卡拉伊姆行為健康計劃常見問題
以下是從技術支援和資訊網路研討會收集的常見問題清單，並提交至 BHCalAIM@dhcs.ca.gov 電子郵件中的提交內容。 DHCS 將每季更新此列表。
合規
各縣應如何監察欺詐、浪費和濫用情況？
每個 MHP 及 DMC/DMC-ODS 計劃均須具備行政、管理安排以及政策和程序，以偵測及防止欺詐、浪費和濫用，符合《消費品安排》第 42 部分 438.608 、附件 A 附件 13 及 DMC-ODS 合約附件 A 附件 I 第 H 段 5 段的規定。 （第 3-5 節是最相關的部分。） 安排及程序包括以下內容：
- 委任合規主任，負責制定和實施反欺詐政策、實踐和程序。
- Appointment of a Regulatory Compliance Committee that is responsible to oversee the entity’s compliance program.
- 設立和實施程序和系統，由專責人員組成，進行常規內部監控和審核合規風險，迅速回應法規遵循問題，調查自我評估和審核過程中發現的潛在合規問題，以及糾正這些問題。
- 如承建商發現有關潛在欺詐、浪費或濫用事件的投訴通知，承辦商除了通知本署之外，承包商還須進行內部調查，以確定問題/投訴的有效性，並在需要時制定和執行糾正措施。
- 定期以抽樣或其他方法進行驗證，受益人是否接收已被表示為由網絡供應商提供的服務。
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.
意圖是欺詐的必要元素。 該部門建議各縣諮詢其縣政府律師，以了解滿足此要素所需的具體要求和證據。