting documentation. CareSources written response to the request for re-evaluation constitutes a Final Determination. Any final amount due to CareSource will be identified in the Final Determination L etter. The am ount due must be paid within 30 calendar days of receipt of the Final Determination L etter. III. Failure to Respond to FWA Recovery Letter A. In the event the Provider/Health Partner fails to respond to an FWA Recovery Letter using one of the above options, CareSource may take steps including butnot limited to rec oup ing and/or recover ing the amount owed from :1. Current payments due (which may in clude claims that are pending and/or onhold for investigation) , or2. Future Claims submitted B. CareSource reserves the right to take legal action to the extent permitted by law to collect any and all outstanding recovery amount s owed.Fraud, Waste and Abuse Recovery ProcessOHIO MEDICARE ADVANTAGEAD-08 25 Effective Date: 11/01/2020 4 IV. Final Determination A. If there is no request for a re-evaluation of the findings within 30 calendar days of the FWA Recovery Letter (unless otherwise required by contract or law) , then the FWA Recovery L etter becomes the Final D etermination. B. If the timely submitte d reques t for re-evaluation is received and reviewed byCareSource and a Final Determination L etter has been sent, any overpayment still owed is due within 30 calendar days of the Final Determination Letter . C. If payment in full is not received within 30 calendar days, CareSource will begin recoupment and take the actions identified in section III above. NOTE : Please note that retaining legal counsel (or obtaining new legal counsel) during the FWA Recovery Process does not change the re-evaluation proces s and does not reset the timeframes noted above. You must comply with the timeframes outlined in the FWA Recovery Process. Extensions of time are NOT permitted unless expressly provided by CareSource in writing. Timeframes are as indicated unless otherwise required contractually or by law for a different timeframe. E. Conditions of CoverageF. Related Policies/Rules CareSource Special Investigation Unit Fraud Waste and Abuse Recovery ProcessG. Review/Revision History DATES ACTIONDate Issued 06/24/2020Date Revised Date Effective 11/01/2020 New Policy Date Archived H. References The Administrative Policy Statement detailed abo ve has recei ved due con sideration as defined in the Administrative Policy Statement Policy and is app roved.