Current through Register Vol. 51, No. 19, September 20, 2024
A. "Medicaid fraud"
means:
(1) Knowingly and willfully making or
causing to be made any false statement or representation of a material fact in
any application for any benefit or payment under a State plan established by
Title XIX of the Social Security Act of 1939;
(2) Knowingly and willfully making or causing
to be made any false statement or representation of a material fact for use in
determining rights to those benefits or payments;
(3) Having knowledge of the occurrence of any
event affecting:
(a) The initial or continued
right to those benefits or payments, or
(b) The initial or continued right to those
benefits or payments to any other individual in whose behalf an application has
been made or in whose behalf benefits or payments are being received, and
concealing or failing to disclose that event with an intent to secure
fraudulently those benefits or payments either in a greater amount or quantity
than is due or when benefits or payments are not authorized;
(4) Having made application to
receive or having received any of those benefits or payments for the use and
benefit of another, and knowingly and willfully converting any part of the
benefit or payment to a use other than for the use and benefit of that other
person;
(5) Fraudulently obtaining,
attempting to obtain, or aiding another person in obtaining or attempting to
obtain any drug product or any medical care, the benefit or payment of any part
of which is or may be made from federal or state funds under a state Medical
Assistance program, by use of:
(a) Fraud,
deceit, misrepresentation, or subterfuge,
(b) Forgery or alteration of a Medical
Assistance prescription, or
(c)
Concealment of any material fact or by the use of false names or
addresses;
(6)
Possession of a blank Medical Assistance prescription, unless possession is
authorized by:
(a) A contract or other power,
right, or permission to manufacture, store, transport, or distribute blank
prescriptions;
(b) A grant of a
rendering privilege as evidenced by the issuance of a rendering number by a
state Medical Assistance program by which one is authorized to prescribe
pharmaceutical products for Medical Assistance recipients if the authorization:
(i) To possess a blank Medical Assistance
prescription terminates 30 days after notice of suspension or termination of
provider status in a state Medical Assistance program or exhaustion of final
appeal rights, whichever is later, and
(ii) Does not extend to possession of blank
Medical Assistance prescriptions which have been obtained from a source not
authorized to distribute blank Medical Assistance prescriptions under
§S(6)(a) of this regulation;
(c) Performance of one's lawful duties as a
law enforcement officer or as one employed by a state Medical Assistance
program; or
(d) The Director,
Medical Care Compliance Administration;
(7) Possession of a Medical Assistance card
or Pharmacy Assistance card without the authorization of the person to whom the
card is issued, unless:
(a) Possession is
obtained by a provider without knowledge that the presenting party lacked
authorization;
(b) Possession is
pursuant to one's lawful duties as a law enforcement officer or as one employed
by a state Medical Assistance program; or
(c) Authorized by the Director, Medical Care
Compliance Administration;
(8) Manufacture, distribution, or possession
of a counterfeit Medical Assistance card, prescription blank, or Pharmacy
Assistance card except when possession is obtained:
(a) By a provider without knowledge that the
card or prescription blank is counterfeit; or
(b) Pursuant to one's lawful duties as a law
enforcement officer or as one employed by a state Medical Assistance program;
and
(9) Manufacture,
distribution, or possession of a provider identification plate used or capable
of use to imprint Medical Assistance prescriptions unless authorized by:
(a) A contract or other power, right, or
permission to manufacture, transport, distribute, handle, or possess the
plates;
(b) Issuance by a state
Medical Assistance program to the party in possession;
(c) Performance of one's lawful duties as a
law enforcement officer or as one employed by a state Medical Assistance
program; or
(d) The Director,
Medical Care Compliance Administration.
B. Examples. The following are examples of
circumstances that may be Medicaid fraud:
(1)
Failure to report income, resources, and family composition at the time of
application or reapplication;
(2)
Failure to report within 10 working days any changes in income, resources, and
circumstances during any period of eligibility;
(3) Lending a Medical Assistance card to
another person;
(4) Using or
attempting to use a Medical Assistance card with intent to secure fraudulently
benefits which are not authorized.
C. LDSS Reporting. All cases of suspected
Medicaid fraud that are discovered by personnel of a local department of social
services shall be reported to the Division of Utilization and Eligibility
Review of the Medical Care Compliance Administration on a form specified by the
Division of Utilization and Eligibility Review.
D. Other Reporting. All cases of suspected
Medicaid fraud that are discovered by agencies other than a local department of
social services, that is, other state or federal agencies, providers, or
concerned citizens, may be reported to the Division of Utilization and
Eligibility Review in writing or by telephone.
E. Division of Utilization and Eligibility
Review. The Division of Utilization and Eligibility Review shall review and,
when appropriate, investigate all referrals when an allegation is made that a
misrepresentation of a material fact has been made or is suspected to have been
made.
F. Disposition of Referrals.
Each referral shall be processed by the Division of Utilization and Eligibility
Review for appropriate resolution which includes, but is not limited to:
(1) Referral for prosecution;
(2) Filing of charges at District
Court;
(3) Recovery of incorrect
benefit payments;
(4) A finding
that the allegation has not been sustained;
(5) Referral to the appropriate agency;
and
(6) Other administrative
action.
G. Penalties. A
person convicted of the crime of Medicaid fraud is subject to penalties as
described in Criminal Law Article, §§8-510 -8-512, Annotated
Code of Maryland.
