Fraud, Waste and Abuse

Fraud, Waste and Abuse Policies and Processes | Reporting Procedures | Laws & Regulations | Training | Additional Resource Links

fwa

Fraud, Waste and Abuse Policies and Processes

• Fraud, Waste and Abuse Policy
• Investigative Process
• SIU Rebuttal Process

reporting

Reporting Procedures

• Potential Fraud, Waste and Abuse Referral Form
• Provider Self-Audit and Referral Form
  • Provider Self-Audit Protocol Updated 04/27/2022
  • Attachment #1 – Carelon Claims Spreadsheet
  • Attachment #2 – Carelon Provider Self-Audit Referral Form
  • Attachment #3 – Carelon Provider Audit Response
  • Attachment #4 – Carelon Provider Self-Audit Work Plan Form
• Providers: Call 1-877-615-8503 and speak with a representative
• Members: Visit http://pa.carelon.com/members/
• Online: https://www.fighthealthcarefraud.com/
  • Select Carelon under the drop-down for “Who is the insurance company?”
• Email: BHSIU@carelon.com

Carelon SIU Department Contact Information

training

Trainings

• Interactive Fraud, Waste, and Abuse Training
• 2021 Trainings
  • 2021 Annual Fraud, Waste and Abuse Training
  • Annual Training with Audio
• 2020 Trainings
  • 2020 Annual Fraud, Waste and Abuse Training
  • Annual Training with Audio
• 2019 Trainings
  • 2019 Annual Fraud, Waste and Abuse Training
    • Annual Training with Audio
• 2018 Trainings
  • 2018 Annual Fraud, Waste and Abuse Training
    • Annual Training with Audio
  • Case Management Training
  • Psychiatric Partial Hospitalization Services

• 2017 Trainings

  • 2017 Annual Fraud, Waste and Abuse Training
    • Annual Training with Audio
  • BHRS Compliance
  • Alternative Treatment Services Monitoring Training
    • Training with Audio
  • Psychiatric Rehabilitation Services: Chapter 5230 Regulation Highlights
    • Psychiatric Rehabilitation Services Training Q&A
    • Assessing Readiness
  • Intensive Outpatient Services: Chapter 5200 Regulation Highlights
    • Intensive Outpatient Services Training Q&A
  • Peer Support Services
    • Peer Support Services Training Q&A

• 2016 Trainings

  • Annual FWA for All Providers
  • Provider Self-Audit Protocol
    • Self-Audit Q&A

• 2015 Trainings

  • 2015 BHRS Summit – Compliance Topics for BHRS
  • Clinician/Staffing Requirements Training – 2015 Updates
  • Compliance Considerations: School Based Services
  • Methadone Compliance Training Part I – Psychotherapy Requirements
  • Methadone Compliance Training Part II – Documentation Requirements
  • Family Based Mental Health Services Training 05/15/2015 – Clinical Practice Standards
  • Documentations Requirements – Part 1: Consent and Treatment Plans
  • Documentations Requirements – Part 2: Progress Notes and Encounter Forms

• 2014 Trainings

  • 2014 Annual Fraud and Abuse Training for All Providers
  • BHRS Summit Fraud and Abuse Training
  • RTF Summit Fraud and Abuse Training
  • Outpatient Psychiatric Services

• 2013 Trainings

  • 2013 Compliance Webinar Series: The Search for Compliance (May 2013)
    • Part I – Provider Responsibilities
    • Part II – Outpatient Psychiatric Services
    • Part III – Recipient Verification Requirements
      • Q&A
    • Part IV – Provider Self-Audits
    • Part V – Compliance Topics for Certified Peer Support
    • Part VI – Compliance Audits & Record Requests
    • Part VII – Compliance Topics for BHRS
    • Part VIII – Compliance Topics to Staffing Requirements
    • Part IX – Compliance Topics for RTF
    • Part X – Compliance Audits

• Archived Trainings

  • 2011 Provider Compliance Training Make-Up
    • Instructions
    • Questionnaire Page
  • DPW BH-MCO Regional Training
  • Program Integrity Presentation PowerPoint (January 2011)
  • Program Integrity Tips
  • OIG — A Roadmap to Avoid Fraud and Abuse

additional

Additional Resource Links

• Department of Health and Human Services (DHS)
• Code of Federal Regulation (TITLE 42-Public Health, Chapter IV-CMS, DHHS, SUBCHAPTER C-Medical Assistance Programs, Part 455- Program Integrity: Medicaid)
• Office of Inspector General (OIG)
• Center for Medicare and Medicaid Services (CMS)
• National Association of Medicaid Fraud Control Units (NAMFCU)
• Pennsylvania Attorney General
• Pennsylvania Bureau of Program Integrity
• Pennsylvania Code – Fraud and Abuse Sanctions (1101.77)
• Pennsylvania Code – Provider (1101.75) and Recipient (1101.92) Prohibited Acts
• Pennsylvania Code – Medicaid Provisions (Medical Assistance Provisions)