c.) Disclosure and Reporting of Health Information; Fraud and Abuse Provisions
The state is required to offer and provide child health screening services,23 and must report to the Secretary the number of children screened,24 the number referred for corrective treatment25 and the number that received dental services.26 If the state covers health home services, each designated provider must report to the state on all applicable quality measures.27 The state must have a mechanism to receive reports and compile data concerning alleged instances of fraud, waste, and abuse28 and must establish a Medicaid fraud control unit29 that investigates and prosecutes violations of all applicable fraud laws30 and maintains procedures for reviewing complaints of abuse or neglect of patients in health care facilities.31 Any information obtained from an electronic claims processing system that relates to fraud or abuse must be given to the fraud control unit.32 The state must comply with provider and supplier screening, oversight and reporting requirements. These requirements include complying with the national system for reporting criminal and civil convictions, sanctions, negative licensure actions and other adverse provider actions33 and providing information and access to information respecting sanctions taken against health care practitioners and providers by state licensing authorities.34 The state must also have a system of reporting any adverse action or finding involving a health care practitioner or entity at the conclusion of any formal proceedings, including a loss of a practitioner or entity’s license or a dismissal or closure resulting from the practitioner or entity surrendering its license or leaving the state.35 The state must provide the Secretary with access to such documents as may be necessary to determine the facts and circumstances concerning the adverse actions and determinations36 and the Secretary may subsequently provide this information to relevant authorities.37 Provider facilities may be subject to surveys conducted by the state and the Secretary to evaluate compliance with statutory provisions, and within 90 days of such a survey, the pertinent findings must be made public.38
Footnotes
- 23. Social Security Act § 1902(a)(43)(B), 42 U.S.C. 1396a(a)(43)(B) (see SCHIP 2108(e) for additional requirements).
- 24. Social Security Act § 1902(a)(43)(D)(i), 42 U.S.C. 1396a(a)(43)(D)(i).
- 25. Social Security Act § 1902(a)(43)(D)(ii), 42 U.S.C. 1396a(a)(43)(D)(ii).
- 26. Social Security Act § 1902(a)(43)(D)(iii); 42 U.S.C. 1396a(a)(43)(D)(iii).
- 27. Social Security Act § 1945, 42 U.S.C. 1396n (available at http://www.ssa.gov/OP_Home/ssact/title19/1945.htm).
- 28. Social Security Act § 1902(a)(64), 42 U.S.C. 1396a(a)(64).
- 29. Social Security Act § 1902(a)(61), 42 U.S.C. 1396a(a)(61).
- 30. Social Security Act § 1903(q)(3), 42 U.S.C. 1396b(q)(3).
- 31. Social Security Act § 1903(q)(4)(A), 42 U.S.C. 1396b(q)(4)(A).
- 32. Social Security Act § 1903(r)(2)(B), 42 U.S.C. 1396b(r)(2)(B).
- 33. Social Security Act § 1902(a)(77), 42 U.S.C. 1396a(a)(77); Social Security Act § 1902(kk)(6), 42 U.S.C. 1396a(kk)(6).
- 34. Social Security Act § 1902(a)(49), 42 U.S.C. 1396a(a)(49).
- 35. Social Security Act § 1921(a)(1), 42 U.S.C. 1396r-2(a)(1) (available at http://www.ssa.gov/OP_Home/ssact/title19/1921.htm).
- 36. Social Security Act § 1921(a)(2), 42 U.S.C. 1396r-2(a)(2).
- 37. Social Security Act § 1921(b), 42 U.S.C. 1396r-2(b).
- 38. Social Security Act § 1902(a)(36), 42 U.S.C. 1396a(a)(36).
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