I.  PURPOSE
 

The purpose of this policy is to ensure compliance with the California Department of Health Care Services (DHCS) requirement for the Los Angeles County Department of Mental Health (DMH) as the local Mental Health Plan (MHP) to report overpayments to providers that are the result of waste, fraud, or abuse.

This reporting of voided claims brings MHPs and their providers into compliance with the Center Medicare and Medicaid Services’ (CMS) Final Rule CMS-2390-P, which applies the Paul Wellstone Mental Health Parity and Addiction Equity Act to Medicaid Managed Care Plans.  All California MHPs are classified as managed care plans under Medicaid and must comply with the program integrity requirements contained in the Code of Federal Regulations (CFR) Title 42 Part 438.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
 

II.  DEFINITIONS
 

Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program. (42 CFR § 455.2)

Fraud: An 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.  It includes any act that constitutes fraud under applicable Federal or State law.” (42 CFR § 455.2)

Mental Health Plan (MHP): The local governmental agency at the county or city level contracted with DHCS to administer the provision of specialty mental health services to residents within that agency’s jurisdiction. The MHPs are required to provide or arrange for the provision of Specialty Mental Health Services (SMHS) to beneficiaries in their counties that meet medical necessity criteria, consistent with the beneficiaries’ mental health treatment needs and goals.

Waste: Generally understood to mean the overutilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act. (DHCS All Plan Letter 17-003)
 

III.  POLICY
 

The reports from all agencies and providers will be compiled into one report for submission to DHCS. CBO will submit this report annually.
 

IV.  PROCEDURES
 

Procedures - Reporting Overpayments Resulting from Waste, Fraud, and Abuse
 

V.  AUTHORITIES
 

Code of Federal Regulations Title 42 Section 455.2
Code of Federal Regulations Title 42 Section 438.606
Code of Federal Regulations Title 42 Section 438.608(d)
California Code of Regulations Title 9 Section 784.28(a)
Department of Health Care Services MHSUDS Information Notice No.: 19-034
 

VI.  ATTACHMENT