Fraud Reporting Policy for Providers
Community Care Connections of Wisconsin (CCCW) is committed to the prevention and detection of financial fraud, misuse and abuse. Investigation and corrective action, when warranted, is taken in response to all reported instances. CCCW will follow all required guidelines in accordance with the Affordable Care Act (ACA) as overseen by the Office of Family Care Expansion (OFCE) or the Bureau of Financial Management (BFM).
CCCW maintains program integrity by following the guidelines detailed in this policy. CCCW has selected a lead person to coordinate and be the main contact for all requirements of the Program Integrity policy. The Program Integrity Compliance Officer (PICO) will be responsible to adhere to the procedures as laid out in this document. This policy outlines and identifies the organizational plan of CCCW to ensure compliance with all PI requirements.
Suspected Fraud Allegations – Reporting Steps – for Provider
Once notified, PICO will work with the “reporter” of the allegation to gather all details of report. All steps will be clearly documented using the “PI Fraud Allegation Report” form. PICO will:
- Establish contact with reporter to gather all details of suspected fraud, abuse, or misuse.
- Interview everyone involved.
- Request internal audit process is began to further examine and clarify evidence. Internal Auditor will return complete details of review to PICO within 5 days including all information gathered and described such as: time cards, paid claims reports, etc.
- Once all documentation has been gathered, PICO will review all evidence to determine credibility of allegation and intent of those involved.
- If PICO/MCO determines there was willful intent to defraud Medicaid, the investigation will be deemed a reportable allegation of fraud and will immediately be reported to the state via the online system and to the OFCE mailbox.
- Evaluate if additional risks may exist and establish procedures to mitigate any potential areas of risk the allegation report may have brought to light.
- Notify internal departments of potential fraud.
- Notify additional authorities if appropriate.
- Report alleged fraud or financial abuse to the State within 10 days of determination that a credible allegation exists.
- PICO will document and track all progress and report back to OFCE/BFM via OFCE mailbox on final resolution of allegation so the case may be closed.