Fraud Waste and Abuse UPMC 2022

Preface All providers new to Community Care Behavioral Health Organization (Community Care) should read and become familiar with Community Care's Fraud, Waste and Abuse (FWA) department's policies and procedures and trainings. This material is located on Community Care's FWA section at the following links: Policies and Procedure:https://providers.ccbh.com/provider-resources/fwa-compliance Trainings:https://providers.ccbh.com/training/fwa-trainings Fraud Waste and Abuse (Program Integrity) Overview As a new provider you are receiving this manual as an introduction to Community Care's FWA department. All our providers undergo FWA audits as a measure to ensure documentation and billing compliance with Medical Assistance regulations. This manual will serve as a guideline and introduction to FWA principle and practices. It is the policy of Community Care to have an FWA compliance program which reflect the regulations, recommendations, standards, and guidance set forth by the following agencies towards the detection, deterrence, and prevention of FWA in Medicaid-funded HealthChoices behavioral health care: •U.S. Justice Department (DOJ) •Office of Inspector General (OIG) •Attorney General's Medicaid Fraud Control Section (MFCS) •Medical Assistance/Medicaid program •Bureau of Program Integrity (BPI) •Office of Mental Health and Substance Abuse Services (OMHSAS) of the Department of Human Services (DHS) •Centers for Medicare and Medicaid Services (CMS) The FWA program makes use of tools and references that include but are not limited to the following: •Code of Federal Regulations •Medical Assistance Regulations and Bulletins •Pennsylvania Code •Licensing regulations •DHS HealthChoices Behavioral Health Program Standards and Requirements: Appendix F Fraud and Abuse Program Requirements (DHS Appendix F) •Fee schedules •Billing Manual •Provider Alerts