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​​CalAIM Behavioral Health Initiative Frequently Asked Questions

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Below is a list of frequently asked questions have been collected from technical assistance and informational webinars and submissions to the BHCalAIM@dhcs.ca.gov email. DHCS will update this list on a quarterly basis. ​

Compliance

How should counties monitor for fraud, waste, and abuse?

Each MHP and DMC/DMC-ODS Plan is required to have administrative and management arrangements or procedures to detect and prevent fraud waste and abuse that meet the requirements of 42 C.F.R. part 438.608 and Exhibit A, Attachment 13 of the MHP contract and Exhibit A, Attachment I, section H, paragraph 5, DMC-ODS contract. (Sections 3-5 are the most relevant sections.) The arrangements and procedures include the following:

  • Appointment of a compliance officer who is responsible for for developing and implementing anti-fraud practices and procedures.
  • Appointment of a Regulatory Compliance Committee that is responsible to oversee the entity's compliance program.
  • The establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, prompt response to compliance issues as they are raised, investigation of potential compliance problems as identified in the course of self-evaluation and audits, correction of such problems
  • If the Contractor identifies an issue or receives notification of a complaint concerning an incident of potential fraud, waste or abuse, in addition to notifying the Department, the Contractor shall conduct an internal investigation to determine the validity of the issue/complaint, and develop and implement corrective action, if needed. 
  • Verification, on a regular basis, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by beneficiaries.

What are the definitions of fraud, waste, and abuse? Is “intent" a requirement for fraud to be present?

Fraud means 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 C.F.R. §§ 433.304, 455.2) Abuse means 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 C.F.R. § 455.2) Waste, which is not defined in federal Medicaid regulations, includes inappropriate utilization of services and misuse of resources. (Medicaid and CHIP Payment and Access Commission)

Intent is a required element of fraud. The Department suggests counties consult with county counsel in regards to the specific requirements and evidence needed to meet this element.​

Last modified date: 2/13/2023 12:04 PM