CalAIM 行为健康计划常见问题解答
以下是从技术援助和信息网络研讨会以及提交至BHCalAIM@dhcs.ca.gov电子邮件中收集的常见问题列表。 DHCS 将每季度更新此列表。
遵守
各县应如何监控欺诈、浪费和滥用行为？
每个 MHP 和 DMC/DMC-ODS 计划都需要有行政、管理安排以及政策和程序来检测和防止欺诈、浪费和滥用，以满足42 CFR 第 438.608 部分和MHP 合同附件 A、附件 13以及DMC-ODS 合同附件 A、附件 I、H 节、第 5 段的要求。 （第 3 至 5 节是最相关的部分。） 相关安排和程序包括：
- 任命一名合规官，负责制定和实施反欺诈政策、实践和程序。
- Appointment of a Regulatory Compliance Committee that is responsible to oversee the entity’s compliance program.
- 建立并执行合规风险日常内部监控与审计的程序和专人制度，对发现的合规问题及时作出回应，对自我评估和审计中发现的合规隐患进行调查并予以纠正。
- 如果承包商发现问题或收到有关潜在欺诈、浪费或滥用事件的投诉通知，除了通知部门之外，承包商还应进行内部调查以确定问题/投诉的有效性，并在必要时制定和实施纠正措施。
- 通过抽样或其他方法定期验证受益人是否收到了网络提供商提供的服务。
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.
意图是欺诈的必要要素。 该部门建议各县咨询其县法律顾问，了解满足这一要素的具体要求和证据。