Credible Allegations of Fraud
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Medi-Cal managed care plans (MCPs) must take certain actions when the Department of Health Care Services (DHCS) has determined that a credible allegation of fraud exists against a participating MCP network provider. To comply with this regulation, Health Net adheres to the course of action described below upon receipt of information that DHCS has determined a credible allegation of fraud exists against a participating provider.
Requirements
If Health Net is notified that a credible allegation of fraud has been identified against a participating provider relating to the provision of Medi-Cal services, Health Net takes one or more of the following four actions and submits supporting documentation to DHCS:
- Terminates the provider from its network.
- Temporarily suspends the provider from its network pending resolution of the fraud allegation.
- Temporarily suspends payment to the provider pending resolution of the fraud allegation.
- Conducts additional monitoring, including audits of the provider's claims history and future claims submission for appropriate billing.
If Health Net elects the fourth action, Health Net follows the steps below and submits documentation to DHCS:
Step 1: Immediately implements enhanced monitoring as follows:
- Monitors relevant claims, claim lines, and encounter data, and completes the initial review within 30 calendar days.
- Provides weekly updates to DHCS until a determination is made as to whether an onsite visit is necessary.
- Makes an initial determination as to whether an onsite visit is necessary after completing the initial review of relevant claims/encounter data. Health Net consults with DHCS on the need for an onsite review within 10 business days of completing the initial review. Health Net is required to obtain DHCS approval if the initial determination concludes an onsite visit is not warranted.
Step 2: If Health Net's initial determination identifies a potential incident(s) of fraud, waste or abuse, or otherwise validates DHCS's credible allegation of fraud finding, Health Net must:
- Commence an audit for the subject provider or subcontractor within 10 business days of validating the credible allegation of fraud, waste or abuse, or within 10 days of validating DHCS's credible allegation of fraud. The audit must be conducted earlier if Health Net identifies activity that warrants immediate action.
- Provide DHCS with a copy of the final audit report and findings within 45 days.
- Provide DHCS with a copy of the corrective action plan it has imposed on the Medi-Cal provider, which will include specific milestones and timelines for completion.
- Provide DHCS with biweekly updates related to the corrective action plan.
- Audit the provider or subcontractor again within six months of closing the corrective action plan to confirm amelioration of the findings.
- Terminate the provider from Health Net's network should there be repeat findings that are significant in nature. Health Net is required to obtain approval from DHCS in situations where the provider is not to be terminated from Health Net's network.
- Provide DHCS with an outline of oversight activity that Health Net will conduct to ensure there is no further fraud, waste or abuse.
Delegated providers
Health Net's delegated providers are required to adhere to the course of action described above upon receipt of information that DHCS has determined a credible allegation of fraud exists against a participating provider.
If the delegated provider elects to terminate a participating provider from its network upon notification from DHCS that a credible allegation of fraud has been found against the participating provider relating to the provision of Medi-Cal services, the delegated provider must notify the Health Net regional Provider Network Management Department in writing, pursuant to the requirements of the provider's Health Net Provider Participation Agreement (PPA). Delegated providers that elect to not terminate a participating provider from its network must provide an explanation for electing this option and are required to continue to monitor the provider and provide the Health Net Provider Network Management Department with a report of oversight activity that is being conducted.
Delegated providers are required to have policies and procedures to detect and deter FWA, including a compliance program as defined in Title 42 CFR section 438.608(a). PPGs must comply with all applicable state and federal laws and regulations, including state and federal false claim acts.
PPGs must report any suspected case of FWA to Health Net within 10 calendar days through the Health Net Fraud Hotline. Additionally, if a PPG receives information about a change in circumstances that may affect a member’s eligibility (e.g., a change in residence or income or the death of a member) they must promptly contact the Health Net Medi-Cal Provider Services Center Community Health Plan of Imperial Valley Provider Services Center or CalViva Health Provider Services Center.
Health Net Delegation Oversight will monitor and evaluate your compliance to all requirements through:
- Health Net annual Compliance audit
- Review of Compliance program policies and procedures including:
- Compliance program description (requirements defined in Title 42 CFR section 438.608(a))
- Mechanisms for detection and prevention of FWA
- Training program for employees and providers
- Plan for routine internal monitoring
- Disciplinary guidelines for non-compliance
- Proof of process execution (meeting minutes, staff interviews, logs, etc.)
- Evidence of routine monitoring
- Review of Compliance program policies and procedures including:
- Additional activities as identified