Fraud, Waste, and Abuse Reviews

In alignment with terms and conditions of the Coordinated Care Organization (CCO) contract and all applicable rules and laws by Exhibit B, Part 9—Program Integrity, the CCOs are required to develop a Fraud, Waste, and Abuse (FWA) Prevention Handbook that includes written policies and procedures in accordance with the federal, state, and contractual requirements that will enable the CCOs’ to detect and prevent potential fraud, waste, and abuse activities that have been engaged in by employees, subcontractors, providers, members, and other third parties. In addition to creating the written FWA Prevention Handbook, each CCO must annually draft a written plan for implementing, analyzing, and reporting on the effectiveness of the policies and procedures set forth in the FWA Prevention Handbook, as well as submit an annual assessment report of the quality and effectiveness of the Annual FWA Prevention Plan and the related policies and procedures included in the FWA Prevention Handbook.

Responsible for monitoring the CCOs’ program integrity activities, OHA has contracted with HSAG to perform annual program integrity reviews to monitor the CCOs’ compliance with the terms and conditions of the CCO contract. A comprehensive evaluation tool is used to assess compliance with the following contract deliverables: Fraud, Waste, and Abuse (FWA) Prevention Handbook, Annual FWA Prevention Plan, and Annual FWA Assessment Report. The results of HSAG’s evaluation are submitted to the CCOs and OHA.

For questions related to the FWA activity, please contact:

       Georgia Wilkison, BSN, RN, CPC
       Associate Director State & Corporate Services
       Telephone: 602.284.9182
       Email: GWilkison@hsag.com