CalAIM Behavioral Health Initiative Cov lus nug nquag nug
Hauv qab no yog cov npe ntawm cov lus nug uas nquag nug tau raug sau los ntawm kev pab cuam thiab cov ntaub ntawv webinars thiab xa mus rau BHCalAIM@dhcs.ca.gov email. DHCS yuav hloov kho cov npe no nyob rau peb lub hlis twg.
Ua raws
Lub nroog yuav tsum saib xyuas kev dag, pov tseg, thiab kev tsim txom li cas?
Txhua qhov MHP thiab DMC/DMC-ODS Plan yuav tsum muaj kev tswj hwm, kev tswj hwm, thiab cov cai thiab cov txheej txheem los xyuas thiab tiv thaiv kev dag, khib nyiab, thiab kev tsim txom uas ua tau raws li cov cai ntawm 42 CFR ib feem 438.608 thiab Exhibit A, Daim ntawv txuas 13 ntawm MHP daim ntawv cog lus thiab Exhibit A, Attachment IOD-5, section H, (Nqe 3-5 yog ntu tseem ceeb tshaj plaws.) Cov txheej txheem thiab txheej txheem muaj xws li hauv qab no:
- Teem ib tus tub ceev xwm ua raws cai uas yog lub luag haujlwm tsim thiab ua raws li cov cai tiv thaiv kev dag ntxias, kev coj ua, thiab cov txheej txheem.
- Appointment of a Regulatory Compliance Committee that is responsible to oversee the entity’s compliance program.
- Kev tsim thiab kev siv cov txheej txheem thiab cov txheej txheem nrog cov neeg ua haujlwm siab rau niaj hnub saib xyuas thiab txheeb xyuas cov kev pheej hmoo ntawm kev ua raws cai, cov lus teb sai rau cov teeb meem ua raws li lawv tau tsa, tshawb xyuas cov teeb meem kev ua raws cai raws li tau teev tseg hauv chav kawm ntawm kev ntsuas tus kheej thiab kev tshuaj xyuas, thiab kho cov teeb meem zoo li no.
- Yog tias tus neeg cog lus txheeb xyuas qhov teeb meem lossis tau txais kev ceeb toom ntawm qhov tsis txaus siab txog qhov xwm txheej ntawm kev dag ntxias, khib nyiab lossis kev tsim txom, ntxiv rau kev ceeb toom rau Lub Tsev Haujlwm, tus neeg cog lus yuav tsum ua qhov kev tshawb xyuas sab hauv los txiav txim siab qhov siv tau ntawm qhov teeb meem / kev tsis txaus siab, thiab tsim thiab siv cov kev kho kom raug, yog tias xav tau.
- Kev txheeb xyuas tsis tu ncua, los ntawm kev ua piv txwv lossis lwm txoj hauv kev, txawm tias cov kev pabcuam uas tau sawv cev los ntawm cov neeg muab kev pabcuam tau txais los ntawm cov neeg tau txais txiaj ntsig.
What are the definitions of fraud, waste, and abuse? Is “intent” a requirement for fraud to be present?
Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 C.F.R. § 433.304, 455.2, and W&I, section 14107.11, subdivision (d)) Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes member practices that result in unnecessary costs to the Medicaid program. (42 C.F.R. § 455.2 and W&I, section 14107.11, subdivision (d) ) Waste, which is not defined in federal Medicaid regulations, includes inappropriate utilization of services and misuse of resources. Definitions for “fraud”, “waste”, and “abuse,” as those terms are understood in the Medicare context, can also be found in the Medicare Managed Care Manual.
Lub hom phiaj yog qhov xav tau ntawm kev dag ntxias. Lub Tsev Haujlwm qhia txog lub nroog sab laj nrog lawv lub nroog tus kws tshaj lij rau cov kev cai tshwj xeeb thiab cov ntaub ntawv pov thawj xav tau los ua kom tau raws li lub hauv paus no.