Provider or Care Coordination Unit Fraud/Illegal or Criminal Acts

Section 240 Section 240.1320  Provider or Care Coordination Unit Fraud/Illegal or Criminal Acts a)         Reporting of Illegal Acts 1)         Any entity involved in the administration of the CCP or in the provision of CCP services, upon receipt of any report of or evidence of an improper or unlawful act having been committed by their employees, for the purpose of illegally obtaining money or extorting payment for care, goods, services or supplies, shall immediately: A)        inform the appropriate law enforcement authorities; and B)        report to the Department, including any documentation which may have been obtained, regarding any alleged theft or missing items having value over $50.00 or such unlawful activities which result in a police report. 2)         Failure of a CCU or provider to make a report to the appropriate law enforcement authorities and to the Department shall result in contract action as delineated in Section 240.1665. b)         Department staff, designated by the Director, shall make an immediate investigation of the alleged improper or unlawful acts.  When the result of the Department's investigations produces evidence that indicates CCU/provider improprieties or unlawful activities, the Department shall make an immediate report to the appropriate law enforcement authorities. c)         Any entity or individual provider involved in the administration/provision of CCP services shall not bill the Department for more services than were provided to or on behalf of CCP participants. 1)         Anyone in receipt of information that the Department has been improperly billed for services shall report the incident to the Department and provide the Department with any report/documentation that may have been obtained. 2)         Department staff, designated by the Director, shall complete an immediate review of the report. 3)         If the Department determines that the allegations in the report are factual, based upon the above cited-review, the Department will advise the CCU or provider in writing regarding what action shall be taken (e.g., no action, if in the best interests of the participant; suspension; termination). d)         Any entity or individual involved in the provision of CCP services shall cooperate with and provide assistance to the Department/law enforcement authorities in any investigation of any alleged illegal or criminal act.