Clearwater COG
Provider Compliance Reviews
All Medicaid waiver providers are required to participate in a Provider Compliance Review during their period of certification. Compliance reviews ensure standards for services that comply with state and federal regulations to ensure the health, safety, and welfare of the people who participate in DODD programs. They are conducted by DODD or county board of developmental disabilities staff.
Clearwater COG conducts provider compliance reviews Medicaid waiver providers on behalf the COG’s seven County Boards of Developmental Disabilities. In order to ensure consistency, a standardized review process is used from the DODD Office of System Support and Standards (OSASS).
Clearwater COG conducts provider compliance reviews Medicaid waiver providers on behalf the COG’s seven County Boards of Developmental Disabilities. In order to ensure consistency, a standardized review process is used from the DODD Office of System Support and Standards (OSASS).
Clearwater COG
Types of Provider Compliance Reviews
Can occur at any time based on credible information
Can occur at any time based on credible information
Pertaining to the health, safety, or welfare of an individual
Complaints of allegations
Based on an MUI that may indicate failure to comply with applicable requirements
Adverse outcomes identified by other entities such as the Ohio Department of Health (ODH) or the Ohio Department of Medicaid (ODM)
Does not affect the routine review schedule
All newly certified providers will have a provider compliance review within the first 9 months of the provider billing for services.
Provider Compliance
Review Process
- All compliance reviews will be conducted using the review tools and forms developed by DODD.
- A compliance summary report will be completed by the reviewer and include the following elements:
- Results of review areas
- Citations (if applicable)
- Rule reference for citations
- Plan of Correction Verification – a follow-up, performed either on-site or as a desk review to ensure that the provider has implemented the Plan of Correction submitted in response to a compliance review.
- Appeal of Citations– Providers have the right to appeal citations within 14 days of citation notification.
Adverse Outcomes
Medicaid Fraud
The Ohio Department of Developmental Disabilities is committed to identifying and eliminating fraud. We view it as our collective responsibility to safeguard the limited resources available to Ohio Medicaid recipients.
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Providers are responsible for ensuring that Medicaid billings are accurate and that they are only billing for services for which they are authorized through the Individual Service Plan (ISP) and have provided.
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The County Boards and Councils of Government (COGs) provide local oversight and monitoring to ensure services are provided in accordance with the plan. Additional oversight is provided by the Department.
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The frequency of opportunities will vary. We will do our best to provide opportunities, but there is no guarantee.
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The Department receives referral information regarding possible fraudulent activity and presents it to the Office of the Attorney General through bi-weekly Medicaid Fraud Control Unit Meetings.
Adverse Outcomes
Suspension, Revocation and Abeyance
Clearwater COG and the Department of Developmental Disabilities is committed to educating providers of the standards that must be followed and assisting them in maintaining compliance with rules through technical assistance and support. However, in some cases when good cause exists, the Department may initiate sanctions against a provider. Suspension of new services or revocation proceedings of a provider’s certification(s) or license(s) may be initiated if the Department finds one or more of the following:
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Substantial violation(s) of applicable requirements when violation(s) present a risk to an individual's health and welfare
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A pattern of non-compliance with either plans of compliance that have been accepted by the county board or those plans of compliance that the department has approved in accordance with this rule
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A pattern of continuing non-compliance with applicable requirements
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A licensed provider has had their license revoked by the licensing authority
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Other good cause, including misfeasance, malfeasance, nonfeasance, confirmed abuse or neglect, financial irresponsibility, or other conduct the director determines is injurious to individuals being served Placement on the Abuser Registry
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Conviction of Medicaid Fraud
