What provider has to do avoid the provider abuse?

Provider Responsibility


When presenting a claim for payment under the Medicaid program, a provider has an affirmative duty to supervise the provision of, and be responsible for, goods and services claimed to have been provided, to supervise and be responsible for preparation and submission of the claim, and to present a claim that is true and accurate and that is for goods and services that:
• Have actually been furnished to the recipient by the provider prior to submitting the claim;
• Are Medicaid-covered goods or services that are medically necessary;
• Are of a quality comparable to those furnished to the general public by the provider’s peers;
• Have not been billed in whole or in part to a recipient or a recipient’s responsible party, except for such co-payments, coinsurance, or deductibles as are authorized by AHCA;
• Are provided in accord with applicable provisions of all Medicaid rules,regulations, handbooks, and policies and in accordance with federal, state and local law; and
• Are documented by records made at the time the goods or services were provided, demonstrating the medical necessity for the goods or services rendered. Medicaid goods or services are excessive or not
medically necessary unless both the medical basis and the specific need for them are fully and properly documented in the recipient’s medical record.

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