New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.21 - Fraud and abuse prevention plans and special investigation units

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Pursuant to
					 Public Health Law section 4414, every MCO that participates in public or
					 government sponsored programs with an enrolled population of 10,000 or more
					 persons in the aggregate in any given year shall develop and file with the
					 commissioner within 180 days of the effective date of these regulations a plan
					 for the detection, investigation and prevention of fraudulent activities in
					 this State and those fraudulent and abusive activities affecting policies or
					 State or local department of social services contracts issued or issued for
					 delivery in this State. The plan must include written policies, procedures and
					 standards of conduct that are distributed to all affected employees and
					 appropriate delegated entities, and that articulate the MCO's commitment to
					 comply with all applicable Federal and State standards and identify and address
					 specific areas of risk and vulnerability. The MCO must designate an officer or
					 director who has responsibility and authority for carrying out provisions of
					 the plan, and who reports directly to senior management. Any MCO that has filed
					 and implemented such a plan with the superintendent in compliance with section 409  of the Insurance Law is exempt from the
					 requirements of this section.
(1) For the
					 purposes of this section, fraud means any type of 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 in a
					 managed care setting, including any act that constitutes fraud under applicable
					 Federal or State law, committed by an MCO, contractor, subcontractor, provider,
					 beneficiary or enrollee or other person(s). A provider includes any individual
					 or entity that receives funds in exchange for the provision, or arranging for
					 the provision, of health care services to an MCO enrollee.
(2) For the purposes of this section, abuse
					 means provider practices that are inconsistent with sound fiscal, business or
					 medical practices and result in an unnecessary cost to the State or Federal
					 government or MCO, or in reimbursement for services that are not medically
					 necessary or that fail to meet professionally recognized standards for health
					 care in a managed care setting, committed by an MCO, contractor, subcontractor,
					 provider, beneficiary or enrollee. It also includes enrollee practices that
					 result in unnecessary cost to the State or Federal government, MCO, contractor,
					 subcontractor or provider. For the purposes of this paragraph, provider
					 includes any individual or entity that receives funds in exchange for
					 providing, or arranging for the provision, of a service.