Filetype Excel XLSX | Posted on 10 Aug 2022 | 3 years ago
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211x Filetype XLSX File size 0.07 MB Source: www.oregon.gov
Sheet 1: Summary
| Reporting Period (Quarter) | ||||||||||||
| MCE Name | ||||||||||||
| Quarterly Fraud, Abuse, and Waste Activity Report MCE Recovery Summary by Quarter |
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| Q1 Recoveries | Q2 Recoveries | Q3 Recoveries | Q4 Recoveries | YTD Recoveries | ||||||||
| Recovery Category | Dollar Amount | Identified $ | Recovered $ | Identified $ | Recovered $ | Identified $ | Recovered $ | Identified $ | Recovered $ | Identified $ | Recovered $ | |
| Medicaid Health Plan Initiated PI Audit Recoveries | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| OHA Referral Recoveries | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Settlement Dollars Recovered | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Dental | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Non Emergent Medical Transportation | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Behavioral Health | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - FQHC, RHC, TC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Pharmacy | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Total | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Quarterly Fraud, Abuse, and Waste Activity Report MCE-administered Sanctions and Fines Summary by Quarter |
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| Q1 Sanctions/Fines | Q2 Sanctions/Fines | Q3 Sanctions/Fines | Q4 Sanctions/Fines | YTD Sanctions/Fines | ||||||||
| Recovery Category | Dollar Amount | Imposed $ | Received $ | Imposed $ | Received $ | Imposed $ | Received $ | Imposed $ | Received $ | Imposed $ | Received $ | |
| Sanctions | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Fines | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Other | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Dental | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Non Emergent Medical Transportation | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Behavioral Health | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - FQHC, RHC, TC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Provider - Pharmacy | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| Total | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| The directions provided below provide further detail on the requirements for each tab of this report. For a complete report all tabs must be completed with accurate information for each MCE | ||
| Field Name | Description | Applicable Workbook |
| Reporting Fiscal Year | State Fiscal Year in YYYY-YY format (ex: 2017-18) | Q# Details; Column A |
| Reporting Fiscal Quarter | Quarter in State Fiscal Year QQ format (ex: Q1) | Q# Details; Column B |
| MCE Internal Tracking Number | Identifier used by the MCE to monitor the case or Program Integrity Audit (PI Audit) | Q# Details; Column C |
| Provider Type | Medicaid provider type | Q# Details; Column D |
| Provider Tax ID | Provider's tax ID number | Q# Details; Column E |
| Provider/Entity Name | Full name of Provider or the Entity being reported (including any known "d/b/a") | Q# Details; Column F |
| Entity Medicaid ID Number | Provider's DMAP ID number | Q# Details; Column G |
| Provider NPI Number (If Applicable) | Provider's National Provider Identifier number | Q# Details; Column H |
| Date Detected | Date issue was first detected by the MCE in format MM/DD/YYYY | Q# Details; Column I |
| Date First Reported to OHA | Date the MCE first reported the issue in format MM/DD/YYYY | Q# Details; Column J |
| Allegation Type | Indicate whether Fraud, Abuse or Waste allegation | Q# Details; Column K |
| Primary Allegation | Main type of Fraud, Abuse, or Waste category being alleged | Q# Details; Column L |
| Secondary Allegation (If Applicable) | Secondary type of Fraud, Abuse or Waste category being alleged | Q# Details; Column M |
| Detection Tool | Indicate tool plan used to detect issue | Q# Details; Column N |
| Preliminary Overpayment Identified | Total preliminary overpayment identified through MCE's PI Audit/recovery activity | Q# Details; Column O |
| Final Overpayment Identified for Recovery | Total final overpayment identified through MCE's PI Audit/recovery activity | Q# Details; Column P |
| Fines and Sanctions Amount (If Applicable) | Total amount of all fines and/or sanctions the MCE imposed on Provider or Subcontractor | Q# Details; Column Q |
| Settlement Amount (If Applicable) | Total amount of settlement agreement between the MCE and Provider or Subcontractor | Q# Details; Column R |
| Recoupment Amount (If Applicable) | Total recovered from provider through MCE's PI Audit/recovery activity to date | Q# Details; Column S |
| Dollar Amount Lost (If Applicable) | Total lost from provider (MCE's exposure that will not be recovered) | Q# Details; Column T |
| Status | Select from either Open or Closed status with details of where in process open investigation/PI Audit is, or what closed outcome is | Q# Details; Column U |
| Other Entity Reported to | Complete list of entities plan has reported complaint to, including MFCU, ODHS, HHS/OIG, etc. | Q# Details; Column V |
| Corrective Action | Type of action the MCE has taken against provider to address issue | Q# Details; Column W |
| Number of Times Provider Reviewed Within Last 5 Years | Number of times the MCE has reviewed, audited, or investigated the reported provider during the last 5 year period | Q# Details; Column X |
| Detailed Update | Free-form narrative from the MCE that must include detailed information related to the progression of the MCE's review/investigation. This should be updated every reporting quarter to show the MCE's review is not stagnant. | Q# Details; Column Y |
| Additional Comments | All other details the MCE wishes to include that are not captured elsewhere or that need further explanation. MCE who have closed a PI Audit, but not yet completed the final audit report, should note its progress here and include a date for anticipated report completion. | Q# Details; Column Z |
| Field Name | Description | Applicable Workbook |
| Reporting Period (Quarter) | Quarter in State Fiscal Year QQ format (ex: Q1) | Summary; B1 |
| MCE Name | The name of the Managed Care Entity (MCE) submitting the report. | Summary; B2 |
| Quarterly Fraud, Abuse, and Waste Activity Report MCE Recovery Summary by Quarter |
Dollar amounts of MCE recoveries are reported separately for each quarter, Q1 through Q4, and as a year to date (YTD) total. | Summary; Columns D-M |
| Medicaid Health Plan Initiated PI Audit, Recoveries, Identified $ | Preliminary overpayment identified by PI Audit in the quarter. | Summary; D6, F6, H6, J6 |
| Medicaid Health Plan Initiated PI Audit, Recoveries, Recovered $ | Overpayment recovered by PI Audit in the quarter. | Summary; E6, G6, I6, K6 |
| OHA Referral Recoveries, Identified $ | Overpayment identified in the quarter by MCE which was identified as a result of one or more referrals by OHA to the MCE. | Summary; D7, F7, H7, J7 |
| OHA Referral Recoveries, Recovered $ | Overpayment recovered in the quarter by the MCE as a result of one or more OHA referrals to the MCE. | Summary; E7, G7, I7, K7 |
| Settlement Dollars Recovered, Identified $ | Dollar amount identified in settlement agreement(s) between the MCE and provider(s) or between MCE and its subcontractor(s) in the quarter. Dollars reported should be the final dollar amount(s) from negotiated settlement agreement(s). | Summary; D8, F8, H8, J8 |
| Settlement Dollars Recovered, Recovered $ | Dollar amount recovered in the quarter from negotiated settlement agreement(s) between the MCE and provider(s) or between the MCE and its subcontractor(s). | Summary; E8, G8, I8, K8 |
| Provider - Dental | Preliminary overpayment identified by PI Audit in the quarter. | Summary; D9, F9, H9, J9 |
| Provider - Dental | Overpayment recovered by PI Audit in the quarter. | Summary; E9, G9, I9, K9 |
| Provider - Non Emergent Medical Transportation | Preliminary overpayment identified by PI Audit in the quarter. | Summary; D10, F10, H10, J10 |
| Provider - Non Emergent Medical Transportation | Overpayment recovered by PI Audit in the quarter. | Summary; E10, G10, I10, K10 |
| Provider - Behavioral Health | Preliminary overpayment identified by PI Audit in the quarter. | Summary; D11, F11, H11, J11 |
| Provider - Behavioral Health | Overpayment recovered by PI Audit in the quarter. | Summary; E11, G11, I11, K11 |
| Provider - FQHC, RHC, TC | Preliminary overpayment identified by PI Audit in the quarter. | Summary; D12, F12, H12, J12 |
| Provider - FQHC, RHC, TC | Overpayment recovered by PI Audit in the quarter. | Summary; E12, G12, I12, K12 |
| Provider - Pharmacy | Preliminary overpayment identified by PI Audit in the quarter. | Summary; D13, F13, H13, J13 |
| Provider - Pharmacy | Overpayment recovered by PI Audit in the quarter. | Summary; E13, G13, I13, K13 |
| MCE Name | |||||||||||||||||||||||||
| Reporting Fiscal Year | Reporting Fiscal Quarter | MCE Internal Tracking Number | Provider Type | Provider Tax ID | Provider/Entity Name | Entity Medicaid ID Number | Provider NPI Number (If Applicable) | Date Detected | Date First Reported to OHA | Allegation Type | Primary Allegation | Secondary Allegation (If Applicable) | Detection Tool | Preliminary Overpayment Identified | Final Overpayment Identified for Recovery | Fines and Sanctions Amount (If Applicable) | Settlement Amount (If Applicable) | Recoupment Amount (If Applicable) | Dollar Amount Lost (If Applicable) | Status | Other Entity Reported to | Corrective Action | Number of Times Provider Reviewed Within Last 5 Years | Detailed Update | Additional Comments |
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